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Objective To evaluate whether increasing body mass index (BMI) alters the efficacy of ultrasound-directed cerclage in women with a history of preterm birth. Methods This was a planned secondary analysis of a multicenter trial in which women with a singleton gestation and prior spontaneous preterm birth (17 to 33 + 6 weeks' gestation) were screened for a short cervix by serial transvaginal ultrasound evaluations between 16 and 22 + 6 weeks. Women with a short cervix (cervical length < 25 mm) were randomly assigned to cerclage or not. Linear and logistic regression were used to assess the relationship between BMI and continuous and categorical variables, respectively. Results Overall, in the screened women (n = 986), BMI was not associated with cervical length (P = 0.68), gestational age at delivery (P = 0.12) or birth at 47 kg/m2. Conclusion In women at high risk for recurrent preterm birth, BMI was not associated with cervical length or gestational age at birth. BMI did not appear to adversely affect ultrasound-indicated cerclage. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Objective: The objective of this study was to determine whether there are any indication-specific variations in risk reduction for fetal Down syndrome after a normal genetic sonogram. Study Design: A second-trimester genetic sonogram was offered to all pregnant women who were at increased risk for fetal Down syndrome (≥1:274) because of either advanced maternal age (≥35 years), an abnormal triple screen, or both. Outcome information included the results of genetic amniocentesis (if performed), the results of pediatric assessment, and follow-up after birth. Normal genetic sonography was defined as the absence of all ultrasound aneuploidy markers. Results: The overall prevalence of fetal Down syndrome in the tested population was 1.41% (53/3753 pregnancies); however, in the presence of normal genetic sonography, the overall prevalence of fetal Down syndrome was 0.21% (7/3291 pregnancies). The overall risk reduction for fetal Down syndrome in the presence of normal genetic sonography was 6.64-fold (95% CI, 3.01-14.62); the overall negative likelihood ratio was 0.15 (95% CI, 0.07-0.33). In the presence of normal genetic sonography, the risk for fetal Down syndrome was reduced by 83% in patients with advanced maternal age, 88% in patients with abnormal triple screen, 89% in patients with abnormal triple screen who were Conclusion: There were no significant variations in the risk reduction for fetal Down syndrome in the presence of normal genetic sonography. Regardless of the indication for testing, the likelihood for fetal Down syndrome was reduced by 83% to 89%. This information will be useful in counseling pregnant women who are at high risk for fetal Down syndrome and who prefer to undergo genetic sonography before deciding about genetic amniocentesis. (Am J Obstet Gynecol 2002;187:1226-9.)

Objective To construct an institution-specific nomogram of fetal abdominal circumference measurements and determine whether previously published nomograms correctly categorize our population's outer centiles. Design Using cross-sectional data from a database of sonographic circumference measurements, a nomogram for abdominal circumference measurements was created by modeling the mean and standard deviation separately. The adequacy of the nomogram was confirmed by assessing the normal distribution of data, verifying goodness-of-fit, and checking residuals. Outer centiles were compared with those from other published nomograms. Results The new nomogram for fetal abdominal circumference measurements from 10 070 fetuses provided sufficient data to derive values for the 5th, 10th, 50th, 90th and 95th centiles based on gestational age. Comparisons with other published nomograms indicated that the false-negative rates for classifying our population as 90th centile ranged from 11.3% to 90.5% and from 0 to 66.4%, respectively. Conclusion Institution-specific nomograms of fetal abdominal circumference measurements are important to avoid incorrect categorization of outer centiles. Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

Objectives To assess the role of cervical sonography and to compare various sonographic cervical parameters in their ability to predict spontaneous preterm birth in high-risk singleton gestations. Design A prospective cohort of 469 high-risk gestations were longitudinally evaluated between 15 and 24 weeks' gestation on 1265 occasions with transvaginal cervical sonography and transfundal pressure. The cervical parameters obtained were funnel width and length, cervical length, percent funneling and cervical index. The information obtained was used for patient management. Restriction of physical activities was initiated at cervical lengths of ≤ 2.5 cm with cerclage as an option for cervical lengths of ≤ 2.0 cm. Results Receiver operating characteristic curve analyses showed that a cervical length of ≤ 2.5 cm between 15 and 24 weeks' gestation was equal to the other sonographic cervical parameters in its ability to predict spontaneous preterm birth. The sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation were 94%, 91%, 83% and 76%, respectively, while the negative predictive values were 99%, 99%, 98% and 96%, respectively. The placement of a cerclage did not influence the positive and negative predictive values. In comparison to women with other risk factors, cervical length was best in the prediction of preterm birth in women with a prior mid-trimester loss; an optimal cut-off of ≤ 1.5 cm had sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation of 100%, 100% 92% and 81%, respectively. The rate of preterm delivery at < 34 weeks' gestation increased dramatically when the cervical length was ≤ 1.5 cm. Cervical length was the only independent variable that entered the logistic regression model for the prediction of preterm delivery at < 34 weeks' gestation. Conclusions In high-risk singleton gestations a cervical length of ≤ 2.5 cm was equal to other sonographic cervical parameters in its ability to predict spontaneous preterm birth and was better for the prediction of earlier forms of prematurity (at < 28 and < 30 weeks) than later forms (at < 32 and < 34 weeks). The optimal cervical lengths and their performance for predicting prematurity may be influenced by obstetric risk factors. Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

This study was undertaken to compare various ultrasonographic cervical parameters with respect to ability to predict spontaneous preterm birth in twin gestations.This prospective study involved 131 women carrying twins who were longitudinally evaluated on 524 occasions between 15 and 28 weeks' gestation with transvaginal cervical ultrasonography and transfundal pressure. The following cervical parameters were obtained: funnel width and length, cervical length, percentage of funneling, and cervical index. Receiver operating characteristic curve analysis was used to determine the ultrasonographic cervical parameter evaluated at 15 to 20 weeks' gestation, 21 to 24 weeks' gestation, and 25 to 28 weeks' gestation that were best for prediction of spontaneous preterm birth at28 weeks' gestation,30 weeks' gestation,32 weeks' gestation, and34 weeks' gestation.The median gestational age at delivery was 36 weeks' gestation (range, 21-41 weeks' gestation). Receiver operating characteristic curve analysis indicted that a cervical length ofor =2.0 cm, regardless of gestational age category at cervical measurement, was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. Between 15 and 20 weeks' gestation a cervical length cutoff value ofor =2.0 cm had specificities of 97%, 98%, 99%, and 100% and negative predictive values of 99%, 98%, 95%, and 89% for delivery at28,30,32, and34 weeks' gestation, respectively. The positive predictive values for delivery at32 and34 weeks' gestation were 80% and 100%, respectively. Between 21 and 24 weeks' gestation a cervical length ofor =2.0 cm had specificities of 84%, 84%, 85%, and 86% and negative predictive values of 99%, 99%, 94%, and 87% for delivery at28,30,32, and34 weeks' gestation, respectively. Between 25 and 28 weeks' gestation cervical length had excellent negative predictive values of 99%, 98%, 95%, and 93% for delivery at28,30,32, and34 weeks' gestation, respectively.In twin gestations a cervical length ofor =2.0 cm measured between 15 and 28 weeks' gestation was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. The high specificities indicate that cervical length was better at predicting the absence than the presence of various degrees of spontaneous prematurity.

Objective: This study was undertaken to compare various ultrasonographic cervical parameters with respect to ability to predict spontaneous preterm birth in twin gestations. Study Design: This prospective study involved 131 women carrying twins who were longitudinally evaluated on 524 occasions between 15 and 28 weeks' gestation with transvaginal cervical ultrasonography and transfundal pressure. The following cervical parameters were obtained: funnel width and length, cervical length, percentage of funneling, and cervical index. Receiver operating characteristic curve analysis was used to determine the ultrasonographic cervical parameter evaluated at 15 to 20 weeks' gestation, 21 to 24 weeks' gestation, and 25 to 28 weeks' gestation that were best for prediction of spontaneous preterm birth at Results: The median gestational age at delivery was 36 weeks' gestation (range, 21-41 weeks' gestation). Receiver operating characteristic curve analysis indicted that a cervical length of ≤2.0 cm, regardless of gestational age category at cervical measurement, was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. Between 15 and 20 weeks' gestation a cervical length cutoff value of ≤2.0 cm had specificities of 97%, 98%, 99%, and 100% and negative predictive values of 99%, 98%, 95%, and 89% for delivery at Conclusions: In twin gestations a cervical length of ≤2.0 cm measured between 15 and 28 weeks' gestation was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. The high specificities indicate that cervical length was better at predicting the absence than the presence of various degrees of spontaneous prematurity. (Am J Obstet Gynecol 2000;183:1103-7.)

We describe a case of hepatic hemangioendothelioma that was first suspected based on prenatal sonographic findings at 19 weeks' menstrual age. At 16 weeks, the patient presented with a markedly elevated maternal serum alpha-fetoprotein level. Serial sonographic examinations revealed that the fetus had cardiomegaly, hepatomegaly with a hepatic mass and dilated intrahepatic vessels, a single umbilical artery, and a placental chorioangioma. Arteriovenous shunting within the hepatic mass was seen using color Doppler and pulsed Doppler sonography. An enlarged artery arising from the abdominal aorta supplying the mass was demonstrated. Postnatal physical examination and radiologic studies supported the diagnosis of hepatic hemangioendothelioma. The evolution in the sonographic appearance of this hepatic lesion in utero over a 17-week period is described.

Objective: To determine sonographic findings in Down syndrome fetuses in the third trimester. Methods: Down syndrome fetuses who had third-trimester ultrasound examinations between 25 and 41 weeks’ gestation were matched for gestational age with three controls each. Fetal structural anomalies, Down syndrome dysmorphology markers (abnormal facial profile, sandal gap, tongue thrusting, clinodactyly, or hypoplastic middle phalanx of the fifth finger), and abnormal long-bone biometry (femur, humerus, tibia, and fibula; femur length to biparietal diameter ratio; and femur length to abdominal circumference ratio were abstracted from the ultrasound reports. The fetal face, hands, feet, profile, and cardiac outflow tracts are routinely evaluated in our center. Results: Seventeen fetuses with Down syndrome who had third-trimester ultrasound evaluations were identified. Anomalies included cardiac defects (five), tongue thrusting (three), clinodactyly (three), abnormal profile (three), sandal gap (two), and duodenal atresia (two). Of the 17 fetuses, at least one long-bone abnormality was found in 13, at least one structural or biometric anomaly was found in 15, and at least two abnormal findings existed in 11. Abnormal ultrasound findings, including structural anomalies, short bones, and Down syndrome dysmorphology markers, were more common in cases than in matched controls. Conclusion: At least one abnormal ultrasound finding was present in 15 of 17 fetuses, and abnormal bone measurements or ratios were discovered in 13 of 17. Abnormal long-bone biometry at third-trimester ultrasound should raise the suspicion of fetal Down syndrome.

Objective To compare pregnancy outcomes in women at risk for pregnancy loss treated with elective versus ultrasound-indicated placement of cerclage. Methods A retrospective cohort study was performed on two groups of patients with singleton gestations. The first group consisted of women at risk for pregnancy loss who were treated with an elective cerclage, while the second group was managed conservatively and followed with serial transvaginal cervical sonography and transfundal pressure. An emergency cerclage was placed in women in the second group when the endocervical canal length shortened to < 20 mm, either spontaneously or in response to transfundal pressure. The two groups were compared with respect to maternal demographics, obstetric and gynecological history, and gestational age, both at time of cerclage placement and delivery. Results A total of 138 patients were identified. Eighty-one patients were treated with an elective cerclage and 57 with an ultrasound-indicated cerclage. Patients treated with elective cerclages were older (32 versus 27 years, p = 0.0003), more commonly white (56.8% versus 38.6%, p = 0.0380), less commonly nulliparous (23.5% versus 43.9%, p = 0.0063), and more often private patients (92.6% versus 28.1%, p < 0.0001). A history of previous treatment with cerclage (45.7% versus 10.5%, odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1–0.4) and one prior midtrimester loss (53.1% versus 33.3%, OR 0.4, 95% CI 0.2–0.9) were also more common in the elective versus ultrasound-indicated cerclage group. However, there was no difference in the rates of previous preterm delivery, two midtrimester losses, two terminations of pregnancy, in utero diethylstilbestrol exposure, uterine anomalies, history of cone biopsy or parity. As expected, gestational age at placement of cerclage was significantly earlier in the elective group (13.0 versus 20.0 weeks, p < 0.0001). The median (range) gestational age at delivery (37 (15–41) versus 37 (17–41) weeks, p = 0.90), the number of early (< 25 weeks) losses (9.9% versus 8.8%, OR 1.6, 95% CI 0.3–7.9), and preterm deliveries (< 37 weeks) (35.8% versus 36.8%, OR 1.1, 95% CI 0.4–3.2) were similar in the elective and ultrasound-indicated cerclage patients, respectively. Conclusion In patients at risk for pregnancy loss, placement of cervical cerclages in response to ultrasono-graphically detected shortening of the endocervical canal length is a medically acceptable alternative to the use of elective cerclage. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

We tested the accuracy of a mathematical model based on computer analysis of the fetal heart rate tracing in predicting umbilical artery pH at birth. In a previous report based on data on 38 growth-restricted fetuses, the second-order polynomial regression equation, umbilical artery pH = 7,28 + 0.002 (duration of episodes of low variation in minutes) + 0.00009 (duration of episodes of low variation in minutes)2, was retrospectively found to be the best model for the prediction of umbilical artery pH at birth. In the present study, this formula was prospectively tested in 29 growth restricted fetuses between 26 and 37 weeks of gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. Computer analysis of the fetal heart rate tracing of 1 hour duration was performed within 1.5–6 hours of cesarean birth prior to the onset of labor. Umbilical artery cord blood was collected at birth with pH determined within 5 minutes of collection. Acidemia was defined as umbilical artery ...

The object was to determine whether there is a correlation between the obstetric history and the ultrasonographically determined endocervical canal length between 15 and 24 weeks gestation. A retrospective cohort study was performed in singleton pregnancies of multigravidas with normal and abnormal obstetric histories. They underwent sonographic evaluation for the determination of the endocervical canal length between 15 and 24 weeks gestation. The shortest endocervical canal length measurements between 15 and 20 weeks and also between 21 and 24 weeks of gestation were recorded. An ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to > 2 cm or a single endocervical canal length measurement > 2 cm. A multivariable general linear regression model was used to correlate the relationship between endocervical canal lengths at 15–20 weeks and 21–24 weeks gestation in the current pregnancy with the earliest gestational age at delivery of prior pre...

Objective: To determine the utilization rate of second-trimester genetic sonogram and its role in influencing the decision for amniocentesis in women at increased risk for fetal trisomy 21. Methods: From November 1, 1993, to December 31, 1996, a second-trimester genetic sonogram or only genetic amniocentesis (as a first choice) were offered to pregnant women referred to our institution who were at increased risk for fetal trisomy 21. Results: During the study period, 2089 women were referred to our unit for genetic prenatal diagnosis; of these, 1426 (68%) chose only genetic amniocentesis, and 663 (32%) chose a genetic sonogram as their first option. The yearly utilization rates of genetic sonogram were two of 477 or 0.4% for 1993, 82 of 495 or 16.6% for 1994, 251 of 523 or 48.0% for 1995, and 328 of 594 or 55.2% for 1996. Adjusting for potential confounders, multivariable logistic regression analysis showed that the most important factors associated with the women's decision to undergo genetic amniocentesis were three or more ultrasound markers present (relative risk [RR] 189.5, 95% confidence interval [CI] 37.1, 980.0), two ultrasound markers present (RR 47.2, 95% CI 9.8, 267.8), one ultrasound marker present (RR 12.7, 95% CI 5.5, 29.7), and abnormal serum biochemistry (RR 3.0, 95% CI 1.0, 8.9). Conclusion: The increasing utilization trend, in conjunction with the fact that an abnormal sonogram was the most influential factor in women's decision to undergo genetic amniocentesis, suggests that genetic sonogram services for detection of trisomy 21 should be added to the armamentarium of all prenatal diagnostic centers.

Objective: To evaluate the effect of narcotic and non-narcotic continuous epidural anesthesia on intrapartum fetal heart rate (FHR) tracings as measured by computer analysis.Methods: We studied 37 women with uncomplicated pregnancies at term with reactive FHR tracings. The women were randomized to receive epidural anesthesia with either bupivicaine with fentanyl or bupivicaine alone. One-hour FHR tracings were obtained before epidural anesthesia. Thirty minutes after the initial bolus of the epidural a repeat computer analysis of 60-minute FHR tracing was obtained. Median values are reported for FHR parameters with statistical analysis performed by the Mann-Whitney U and Wilcoxon signed rank tests where appropriate. A power calculation was performed using a power of 90% to determine a required sample size of 28 patients. Statistical significance was set at P

Objective To investigate which second-trimester ultrasound markers for aneuploidy are the most diagnostically efficient in detecting fetal trisomy 21. Methods All second-trimester genetic sonograms performed since November 1,1992 for women at increased risk for fetal trisomy 21 were analyzed retrospectively. Statistical analysis included descriptive statistics, the test of proportions, and univariate and multivariable logistic regression analysis using trisomy 21 as the dependent variable and ten aneuploidy ultrasound markers as independent variables. Results There were 581 normal fetuses, 23 with trisomy 21 and four with other chromosomal abnormalities. When one or more abnormal ultrasound markers were present, the sensitivity and false-positive rate for trisomy 21 were 87% and 13.4%, respectively. After adjusting for confounders, multivariate logistic regression analysis showed the best combination of ultrasound markers for detecting trisomy 21 to be nuchal fold thickening (relative risk [RR] 85.5; 95% confidence interval [CI] 20.4,357.7), pyelectasis (RR 25.2; 95% CI 6.7, 95.0), and short humerus (RR 20.4; 95% CI 4.5, 92.1). The model combining these three ultrasound markers yielded a sensitivity of 87% and a false-positive rate of 6.7%. Conclusion By using only three ultrasound markers (combination of nuchal fold thickening, pyelectasis, and short humerus) the false-positive rate is decreased from 13.4% to 6.7% without any compromise in the sensitivity (87%). The clinical usefulness of evaluating the various second- trimester ultrasound markers needs to be evaluated in prospective studies.

For several decades, visual analysis of the antepartum fetal heart rate tracing has been a primary mode of fetal surveillance despite lack of proof from randomized trials that its use leads to a reduction in perinatal mortality in high risk pregnancies. A meta-analysis of these trials offered the same conclusion. The trials were performed in the early 1980's with fetal monitors with poor signal to noise ratios and poorer testing schemes in comparison to today. Therefore the results may no longer be pertinent, however, it is unlikely that these trials will be repeated because of present medico-legal constraints. Nonetheless, the use of non-stress testing alone is an accepted mode of fetal surveillance because of associated low fetal death rates within 1 week of a normal test; 1.9 to 3.2/1000 patients tested. The expense associated with this low fetal death rate is a low positive predictive value of 25% to 50%. Interrelated with this inefficiency, is the considerable inter- and intra-observer variation in the interpretation of antepartum fetal heart rate tracings. Variation in the interpretation of antepartum fetal heart rate tracings continues to exist despite the increase in experience and knowledge of fetal heart rate monitoring and improvement in fetal heart rate monitors. The end result is a form of fetal surveillance that is of questionable value and inefficient, requiring frequent back up testing to clarify fetal condition.

Cardiac neonatal lupus (cardiac-NL), initiated by surface binding of anti-Ro60 autoantibodies to apoptotic cardiocytes during development, activates the urokinase plasminogen activator/urokinase plasminogen activator receptor (uPA/uPAR) system. Subsequent accumulation of apoptotic cells and plasmin generation facilitates increased binding of anti-Ro60 by disrupting and cleaving circulating β2-glycoprotein I (β2GPI) thereby eliminating its protective effect. The association of soluble levels of components of the uPA/uPAR system with cardiac-NL was examined.Levels of the uPA/uPAR system were assessed by ELISA in cord blood and immunohistological evaluation of autopsies.uPA, uPAR and plasminogen levels were each significantly higher in cord blood from cardiac-NL (n = 35) compared with non-cardiac-NL (n = 26) anti-Ro-exposed neonates: 3.3 ± 0.1 vs 1.9 ± 0.05 ng/ml (P0.0001), 6.6 ± 0.3 vs 2.1 ± 0.2 ng/ml (P0.0001) and 435 ± 34 vs 220 ± 19 ng/ml (P0.0001), respectively. In three twin pairs discordant for cardiac-NL, the twin with cardiac-NL had higher levels of uPA, uPAR and plasminogen than the unaffected twin (3.1 ± 0.1 vs 1.9 ± 0.05 ng/ml; P = 0.0086, 6.2 ± 1.4 vs 2.2 ± 0.7 ng/ml; P = 0.147 and 412 ± 61 vs 260 ± 27 ng/ml; P = 0.152, respectively). Immunohistological evaluation of three hearts from fetuses dying with cardiac-NL revealed macrophages and giant cells expressing uPA and plasminogen in the septal region.Increased soluble uPA, uPAR and plasminogen in cord blood and expression in affected tissue of fetuses with cardiac-NL supports the hypothesis that fetal cardiac injury is in part mediated by plasmin generation initiated by anti-Ro binding to the apoptotic cardiocyte.

The objective of this study was to determine the effects of removal of amniotic fluid in cases of symptomatic severe polyhydramnios on Doppler waveform indices of the uterine and umbilical arteries and flow velocities of the uterine arteries. Nine women underwent therapeutic amniocentesis during ten pregnancies for symptomatic polyhydramnios due to Beckwith-Wiedemann Syndrome (n = 1), esophageal atresia (n = 2), chorioangioma (n = 1), twin-twin transfusion syndrome (n = 3), a presumed autosomal recessive syndrome (n = 2), and an unbalanced double translocation (n = 1; partial dup 3q and partial del 9p syndrome). An average of 2.78 +/- 0.9 (range 1-4) 1 of fluid were removed at each procedure between the gestational ages of 18 and 34 weeks (mean of 28 weeks). The systolic/diastolic (S/D) ratio, pulsitility index (PI), and resistance index (RI) of the uterine and umbilical arteries were obtained before and after the procedure using color and pulsed Doppler. After angle correction, the peak systolic velocity (PSV) and mean velocity (MV) in centimeters/second (cm/s) of the uterine arteries were also determined. The presence or absence of a uterine artery waveform notch was determined. Dominant uterine arteries were defined as those with lower impedance indices or higher flow velocities. Statistical analysis was performed with the Wilcoxon signed-rank test. Significance was set at P0.05. There was a significant increase in the median value of the uterine artery MV (43.8 vs. 81.1 cm/s, P = 0.005) and PSV (74.2 vs. 125.5 cm/s, P = 0.007) after amniocentesis. The uterine S/D (3.0 vs. 1.84, P = 0.007), PI (1.12 vs. 0.68, P = 0.008), and RI (0.60 vs. 0.45, P = 0.005) impedance indices significantly decreased following amniocentesis. When uterine arteries were categorized as dominant vs. nondominant, there were greater improvements in impedance indices and flow velocities in the nondominant uterine arteries. There were three cases of unilateral and one case of bilateral early diastolic notches of the uterine artery waveforms which either resolved (n = 4) or improved (n = 1). There was no effect on the umbilical artery impedance indices. Therapeutic amniocentesis significantly improved uterine artery impedance indices and resulted in improved flow velocities, while there was no effect on umbilical artery waveform indices. The procedure resulted in the disappearance or improvement of the uterine waveform notch. Our findings suggest that in cases of severe polyhydramnios abnormal uterine artery velocimetry may not be due to lack of trophoblastic invasion of the spiral arteries but to increased intrauterine pressure secondary to polyhydramnios.

Objective To establish the efficacy of second-trimester fetal long-bone biometry (femur, humerus, tibia, and fibula length) in detecting trisomy 21 and to generate tables for adjusting the risk of trisomy 21 according to long-bone biometry. Methods Four long bones—femur, humerus, tibia, and fibula—were measured ultrasonically in singleton fetuses before genetic amniocentesis. Fetuses with normal karyotypes were used to derive regression equations describing predicted lengths on the basis of the biparietal diameter measurement. The efficacy of each abnormally short bone, alone and in combination, was determined in 22 fetuses with trisomy 21 encountered during the study period. After the sensitivity and specificity of long-bone biometry were established, appropriate tables were generated by Bayes' theorem to adjust the risk of trisomy 21 in the second trimester depending on long-bone biometry. Results Of 515 patients between 14 and 23 weeks' gestation, 493 had normal fetal karyotypes and 22 had trisomy 21. The sensitivity of an abnormal ultrasound, as defined by the presence of one or more short bones, was 63.6% and the specificity was 78.5%. According to Bayes' theorem, genetic amniocentesis may not be recommended for women less than 40 years old in the presence of normal long-bone biometry (ie, all four bones normal). Conclusion Second-trimester fetal long-bone biometry is useful in detecting trisomy 21 and may be used to adjust the a priori risk of both high- and low-risk women for trisomy 21 and, therefore, the need for genetic amniocentesis.

Ultrasonography has increasingly become essential in the practice of obstetrics and gynecology. Its antenatal use is well described in the literature and is a continuing subject of study. However, the use of ultrasonography in the labor and delivery suite has not been the subject of many articles. The purpose of this chapter is to review the pertinent literature along with the experience of the authors in order to define the role of ultrasonography in the Labor and Delivery Suite.

We report the prenatal diagnosis of mid shaft hypospadias and describe the sonographic features of fetal hypospadias including an abnormal urethral canal, ventral curvature of the distal penis, extension of the penile glans beyond the prepuce, and fetal micturation in a plane perpendicular to the penile shaft. An accurate family history is an essential part of the evaluation of the milder degrees of fetal hypospadias.

The objective of this study was to determine whether vacuum extraction is associated with umbilical cord blood acid-base changes when used electively or in the presence of suspected fetal distress. Data from 1,428 patients from a previously published randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify differences in umbilical cord blood acid-base measurements associated with the elective use of vacuum extraction (patients with duration of second stage of labor 60 min or less) and also in the presence of suspected fetal distress during the second stage of labor. When used electively, vacuum extraction was associated with lower pH (in both umbilical cord artery and vein), lower venous base excess, and higher venous carbon dioxide tension (PCO2), as compared to normal spontaneous vaginal delivery. After correcting for duration of second stage of labor, elective vacuum delivery was significantly associated only with a decrease in cord venous pH and increase in venous PCO2. However, these cord blood acid-base changes were not accompanied by any differences in perinatal morbidity and mortality or in the number of neonates born with acidemia (cord arterial pH < 7.15 or < 7.10). In cases of suspected fetal distress, the use of vacuum extraction was not associated with any detectable cord blood acid-base changes as compared to normal spontaneous vaginal delivery. These data support the continued use of vacuum extraction, especially in cases of suspected fetal distress during the second stage of labor.

We present a case of congenital cystic adenomatoid malformation (CCAM) of the lung diagnosed at 17 weeks and 6 days of gestation, initially classified as a type II lesion and reclassified as a type I lesion at 19 weeks, which shows that the natural evolution of CCAM of the lung can include cyst enlargement leading to reclassification. At 22 weeks of gestation ascites developed. The second successful in-utero treatment of hydrops secondary to this condition hy serial simple aspiration is described.

Objective To use a meta-analysis of all published randomized trials to determine whether the use of continuous electronic fetal heart rate monitoring (EFM) as the main method of intrapartum fetal surveillance is associated with improved pregnancy outcome compared to intermittent auscultation. Data Sources We used the MEDLINE data base and reference lists of articles to identify all published randomized trials of EFM versus intermittent auscultation. Methods of Study Selection A total of nine randomized trials published in peer-review journals were identified. The selection criterion was the use of EFM or intermittent auscultation as the main intrapartum fetal surveillance technique. Data Extraction and Synthesis A total of 18,561 patients were included in the nine published randomized trials, 9398 in the EFM group and 9163 in the auscultation group. Measures of pregnancy outcome included cesarean delivery, cesarean for suspected fetal distress, overall use of forceps or vacuum, use of forceps or vacuum for suspected fetal distress, overall perinatal mortality, and perinatal mortality due to fetal hypoxia (intrapartum or early neonatal death) attributable to the method of intrapartum monitoring. The metaanalysis showed that the patients monitored electronically had a significantly higher overall cesarean rate (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.17–2.01), higher cesarean rate for fetal distress (OR 2.55, 95% CI 1.81–3.53), overall increased use of forceps or vacuum (OR 1.23, 95% CI 1.02–1.49), increased use of forceps or vacuum for suspected fetal distress (OR 2.50, 95% CI 1.97–3.18), and decreased perinatal mortality due to fetal hypoxia (OR 0.41, 95% CI 0.17–0.98). Conclusion Electronic fetal monitoring is associated with increased rates of surgical intervention and decreased perinatal mortality due to fetal hypoxia.

To assess cerclage benefit in women with short cervix also receiving 17-α-hydroxyprogesterone caproate (17P) to prevent recurrent preterm birth (PTB).Secondary analysis of a multicenter trial of ultrasound-indicated cerclage for shortened cervical length (CL). Women with prior spontaneous PTB at 16-33 6/7 weeks, singleton gestation and CL25 mm between 16 and 22 6/7 weeks were counseled on use of 17P and randomized to cerclage or no cerclage. Outcomes of women who received 17P were analyzed by randomization group. Primary outcome was PTB35 weeks.99 women received 17P: 47 cerclage; 52 no cerclage. Rates of PTB35 weeks were similar, 30% for cerclage and 38% for no cerclage (aOR 0.64 (0.27-1.52)). In women with CL15 mm, PTB35 weeks was reduced for the cerclage group (17% vs. 75%, p = 0.02). However, this difference was nullified after controlling for total progesterone doses received (p = 0.40).Cerclage was shown not to offer additional benefit for the prevention of recurrent PTB in women with short CL25 mm receiving 17P, but the sample size is insufficient for a definite conclusion given the 36% nonsignificant decrease in the odds of PTB35 weeks. Cerclage may further offer substantial benefit to women with very short CL15 mm and further study is needed.

OBJECTIVE: To estimate the value of second-trimester genetic sonography in detecting fetal Down syndrome in patients with advanced maternal age (at least 35 years) and normal triple screen. METHODS: Since July 1999, a prospective collection and recording of all individual triple screen risks for fetal Down syndrome was initiated for all patients with advanced maternal age presenting in our ultrasound unit for second-trimester genetic sonography. Genetic sonography evaluated the presence or absence of multiple aneuploidy markers. Outcome information included the results of genetic amniocentesis, if performed, and the results of pediatric assessment and follow-up after birth. RESULTS: By June 2001, 959 patients with advanced maternal age and normal triple screen were identified. Outcome information was obtained in 768 patients. The median risk for fetal Down syndrome based on maternal age was 1:213 (range 1:37–1:274). The median risk for fetal Down syndrome based on triple screen results was 1:1069 (range 1:275–1:40,000). A total of 673 patients had normal genetic sonography, and none (0%) had Down syndrome; 95 had one or more aneuploidy markers present, and four (4.2%) had fetuses with Down syndrome. The triple screen risks for these four fetuses ranged from 1:319 to 1:833. CONCLUSION: This study suggests that patients with advanced maternal age and normal genetic sonography carried very little risk for Down syndrome. The use of genetic sonography may increase the detection rate of fetal Down syndrome in this group of pregnant women.

The purpose of this study was to evaluate the effect of earliest previous spontaneous preterm birth (SPTB) gestational age on cervical length, pregnancy duration, and ultrasound-indicated cerclage efficacy in a subsequent gestation.Planned secondary analysis of the National Institute of Child Health and Human Development-trial of cerclage for cervical length of25 mm. Women with at least 1 previous SPTB between 17-33 weeks 6 days of gestation underwent serial vaginal ultrasound screening between 16 and 23 weeks 6 days of gestation; cervical length at qualifying randomization evaluation was used.We observed a significant correlation (P = .0008) between previous SPTB gestational age and qualifying cervical length. In a linear regression model that was controlled for cervical length and cerclage, neither previous SPTB gestational age nor the interaction between cerclage and previous birth gestational age was significant predictor of subsequent birth gestational age.Although there is an association between previous SPTB gestational age and cervical length in women with a mid-trimester cervical length of25 mm, there does not appear to be a disproportionate benefit of cerclage in women with earlier previous SPTB.

The primary risk factors for recurrent spontaneous preterm birth (SPTB) are a history of SPTB and a short cervical length (CL) found on second trimester transvaginal ultrasound (TVU). In women with prior SPTB or a short CL, the most frequently used interventions to prevent preterm birth (PTB) are cerclage and progesterone supplementation. It is unclear whether the effects of the progesterone agent 17-alpha-hydroxyprogesterone caproate (17P) are additive in women with both primary risk factors. It is also unclear whether 17P is beneficial for women with a prior SPTB and a short CL not undergoing TVU-indicated cerclage. The aim of this study was to evaluate the effect of 17P for the prevention of PTB in pregnant women with prior SPTB, and a short CL, with and without TVU-indicated cerclage. The study was a secondary analysis of a randomized controlled trial sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, evaluating cerclage for singleton women with prior SPTB (17-33 6/7 weeks), and CL

To date, the prenatal diagnosis of cerebellar hemorrhage has been limited to isolated case reports, which have demonstrated either a hyperechoic cerebellar hemisphere or a hyperechoic mass within the cerebellum in near-term fetuses. We demonstrate the ultrasonographic findings of intracerebellar hemorrhagic infarction in a fetus at approximately 21 weeks' gestation. In contrast to previous case reports, the hemorrhagic infarcts seen in our case were hypoechoic.

Transabdominal ultrasonography in obese pregnant women is often unsatisfactory because of the poor transmission of ultrasound through a thickened abdominal wall. We report our experience with the placement of a transvaginal probe in the umbilicus to improve resolution in obese pregnant patients. The technique, which involves filling the umbilicus with ultrasound transmission gel and inserting the transvaginal probe into the umbilicus, was applied in 25 consecutive obese patients who had unsatisfactory fetal imaging by the standard transabdominal approach. The most frequent reason for incomplete fetal survey by the standard transabdominal approach was unsatisfactory imaging of the fetal heart (19 of 25 cases, 76%). The transumbilical approach resulted in improved resolution and satisfactory cardiac examination in 18 of these 19 cases (95%). In two cases, color and pulsed Doppler interrogation of intrafetal vessels become possible. A complete fetal survey was accomplished in 96% of the cases.

We present a case of continuous abnormal fetal breathing which was associated with a severely asphyxiated neonate. The period of apnea was fixed at approximately 3 s and the breathing activity consisted of a single inspiratory and expiratory movement. The depth of each breath appeared similar. No movement or tone was observed. This “picket fence” fetal breathing pattern, which has been described in fetal lambs as a preterminal event, has not been reported previously in humans.

To determine the usefulness of a fetal ear length nomogram in the prenatal detection of fetal aneuploidy and to determine whether ear smallness in cases of aneuploidy is a primary or secondary event.Ear lengths of 447 singleton fetuses (October 1996 to October 1997)were prospectively evaluated between 14 and 41 weeks to establish a nomogram created by modeling the mean and SD separately. Records of aneuploid fetuses were retrospectively reviewed, and their ear lengths were plotted against the nomogram to determine detection rates, with ear length in or below the 10th and 50th percentiles for a given gestational age and biparietal diameter used as abnormal cutoffs.The nomogram for fetal ear length measurements provided sufficient data to derive the 10th, 50th, and 90th percentiles on the basis of gestational age and biparietal diameter. The ear length of euploid fetuses was significantly correlated with gestational age (R2 = 0.96; P.001) and biparietal diameter (R2 = 0.95; P.001). From 96 aneuploid fetuses identified, 63 had ear lengths in or below the 10th percentile for gestational age (sensitivity, 66%). When using ear length against biparietal diameter, the sensitivities for all aneuploid fetuses for cutoffs at or below the 10th and 50th percentiles were 43% (40 of 93) and 83% (77 of 93), respectively.Most aneuploid fetuses have sonographically small ears (or = 10th percentile for gestational age). This smallness is not entirely related to overall small fetal size, but in almost half the cases, the fetal ear length is disproportionately smaller than the biparietal diameter.

Objective To describe the prenatal detection of fetal trisomy 18 through abnormal sonographic features and to determine the sensitivity of sonographically detecting fetuses with trisomy 18. Methods All genetic and cytogenetic records of fetuses with trisomy 18 were reviewed retrospectively (1992-2002). From these, singleton fetuses who had prenatal sonography at our unit were identified. The maximal numbers of individual abnormalities from 1 sonographic examination (not limited to type of organ system) were recorded. Each abnormality was classified as major, minor, or "other," and each organ system was classified as abnormal only once, regardless of the number of individual abnormalities identified in that system. The sensitivity of sonography in detecting abnormalities of trisomy 18 was determined. Results Of 38 fetuses identified with trisomy 18, all had 4 or more prenatally detected sonographic abnormalities (sensitivity of sonographic detection of fetuses with trisomy 18, 100%). The median number of abnormalities per examination was 8 (range, 4-19). Sonographically detected major abnormalities were cardiac (84%; n = 32), central nervous system (87%; n = 33), gastrointestinal (26%; n = 10), and genitourinary (16%; n = 6). Sonographically detected minor abnormalities were short ear length below the 10th percentile for gestational age (96%; n = 26/27), upper extremities and hands (95%; n = 36), lower extremities and feet (63%; n = 24), and face (53%; n = 20). Fifty percent (19 of 38) had choroid plexus cysts identified, but this was never an isolated finding. Conclusions In experienced hands, the sensitivity of detecting fetal trisomy 18 on prenatal sonography is 100%, and all cases will have multiple anomalies visualized.

To determine the sensitivity of using a complete anatomic sonographic survey in detecting fetal abnormalities via correlation with perinatal autopsy results.All perinatal autopsies (1994-2001) with positive findings for at least 1 fetal abnormality and performed by a single perinatal pathologist at our institution were retrospectively reviewed. From these cases, singleton fetuses who received prenatal sonography solely in our unit were identified. The sensitivity of sonography in detecting anomalous fetuses as well as fetal abnormalities and abnormalities by organ system was determined. Abnormalities were classified as major or minor In addition, findings from sonography and autopsy were compared, and their correlation was assigned to 1 of 3 categories.Of 88 fetuses identified, 85 had 1 or more abnormal structural sonographic findings (sensitivity for fetuses with anomalies, 97%). A total of 372 separate abnormalities were found on autopsy; of the 299 major and 73 minor abnormalities, prenatal sonography showed 224 (75%) and 13 (18%), respectively. There was either complete agreement or only minor differences between sonographic and autopsy findings in 57 (65%) of 88. The sensitivity of sonography in identifying abnormalities was greater than 70% in these systems: central nervous system, cardiac system, urinary system, extremities, genitalia, ribs, and hydrops.In experienced hands, sonography has 97% sensitivity in detecting anomalous fetuses when compared with perinatal autopsy results. Although the sensitivity of sonography in detecting major fetal abnormalities is 75%, the sensitivity for minor abnormalities is poor, even when using a complete anatomic sonographic survey. Although it has limitations, this type of survey is invaluable for both patients and physicians in diagnosing fetal abnormalities.

The objective of this study was to determine the frequency of prenatally diagnosed unilateral cerebral ventriculomegaly and also to assess neonatal outcome in infants with this prenatal diagnosis. A computerized ultrasonography database identified fetuses with isolated and nonisolated unilateral cerebral ventriculomegaly from October 1994 to June 1999. The Denver II Developmental Screening Test was used to assess developmental skills. Unilateral cerebral ventriculomegaly was diagnosed in 15 of 21,172 (1 per 1,411) pregnancies. The width of the enlarged lateral ventricle ranged from 1.0 to 1.9 cm. In 10 (67%) of 15 cases unilateral cerebral ventriculomegaly was an isolated finding. Eight of the 14 infants who were born at 36 weeks' gestation or later had postnatal cranial imaging, and ventricular asymmetry was confirmed in 5 (63%). One infant with an arachnoid cyst and cerebral palsy died at 2 years of age. The remaining 11 infants in whom developmental milestones were assessed had age-appropriate skills. Unilateral fetal ventriculomegaly is usually an isolated finding and when isolated has little measurable effect on developmental outcome.

Although cervical cerclage is widely used to prevent preterm birth in women with a history of preterm birth during the second trimester, its use is controversial and has not been supported by several randomized trials. This randomized controlled trial investigated the effectiveness of cerclage to prevent recurrent preterm birth in women with short cervix. Singleton women with a history of spontaneous preterm birth before 34 weeks' gestation and a mid-trimester cervical length less than 25 mm were randomly assigned to either cerclage (n = 148) or no cerclage (n = 153). Cervical length was considered to be a surrogate for cervical competence. The interaction between cerclage efficacy and cervical length was compared for cervical length strata of < 15 mm and 15 to 24 mm. The primary outcome of preterm birth less than 35 weeks' gestation was observed in 32% of women assigned to cerclage and 42% in the no-cerclage group (P = 0.09). Previable birth less than 24 weeks occurred less frequently in the women treated with cerclage than in those who were not (6.1% vs. 14%; P = 0.03). The rates of perinatal death were also significantly less with cerclage (8.8% vs. 16%; P = 0.046). In stratified analysis, comparison of cervical length strata showed that cerclage provided a significant benefit in the less than 15 mm stratum (P = 0.03) but not in the 15 to 24 mm stratum. These findings show that cerclage reduces previable birth and perinatal mortality in women with a history of spontaneous preterm birth at less than 34 weeks' gestation and a cervical length less than 25 mm, but does not prevent birth before a gestational age of 35 weeks unless the cervical length is less than 15 mm.

Sonographic fetal foot length is highly predictive of gestational age. In order to assess the reliability of this parameter in predicting gestational age in cases of abnormal fetal growth, we examined fetal foot length in small- and large-for-gestational-age fetuses. A nomogram of foot length versus gestational age between 15 and 37 weeks was constructed using cross-sectional data obtained from 5372 singleton fetuses. Fetal foot lengths for small-for-gestational-age fetuses (estimated fetal weight below the 10th percentile) and large-for-gestational-age fetuses (above the >90th percentile) fetuses were plotted against the foot length nomogram in order to determine the number of small-for-gestational-age fetuses and large-for-gestational-age fetuses with foot lengths below the 10th and above the 90th percentiles, respectively. Of the 586 small-for-gestational-age fetuses, 355 (60.6%) had foot lengths below the 10th percentile on the nomogram. When foot lengths from large-for-gestational-age fetuses were plotted on the foot length nomogram, 29.4% (219 of 744) had measurements above the 90th percentile. Fetal foot length can be influenced by growth restriction as well as states of accelerated fetal growth. Our findings imply that there are limitations to the use of fetal foot length for gestational age assessment, particularly in fetuses with growth abnormalities.

Objective: The object of this study was to determine whether there are any clinically significant indication-specific variations in the accuracy of second-trimester genetic ultrasonography and to provide a risk adjustment for fetal trisomy 21 according to the results of genetic ultrasonography. Study Design: From November 1, 1992, to September 30, 1998, a second-trimester genetic sonogram was offered to all pregnant women who were at an increased risk for fetal trisomy 21 (≥1:274) because of either advanced maternal age (≥35 years) or abnormal serum biochemical profile or both of these. Outcome information included the results of genetic amniocentesis if performed and the results of pediatric assessment and follow-up after birth. In determining diagnostic accuracy of the genetic sonogram the presence of ≥1 abnormal ultrasonographic marker was considered an abnormal test result. Results: A total of 1835 fetuses with known outcomes underwent genetic ultrasonography between 15 and 24 weeks' gestation; of these 1792 had normal results, 34 had trisomy 21, and 9 had other chromosomal abnormalities. The likelihood of fetal trisomy 21 was reduced by 80% after a normal result of genetic ultrasonography. The overall sensitivity, specificity, and positive and negative predictive values of genetic ultrasonography for the detection of trisomy 21 were 82%, 91%, 15%, and 99.6%, respectively. There were no significant indication-specific variations in the accuracy of second-trimester ultrasonography. The sensitivity for the detection of fetal trisomy 21 ranged from 80% among women with advanced maternal age to 100% among women with both an abnormal biochemical profile and advanced maternal age. Conclusions: The likelihood of fetal trisomy 21 risk was reduced 80% after a normal result of genetic ultrasonography. In addition there were no significant indication-specific variations in the detection rate of genetic ultrasonography. (Am J Obstet Gynecol 1999;181:1045-8.)

Objective: Our objective was to determine whether there were any differences in the placental lesions of high-risk patients with versus without ultrasonographic evidence of cervical shortening between 15 and 24 weeks' gestation. Study Design: Women who were at risk for pregnancy loss and spontaneous preterm birth were followed by serial transvaginal cervical ultrasonography with transfundal pressure between 15 and 24 weeks' gestation. Two groups of women were identified: those in whom progressive cervical shortening developed to below 2 cm, either spontaneously or induced by transfundal pressure, and those in whom it did not. A perinatal pathologist who was blinded to the pregnancy outcome retrospectively examined placental histologic slides. The histologic placental lesions were categorized as acute or chronic inflammatory lesions, decidual vascular lesions, and coagulation-related lesions. Results: There were 278 women who were followed during the study. Placentas were submitted for histologic examination in 189 cases (125 singleton, 45 twin, and 19 triplet gestations). There were 72 pregnancies with and 117 pregnancies without an ultrasonographic diagnosis of cervical shortening, respectively. Overall, there were significantly more acute inflammatory lesions in patients in whom cervical shortening developed, as determined by ultrasonographic examination. However, there were significantly more decidual vascular lesions in women in whom cervical shortening did not develop. When we examined the distribution of the placental histologic lesions in the 64 cases of multiple gestations, the only significant finding was again a greater frequency of acute inflammatory lesions in patients in whom cervical shortening developed. There was no difference in the distribution of the placental histologic lesion categories among women treated with bed rest versus cervical cerclage because of the ultrasound diagnosis of cervical shortening. Conclusion: Acute inflammatory lesions of the placenta were more frequent in patients with second-trimester cervical shortening. These findings support that patients with cervical shortening in the second trimester are prone to acute placental inflammation. (Am J Obstet Gynecol 1999;181:793-7.)

To determine the weekly cervical shortening rates of the endocervical canal between 15 and 24 weeks' gestation in women at risk for pregnancy loss or spontaneous preterm birth.We performed a retrospective cohort study of transvaginal sonographic measurements of the endocervical canal length done at least twice between 15 and 24 weeks' gestation in women at risk for pregnancy loss and spontaneous preterm birth. The ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to 2 cm or less either spontaneously or after application of transfundal pressure. Multivariable linear regression models were developed to determine the weekly crude rate of endocervical canal length shortening rates in cases of competent cervices and incompetent cervices, with incompetent cervices further stratified as those diagnosed at 15-19 weeks' and 20-24 weeks' gestation. Comparisons of the models for weekly rate of endocervical canal length shortening were performed.The endocervical canal lengths were measured in 61 women (180 measurements) who did not develop ultrasound evidence of cervical incompetence and 28 women (103 measurements) who had ultrasound evidence of cervical incompetence. Between 15 and 24 weeks' gestation, competent cervices had a nonsignificant rate of endocervical canal length shortening (-0.03 cm/week). During this period in gestation, incompetent cervices had significantly greater endocervical canal length shortening (-0.41 cm/week, P.001). The rate of endocervical canal length shortening of incompetent cervices diagnosed between 15 and 19 weeks' gestation was -0.52 cm/week (P.001). The rate of endocervical canal length shortening in incompetent cervices diagnosed between 20 and 24 weeks' gestation was significant and varied from -0.49 cm/week to -0.80 cm/week at 20 and 24 weeks' gestation, respectively (P.001). The models describing the rate of cervical shortening in the two groups of incompetent cervices were significantly different (P.001). The sonographic detection of endocervical canal length shortening in the 28 cases of cervical incompetence was identified at a median (range) gestational age of 20 (16-24) weeks.Weekly rates of endocervical canal length shortening were established, which may be useful for detecting and managing cervical incompetence in high-risk women examined with cervical sonography.

Objective Our purpose was to compare various noninvasive stress techniques for their ability to elicit ultrasonographic cervical changes and to determine their efficacy in detecting ultrasonographic cervical incompetence. Study design Eighty-nine patients at risk for pregnancy loss and preterm birth underwent ultrasonographic evaluation of the cervix at least twice between 15 and 24 weeks of gestation. With use of a transvaginal probe, the funnel width, funnel length, and endocervical canal length were measured in millimeters with the patient in the supine position. These measurements were repeated after three stress tests: transfundal pressure, coughing, and standing. The difference between the baseline measurements and those obtained after the stress tests were determined. A positive response to stress was defined as any decrease in endocervical canal length accompanied by an increase in funnel width and length. Improvement was defined by any increase in endocervical canal length accompanied by a decrease in funnel width and length. Cervical incompetence was defined as the presence of progressive cervical changes on ultrasonographic examinations with final endocervical canal length measurements below 26 mm. Results are reported as median (range). Results: The number of positive cervical responses to transfundal pressure (19%, 17/89) was significantly greater than to coughing (3.3%, 3/89) and standing (9.0%, 8/89). The status of the cervix improved with standing in three cases, whereas this was not seen with transfundal pressure or coughing. There was no case where there was a positive response to standing or coughing and not to transfundal pressure. When the changes in funnel width and length and endocervical canal length as a result of transfundal pressure and standing in the 17 cases that responded to transfundal pressure, transfundal pressure resulted in a significantly greater increase in funnel width and length and a decrease in endocervical canal length. The efficacy of transfundal pressure in detecting the cervix that had subsequent progressive changes on ultrasonography was as follows: sensitivity 83.3%, specificity 97.2%, and positive and negative predictive values 88.2% and 95.8%, respectively. The efficacy of coughing was sensitivity 16.7%, specificity 100%, and positive and negative predictive values 100% and 85.5%, respectively. The efficacy of standing was sensitivity 33.3%, specificity 97.2%, and positive and negative predictive values 75% and 85.2%, respectively. Similar results were obtained when the analysis was confined to 37 patients who had a prior history of a midtrimester miscarriage. Conclusion: Transfundal pressure was the most effective technique in eliciting cervical changes during the active assessment of the cervix during pregnancy and the most sensitive in detecting the cervix that had progressive second-trimester cervical shortening during pregnancy, compared with coughing or standing position.

OBJECTIVE: Our purpose was to observe the evolution of the endocervical canal length in women at risk for cervical incompetence after a positive response to transfundal pressure. STUDY DESIGN: Ten women at risk for cervical incompetence had a midtrimester cervical evaluation with transvaginal ultrasonography and transfundal pressure. With a transvaginal probe, the endocervical canal length was first measured. Transfundal pressure was then applied and the endocervical canal length was remeasured. All patients had a positive response to transfundal pressure as defined by a decrease in endocervical canal length after application of transfundal pressure. At the initial evaluation the digital examination of the cervix had revealed a closed and long cervix in all 10 cases. In 9 of the 10 patients repeat examinations were performed until the endocervical canal length progressively shortened to

Bronchopulmonary sequestration is a congenital abnormality of nonfunctional pulmonary tissue that lacks normal connections with the bronchial tree. The sequestered tissue typically receives the majority of its blood supply from systemic vessels, most often the distal thoracic or upper abdominal aorta. These lesions often are associated with fetal hydrops, polyhydramnios, and persistent masses postnatally. Bronchopulmonary sequestrations are thought to require resection owing to their predisposition for chronic pulmonary infections later in life. However, spontaneous in utero resolution of these lesions can occur. This report describes the real time, color Doppler, and duplex Doppler ultrasonographic investigation of an intrathoracic bronchopulmonary sequestration that resolved spontaneously. Our investigation of this case provides new insight into a possible mechanism for spontaneous regression of bronchopulmonary sequestration.