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Report survival rates, neonatal mortality and morbidity and long-term outcomes of monochorionic (MC) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) or TTTS plus selective fetal growth restriction (sFGR) treated by endoscopic laser surgery.Retrospective cohort study including 149 MC twin pregnancies complicated by TTTS or TTTS plus sFGR.Medical records were reviewed for survival rates, neonatal mortality, neonatal morbidity and long-term outcomes at 2 and 6 years of age.Survival of both babies was higher in the TTTS group than in the TTTS plus sFGR group (72.9%vs.54.8%); survival of at least one baby was similar in the two groups (90.7% and 88.1%). The incidence of severe neurological disability was not significantly different between TTTS and TTTS plus fetal growth restriction group at both stages, 1.9% versus 2.3% (p-value = 1) and 3.4%vs6.1% (p-value = 0.31). Multivariable analysis demonstrated that intact neurological outcome at 2 years of age was related with gestational age (GA) at birth and z score birthweight (Z BW), and at 6 years of age with GA at birth, Z BW and TTTS stage4. sFGR or abnormal brain findings at neonatal ultrasound were not related with impaired neurological outcome at two or 6 years of age.In pregnancies with TTTS and TTTS plus sFGR survival of at least one baby and long-term neurological outcome are comparable between both groups.

The indications for induction of labor have been consistently on the rise. These indications are mainly medical (maternal or fetal) or social or related to convenience or maternal preferences. With the increase in the prevalence of these indications, the incidence rates of induction of labor are expected to rise continuously. This poses a substantial workload and financial burden on maternity healthcare systems. Failure rates of induction of labor are relatively high, especially when considering the maternal, fetal, and neonatal risks associated with emergency cesarean deliveries in cases of failure. Therefore, it is essential for obstetricians to carefully select women who are eligible for induction of labor, particularly those with no clinical contraindication and who have a reasonable chance of ending up with a successful noncomplicated vaginal delivery. Ultrasound has an established role in the various areas of obstetrical care. It is available, accessible, easy to perform, and acceptable to the patient. In addition, the learning curve for skillful obstetrical ultrasound scanning is rather easy to fulfill. Ultrasound has always had an important role in the assessment of maternal and fetal well-being. Indeed, it has been extensively explored as a reliable, reproducible, and objective tool in the management of labor. In this review, we aimed to provide a comprehensive update on the different applications and uses of ultrasound before induction of labor for the prediction of its success and the potential improvement of its health-related maternal and fetal outcomes.

Background: In women with a singleton pregnancy and sonographic short cervix in midgestation, vaginal administration of progesterone reduces the risk of early preterm birth and improves neonatal outcomes, without any demonstrable deleterious effects on childhood neurodevelopment. In women with twin pregnancies the rate of spontaneous early preterm birth is 10-times higher than in singletons and in this respect all twins are at increased risk of preterm birth. However, six trials in unselected twin pregnancies reported that vaginal progesterone from mid-gestation had no significant effect on the incidence of early preterm birth. Such apparent lack of effectiveness of progesterone in twins may be due to inadequate dosage or treatment which is started too late in pregnancy. Objective: The Early vaginal progesterone for the preVention of spontaneous prEterm birth iN TwinS: A randomized, placebo controlled, double-blinded trial (EVENTS) was designed to test the hypothesis that, among women with twin pregnancies, vaginal progesterone at a dose of 600 mg per day from 11-14 until 34 weeks’ gestation, as compared with placebo, would result in a significant reduction in the incidence of spontaneous preterm birth between 24+0 and 33+6 weeks. Methods: The trial was conducted at 22 hospitals in England, Spain, Bulgaria, Italy, Belgium and France. Women were randomly assigned in a 1:1 ratio, to receive either progesterone or placebo and in the random-sequence generation there was stratification according to participating center. Primary outcome was spontaneous birth between 24 +0 and 33+6 weeks’ gestation. Statistical analyses were performed on an intention-to-treat basis. Logistic regression analysis was used to determine the significance of difference in incidence of spontaneous birth between 24+0 and 33+6 weeks’ gestation between the progesterone and placebo groups, adjusting for the effect of participating centre, chrorionicity, parity and method of conception. Prespecified tests of treatment interaction effects with chrorionicity, parity, method of conception, compliance and cervical length at recruitment were performed. A post hoc analysis using mixed effects Cox regression was used for further exploration of the effect of progesterone on preterm birth. Results: We recruited 1,194 women between May 2017 and April 2019; 21 withdrew consent and 4 were lost to follow up, which left 582 in the progesterone group and 587 in the placebo group. Adherence was good, with reported intake of ≥80% of the required number of capsules in 81.4% of the participants. After excluding births before 24 weeks and indicated deliveries before 34 weeks, spontaneous birth between 24+0 and 33+6 weeks occurred in 10.4% (56/541) participants in the progesterone group and in 8.2% (44/538) in the placebo group (odds ratio in the progesterone group, adjusting for the effect of participating center, chrorionicity, parity and method of conception, 1.35; 95% CI 0.88 - 2.05; p=0.17). There was no evidence of interaction between the effects of treatment and chorionicity (p=0.28), parity (p=0.35) method of conception (p=0.56) and adherence (p=0.34); however, there was weak evidence of an interaction with cervical length (p=0.08) suggestive of harm to those with cervical length ≥30 mm (odds ratio 1.61, 95% CI 1.01-2.59) and potential benefit for those with cervical length

INTRODUCTION This study aimed to evaluate the quality of the brain volumes acquired following an evidence-based guideline for the acquisition of brain volumes. MATERIAL AND METHODS This was a prospective multicenter study. Five centers recruited five cases each, acquiring two volumes per case, at different gestational age ranges. From the collected volumes, 10 operators performed an advanced neurosonography of each case. The evaluable anatomic structures were counted in each volume and expressed as a percentage. The results were compared with those obtained in a previous study where no recommendations had been made for the acquisition of the volumes. RESULTS Five hundred evaluations were included in the study. In the axial plane, 91.5% of the structures were satisfactorily evaluated, 81.8% in the coronal plane and 89.9% in the sagittal plane. These results were significantly better than those obtained in a previous study where the volumes had been acquired without any guidelines and the percentage of evaluable structures were 80% (P

OBJECTIVE To examine the performance of screening for early, preterm and term pre-eclampsia (PE) at 11-13 weeks' gestation by maternal factors and combinations of mean arterial pressure (MAP), uterine artery (UtA) pulsatility index (PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A). METHODS The data for this study were derived from three previously reported prospective non-intervention screening studies at 11 + 0 to 13 + 6 weeks' gestation in a combined total of 61 174 singleton pregnancies, including 1770 (2.9%) that developed PE. Bayes' theorem was used to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics, with various combinations of biomarker multiples of the median (MoM) values to derive patient-specific risks of delivery with PE at

OBJECTIVES To examine the effect of first-trimester screening for pre-eclampsia (PE) on the prediction of delivering a small-for-gestational-age (SGA) neonate and the effect of prophylactic use of aspirin on the prevention of SGA. METHODS The data for this study were derived from two multicenter studies. In SPREE, we investigated the performance of screening for PE by a combination of maternal characteristics and biomarkers at 11-13 weeks' gestation. In ASPRE, women with a singleton pregnancy identified by combined screening as being at high risk for preterm PE (> 1 in 100) participated in a trial of aspirin (150 mg/day from 11-14 until 36 weeks' gestation) compared to placebo. In this study, we used the data from the ASPRE trial to estimate the effect of aspirin on the incidence of SGA with birth weight 1 in 100. RESULTS In SPREE, screening for preterm PE by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index and serum placental growth factor identified a high-risk group that contained about 46% of SGA neonates

Objective To examine the performance of screening for preterm and term pre-eclampsia (PE) in the study population participating in the ASPRE (Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention) trial. Methods This was a prospective first-trimester multicenter study on screening for preterm PE in 26 941 singleton pregnancies by means of an algorithm that combines maternal factors, mean arterial pressure, uterine artery pulsatility index and maternal serum pregnancy-associated plasma protein-A and placental growth factor at 11–13 weeks' gestation. Eligible women with an estimated risk for preterm PE of > 1 in 100 were invited to participate in a double-blind trial of aspirin (150 mg per day) vs placebo from 11–14 until 36 weeks' gestation, which showed that, in the aspirin group, the incidence of preterm PE was reduced by 62%. In the screened population, the detection rates (DRs) and false-positive rates (FPRs) for delivery with PE

Objective To investigate fetal-survival rates following laser surgery for twin-to-twin transfusion syndrome (TTTS) and the impact of Doppler analysis. Methods The present retrospective single-center study included data from patients with pregnancies exhibiting TTTS treated with fetoscopic laser surgery between January 1, 2007, and December 31, 2016. Perinatal outcomes were examined and variables were compared between the donor and recipient fetuses that survived and died, respectively. Results There were 86 pregnancies exhibiting TTTS treated with fetoscopic laser surgery included in the study. The median length of pregnancy at the time of surgery was 21.1 weeks. Both twin fetuses and at least one fetus survived in 61 (71%) and 73 (85%) pregnancies, respectively. Among recipient fetuses, ductus venosus a-wave anomalies (P=0.026), shorter cervical length (P=0.044), and a greater than 25% discrepancy in the estimated weight of the twin fetuses (P=0.045) were associated with reduced survival. Conclusion Among pregnancies exhibiting TTTS, laser surgery was associated with significant dual-fetus survival. Preoperative ductus venosus anomalies were associated with lower survival among recipient fetuses, and 1-week postsurgical ultrasonography data demonstrated lower survival among recipient fetuses with persistent anomalous ductus venosus compared with normalized ductus venosus. This article is protected by copyright. All rights reserved.

Transient or acoustic radiation force elastography (ARFE) is becoming the most extended technology to assess cervical effacement, additionally to the Bishop test and conventional ultrasound. However, a debate on the fetal safety has been opened due to the high intensity focused beam emitted to produce shear waves. This work is aimed at providing preliminary data to assess clinical effects of fetal exposure. A follow-up study in newborns of 42 women exposed to ARFE during pregnancy was carried out to explore neonatal hypoacusia, Apgar test, and anthropometry. No hypoacusia cases attributable to ARFE were observed. The Apgar test at five minutes scored normally in all the newborns. Comparisons between anthropometric measurements showed no significant statistically differences. The results preclude to state the harmfulness nor the safety of ARFE. However, given the concern on the high level of energy and the potential risk of harmful bioeffects, larger studies are recommended., Ministry of Education DPI2017-85359-R UNGR15-CE-3664 PI16/00339, Carlos III Feder fund, Junta de Andalucía PIN-0030-2017 PI-0107-2017, Spanish Government TEC2014-57394-P, MNat Scientific Unit of Excellence UCE.PP2017.03

Objective to evaluate the acquisition-related factors influencing the quality of the brain volumes for further study of advanced neurosonography. Methods This was a prospective multicentre study. Five centres were asked to include five cases each, acquiring two volumes per case, at different gestational ages. Ten operators performed an advanced neurosonography per case. The potential influence of the following factors on the number of evaluable structures was assessed: vaginal/ abdominal acquisition, position of the head, gestational age, subjective quality of the volume, and the acquiring operator itself. Results Four hundred and thirty-two evaluations were included in the study. 80% of the structures were evaluated satisfactorily in the axial plane, 67.1% and 55.1% in the coronal and sagittal plane respectively. Sagittal volumes acquired transvaginally had a better quality than those acquired transabdominally. Gestational age affected the quality of axial and sagittal volumes (p

Objective To compare the incidence of twin-to-twin transfusion syndrome (TTTS) in spontaneous versus IVF-conceived twin pregnancies. Design Retrospective multicenter study. Setting University-affiliated tertiary medical centers. Patient(s) Women admitted for 11–14 week's scan between January 1997 and July 2013 who were diagnosed with monochorionic (MC) diamniotic twin pregnancies. Intervention(s) None. Main Outcome Measure(s) Mode of conception, TTTS. Result(s) The study cohort included 327 pregnant women with live MC diamniotic twins. Of them, 284 (86.9%) and 43 (13.1%) were spontaneous and IVF conceived, respectively. The mean maternal age was significantly higher in IVF compared with in spontaneously conceived pregnancies (33.8 ± 5.5 vs. 31.6 ± 5.4, respectively). Thirty-seven twins (11.3%) had TTTS, of whom 36/284 (12.7%) versus 1/43 (2.3%) were spontaneously and IVF conceived, respectively. The mean week of delivery was significantly lower in MC twins diagnosed with TTTS compared with those without TTTS (32.7 ± 3.3 vs. 35.5 ± 2.5, respectively). Furthermore, there was a significantly higher birthweight discordancy in twins diagnosed with TTTS compared with those without (20.6% vs. 11%, respectively). Conclusion(s) The significantly lower proportion of TTTS found in IVF-conceived twins may suggest a different embryological process that lies at the core of IVF conception of monozygotic twinning.

BackgroundPreeclampsia is a major pregnancy complication with adverse short- and long-term implications for both the mother and baby. Screening for preeclampsia at 11-13 weeks’ gestation by a combination of maternal demographic characteristics and medical history with measurements of biomarkers can identify about 75% of women that develop preterm-preeclampsia with delivery at ObjectiveTo examine the effect of prophylactic use of aspirin during pregnancy in women at high-risk of preeclampsia on length of stay in the neonatal intensive care unit.Study designThis was a secondary analysis of data from the Aspirin for Evidence-Based Preeclampsia Prevention trial to assess evidence of differences in the effect of aspirin on length of stay in neonatal intensive care. Bootstrapping was used for the comparison of mean length of stay between the aspirin and placebo groups. Logistic-regression was used to assess treatment effects on stay in the neonatal intensive care unit.ResultsIn the trial there were 1620 participants and 1571 neonates were liveborn. The total length of stay in neonatal intensive care was substantially longer in the placebo than aspirin group (1696 vs. 531 days). This is a reflection of significantly shorter mean lengths of stay in babies admitted to the neonatal intensive care unit from the aspirin than the placebo group (11.1 vs. 31.4 days; a reduction of 20.3 days (95% confidence interval, 7.0-38.6; p=0.008). Neonatal intensive care of babies born at ConclusionsIn pregnancies at high-risk of preeclampsia administration of aspirin reduces the length of stay in the neonatal intensive care unit by about 70%. This reduction could essentially be attributed to a decrease in the rate of births at

Since 1979, multiple studies have shown that low-dose aspirin in pregnancy can lower the occurrence of preeclampsia. Subsequent studies have shown that doses greater than 100 mg/d started before 16 weeks of gestation are most effective. Another recent study found that screening pregnant women for preeclampsia risk based on a combination of maternal factors and biochemical and physical measurements early in pregnancy could identify heightened risk of preeclampsia twice as well as predicting risk based on history alone. In this trial (the CombinedMultimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-based Preeclampsia Prevention [ASPRE trial]), women identified as being at high risk of developing preeclampsia were treated with daily low-dose aspirin and compared with women who were treated with placebo. A double-blind randomized controlled trial was performed to assess the impact of 150 mg of aspirin daily from 11 to 14 weeks until 36 weeks of pregnancy in a group of women who were screened and found to be at high risk of preeclampsia. A total of 1776 women with singleton pregnancies were enrolled in the trial, which was analyzed on an intention-to-treat basis. After some women dropped out of the trial and some were lost to follow-up, there remained 822 participants in the placebo group and 798 in the aspirin group. Of these participants, 4.3% of the placebo group and 1.6% of the aspirin group developed preeclampsia before 37 weeks' gestation (odds ratio in the aspirin group, 0.38; 95% confidence interval, 0.20-0.74; P = 0.004). The occurrence of adverse outcomes such as miscarriage or stillbirth was not significantly different between the 2 groups. Sensitivity analyses showed that these results were not affected by the enrollees who dropped out of the trial by either choice or loss at follow-up. Compliance of participants was good, with nearly 80% taking 85% of their required aspirin doses. This study confirmed that a regimen of low-dose aspirin (150 mg/d) during pregnancy can lower the occurrence of preeclampsia in susceptible populations. In this trial, preeclampsia was reduced by more than half in women taking aspirin as compared with those taking a placebo.

There is a challenge in characterizing the soft tissue mechanical functionality in cylindrical geometries by current elastography techniques applied to small organs. Torsional waves are a type of shear elastic waves that propagate through soft tissue radially and in depth in a curled geometry, ideally suited to explore structures such as the cervix. Here, a sensor based on a novel arrangement of concentric sandwiches of piezo- and electromechanical elements is prototyped and tested to quantitatively assess stiffness in human cervix. The purpose is to determine the robustness of a torsional wave elastography (TWE) sensor prototype to quantify cervical stiffness, as a first step to validate a reliable measurement protocol using TWE. An array of tests designed to validate a set of hypothesis about the contact conditions were performed on up to 3 different nonpregnant voluntary women. The mechanical properties were reconstructed from the recorded TWE signals, and the outcomes were statistically analyzed to validate the contact condition hypothesis. The results suggest that, although future tests need to be performed to fully assess the repeatability and quality of the measurements, some characteristics of the measurement protocol become clear; in particular: (1) the use of speculum is recommended since it not only stabilizes the measurements, but also corrects and stabilizes the orientation of the cervical neck, and allows to visually verify the positioning and alignment of the probe, while not significantly increasing discomfort to women during this test; (2) the use of lubricant gel has no significant effect on the measurement quality; (3) 1cm off-centering from external cervical os is not acceptable; (4) a range of applied force between 500-2000 N does not significantly vary measurement signal quality, but the reconstructed value of the shear modulus does vary, probably due to its constitutive nonlinearity; (5) breathing movements affects measurements, but short duration of TWE pulse (0.3 s) allows to take measurements in apnea.

Objective To examine the diagnostic accuracy of a previously developed model for prediction of pre-eclampsia (PE) by a combination of maternal factors and biomarkers at 11–13 weeks' gestation. Methods This was a prospective first-trimester multicenter study of screening for PE in 8775 singleton pregnancies. A previously published algorithm was used for the calculation of patient-specific risk of PE in each individual. The detection rates (DRs) and false-positive rates (FPRs) for delivery with PE

Objective Elastography is a valuable promising tool to provide additional information on the process of cervical effacement to that obtained from digital examination and conventional ultrasound. Among the different techniques, transient, or acoustic radiation force elastography (ARFE) is becoming the most common commercial elastography technique. However, the high intensity focussed beam that ARFE emits to generate the shear waves has raised some concerns about its safety during pregnancy. Here, we open a debate to assess the safety of this type of elastography, and in particular provide preliminary follow-up observations of cochlear damage in exposed foetus. The purpose of this work is to explore the teratogenous effect of ARFE, through a follow-up study to assess the prevalence of hypoacusia and other disorders on exposed children during fetal period. Methods In a previous study, we used elastography technique to quantify the cervical stiffness on a total of 42 pregnant women. Four years later, a follow-up study of born children was performed, focused on the outcomes of the neonatal hypoacusia screening test and other medical records. The exposed population was compared to the reference population through a contingency table with Chi-square test and p-value. Results: Although no hypoacusia cases were observed, the sample size provides no statistically significance (p-value = 0.538). Conclusion The results allow neither to conclude the harmfulness nor the safety of fetal exposure to ARFE. Given the sample size limitation and the recent concerns about the high intensity pulses required for acoustic radiation force, we suggest initiating a discussion and further studies with a larger sample are needed.

Resumen La realizacion temprana en el primer trimestre de la gestacion de un test de cribado combinado de parto pretermino y la instauracion temprana de estrategias preventivas en los pacientes de alto riesgo pueden disminuir mas eficazmente las tasas de parto pretermino. En este articulo de revision, repasamos las distintas variables maternas, gestacionales, marcadores ecograficos, bioquimicos y los modelos predictivos publicados hasta la fecha para el cribado de parto pretermino en el primer trimestre de la gestacion.

Objectives: To describe the results of a technique of laser ablation of placental vessels in the treatment of severe twin-twin transfusion syndrome (TTTS), which is characterized by separation of the fetoplacental vascular territories and dichorionization of the placenta. Patients and Methods: Descriptive analysis of TTTS cases treated with the endoscopic laser dichorionization of the placenta (ELDP) procedure. The variables evaluated were the occurrence of reversal of the donor-recipient phenotype, persistence of TTTS or twin anemia-polycythemia sequence (TAPS); gestational age at delivery; discharge from the hospital of at least 1 or 2 live neonates, and incidence of neurological alterations among survivors. Results: 67 patients were treated with the ELDP procedure. There was no persistence of TTTS, reversal of the donor-recipient phenotype or TAPS. The median gestational age at delivery was 33.0 (23.6-37.7) weeks. The rate of discharge from the hospital of at least 1 or 2 live neonates was 88.2% (67/76) and 71.1% (54/76), respectively. Among survivors, 17 (17/121 = 14.0%) children presented with neurodevelopmental alterations during clinical follow-up. Conclusions: The major contribution of this study was the demonstration that the ELDP technique appears to be associated with a low risk of persistence or recurrence of TTTS and TAPS.

A sensor based on torsional waves is proposed, designed and validated to quantify elastic constants of soft tissue. The proposed transducer design is able to deploy a shear wave elastography technique that accurately quantifies the shear viscoelastic moduli of the tissue, which, as opposed to compression waves, are strongly dependent on the stroma architecture, thus serving as a new biomarker.

To evaluate the acquisition-related factors influencing the quality of the brain volumes for further study of advanced neurosonography.This was a prospective multicentre study. Five centres were asked to include five cases each, acquiring two volumes per case, at different gestational ages. Ten operators performed an advanced neurosonography per case. The potential influence of the following factors on the number of evaluable structures was assessed: vaginal/ abdominal acquisition, position of the head, gestational age, subjective quality of the volume and the acquiring operator itself.Four hundred and thirty-two evaluations were included in the study. A total of 80% of the structures were evaluated satisfactorily in the axial plane, 67.1% and 55.1% in the coronal and sagittal plane, respectively. Sagittal volumes acquired transvaginally had a better quality than those acquired transabdominally. Gestational age affected the quality of axial and sagittal volumes (p 0.001), and the best quality was obtained between 20 and 27 weeks. In axial and sagittal volumes, the head position influenced the percentage of structures visualized (p 0.001, p 0.001).Factors affecting the quality of the volume for advanced neurosonography are gestational age, fetal head position, transvaginal acquisition in sagittal volumes, the acquiring operator and the subjective quality of the volume. © 2016 John WileySons, Ltd.

Resumen La secuencia de perfusion arterial reversa (twin reversed arterial perfusion [TRAP]) es una rara complicacion exclusiva de las gestaciones multiples monocoriales. Se caracteriza por la presencia de un feto malformado que tiene un corazon rudimentario o ausente, y no tiene perfusion directa placentaria, sino que esta le llega a traves de una comunicacion arterio-arterial (A-A) desde el co-gemelo estructuralmente normal (o feto bomba) y luego doblemente desoxigenada tras perfundir al acardio, retorna al feto bomba por una conexion veno-venosa (V-V). La historia natural de la enfermedad es la muerte por fallo cardiaco del gemelo bomba en un 35-55% de los casos. El proposito de este articulo es revisar tanto los aspectos basicos como el estado actual de esta condicion, incidiendo principalmente en el diagnostico, en las opciones de manejo, alternativas de tratamiento invasivo prenatal, y ofrecer la revision de nuestra experiencia.

Resumen El hidrotorax fetal es una condicion rara con una incidencia reportada de uno en cada 10.000-15.000 embarazos, y consiste en una acumulacion severa de liquido en el espacio pleural. En la ecografia prenatal el derrame pleural se aprecia como un area anecoica uni- o bilateral en el torax que rodea los pulmones fetales. La evolucion varia desde su resolucion espontanea hasta su aumento progresivo y el posterior desarrollo de hidrops fetal y polihidramnios con un alto riesgo de parto pretermino y muerte intrauterina o neonatal debido a que el efecto masa que produce puede causar hipoplasia pulmonar. El enfoque optimo del manejo prenatal esta todavia en debate ya que el curso natural de la enfermedad puede variar, pero es una condicion seria con tasas de morbimortalidad elevadas y la terapia prenatal puede estar indicada en casos seleccionados. El proposito de este articulo es revisar tanto los aspectos basicos como el estado actual de esta condicion, incidiendo principalmente en el diagnostico, opciones de manejo, alternativas de tratamiento invasivo prenatal, y ofrecer la revision de nuestra experiencia.

Objective To evaluate a novel ultrasound measurement, the prefrontal space ratio (PFSR), in second-trimester trisomy 21 and euploid fetuses. Methods Stored three-dimensional volumes of fetal profiles from 26 trisomy 21 fetuses and 90 euploid fetuses at 15–25 weeks’ gestation were examined. A line was drawn between the leading edge of the mandible and the maxilla (MM line) and extended in front of the forehead. The ratio of the distance between the leading edge of the skull and that of the skin (d1) to the distance between the skin and the point where the MM line was intercepted (d2) was calculated (d2/d1). The distributions of PFSR in trisomy 21 and euploid fetuses were compared, and the relationship with gestational age in each group was evaluated by Spearman’s rank correlation coefficient (rs). Results The PFSR in trisomy 21 fetuses (mean, 0.36; range, 0–0.81) was significantly lower than in euploid fetuses (mean, 1.48; range, 0.85–2.95; P < 0.001 (Mann–Whitney U-test)). There was no significant association between PFSR and gestational age in either trisomy 21 (rs = 0.25; 95% CI, −0.15 to 0.58) or euploid (rs = 0.06; 95% CI, −0.15 to 0.27) fetuses. Conclusion The PFSR appears to be a highly sensitive and specific marker of trisomy 21 in the second trimester of pregnancy. Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.

Objectives: To determine the outcome of twin reversed arterial perfusion (TRAP) sequence treated with or scheduled for treatment with interstitial laser therapy. Methods: This is a retrospective study on ten pregnancies diagnosed with TRAP sequence. Seven of the ten pregnancies were treated with interstitial laser therapy, and two pregnancies were scheduled for later treatment. One pregnancy was treated with fetoscopic laser ablation and excluded from analysis. The delivery reports of all pregnancies were collected, the neonatal health status recorded and the median time of delivery and the treatment to delivery interval calculated. Results: Six of seven pump fetuses in TRAP pregnancies treated with interstitial laser therapy at a median of 16+2 (range 13+1 to 20+3) gestational weeks were born healthy at a median of 38+0 (range 34+3 to 40+6) gestational weeks. One fetus treated with interstitial laser died after the procedure at 20+3 weeks. Two pump twins scheduled for later treatment died before the gestational age of 16 weeks. The median treatment to delivery interval for the surviving fetuses was 153 days (range 128-194). Conclusion: Treatment of TRAP sequence by interstitial laser therapy is feasible from the 13th week of gestation and has a good outcome.

The WHO estimates that 15 million babies yearly (1 in 10) will be born preterm. Worldwide, complications of preterm births have supplanted pneumonia as the primary cause of child mortality [1]. The biology of cervical ripening that leads to birth is poorly understood, and there is no clinical tool to quantitatively evaluate the cervical biomechanical state, which in words of Feltovich [2]“… likely contributes to the reason the singleton spontaneous preterm birth rate has not changed appreciably in more than 100 years.” Towards this problem, we work on enabling new sensor technologies sentient to soft tissue biomechanics, to endow a new class of biomarkers that quantify the mechanical functionality of the cervix, and indeed any soft tissue, ranging pathologies from tumors, atherosclerosis, liver fibrosis to osteoarticular syndromes. Ultrasonic characterization of soft tissue has been developed as a clinical diagnostic tool [3] and evolved through different technologies including our torsional wave principle [4]. Our recent advances covering (a) torsional waves (shear elastic waves that propagate in quasifluids radially and in depth in a curled geometry), (b) sensors (based on a novel arrangement of concentric sandwiches of elements), (c) propagation models and (d) patient testing, are allowing to quantify the mechanical functionality beyond linear parameters: dispersive and nonlinear. [1] WHO, 2012; [2] Feltovich. AJOG207(2012):345–354 [3] Barr. Ultras Quart28(2012):13–20; [4] Melchor. Ultrasonics, 54(2014):1950–1962.

Objetive: Evaluate the intrauterine blood transfusions performed in fetuses with anemia due to red blood cell alloimmunization in our unit and the detection rate of the middle cerebral artery Doppler to predict anemia after the first transfusion. Material and methods: We performed 53 intrauterine blood transfusions in 15 patients with red blood cell alloimmunization. We analyze the characteristics of the cases and the value of the middle cerebral artery Doppler to predict fetal anemia. Results: The detection rate of fetal anemia with the peak systolic velocity Doppler in the middle cerebral artery was 85% after the first transfusion and 72% after the second or more. There were no false positive results of the test in our series.

Resumen Objetivo Evaluar los resultados obtenidos en el tratamiento de gestaciones monocoriales biamnioticas complicadas con sindrome de transfusion feto-fetal (STFF) grave o crecimiento intrauterino retardado (CIR) selectivo mediante la fotocoagulacion laser de las anastomosis vasculares placentarias. Material y metodos Se realizo esa terapia en 22 gestaciones, 17 por STFF severo y 5 por CIR selectivo. Se analizan la gravedad de los casos antes de la cirugia, las complicaciones obstetricas y la supervivencia fetal. Resultados Hubo 17 casos de STFF grave; en 15 (88%) de ellos sobrevivio al menos uno de los gemelos. En los 5 casos por CIR selectivo, el feto con crecimiento normal vivio en 3 casos, incluido uno donde el feto con CIR tambien vivio. Conclusiones Los resultados muestran la implementacion exitosa de la cirugia laser endoscopica en una de las unidades de referencia de medicina fetal de Espana tras un entrenamiento apropiado del operador.

Purpose To explore the feasibility of transient elastography (TE) to quantify cervical stiffness changes during normal pregnancy and its spatial variability. Materials and Methods TE was used to quantify the cervical stiffness in four anatomical regions. 42 women between 17 and 43 years of age and at 6 – 41 weeks of gestation were studied. The stiffness was related to gestational age at the time of examination, interval from ultrasound examination to delivery and cervical length to evaluate the potential of TE to assess cervical ripening. In addition, a sensitivity analysis based on Cronbach’s alpha coefficient was carried out to assess the concordance between inter/intra-operator measurements. Results There were significant correlations between cervical stiffness measured in the four regions with gestational age and the remaining time for delivery. Results confirm stiffness variability within the cervix. No significant association was found between cervical length and stiffness in the four ROIs. Associations between gestational age and remaining time for delivery with cervical length present weaker correlations than with cervical stiffness. The external part of the cervix was significantly softer than the internal one, and these stiffness values vary significantly in the anterior compared to the posterior cervix. The measurements taken by the same and by two different observers for different regions in the cervix were reliable and reproducible. Conclusion It is feasible to objectively quantify the decrease of cervical stiffness correlated to gestational age. Transient elastography is a valuable promising tool to provide additional information on the process of cervical effacement to that obtained from digital examination and conventional ultrasound. Further studies are needed to assess the feasibility of the technique in obstetric clinical applications, such as prediction of preterm birth or success in labor induction.

Capítulo de libro sobre el uso de la ecografía y la elastografía como valor pronóstico antes de una induccion de parto y el uso de la ecografía intraparto para la valoracion objetiva de la progresión de la presentación fetal, decidir la via de parto en fase de expulsivo y el tipo de parto instrumental si se precisa.

Capítulo de libro sobre el uso de la ecografía y la elastografía como valor pronóstico antes de una induccion de parto y el uso de la ecografía intraparto para la valoracion objetiva de la progresión de la presentación fetal, decidir la via de parto en fase de expulsivo y el tipo de parto instrumental si se precisa.

First-trimester estimates of 2 biomarkers of placental origin, pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG), are increasingly used along with ultrasound measurement of nuchal translucency thickness to screen for trisomy 21 and other aneuploidies. There are preliminary indications that reduced levels of these markers-especially PAPP-A-may help to identify at-risk pregnancies including those resulting in delivery of a small-for-gestational age (SGA) infant. The study population included singleton pregnancies with chromosomally normal fetuses that were screened at 11 to 14 weeks' gestation. Biochemical marker levels were converted to multiples of the expected normal median (MoM) for a pregnancy of the same gestational age. Associations between levels of free β-hCG and PAPP-A and the incidence of SGA were assessed by comparing relative incidence rates at MoM cutoffs and birth weight centile cutoffs. A total of 46,262 pregnancies resulted in live births of infants weighing at or above the 10th centile, whereas 3539 others produced SGA infants weighing less than the 10th centile for gestation. The risk of an SGA infant was significantly and inversely associated with maternal serum PAPP-A MoM, but not with free β-hCG MoM. In pregnancies with PAPP-A levels below the 10th, 5th, and 3rd percentile, the incidence of SGA was 12%, 14%, and 16%, respectively, and the odds ratios for SGA were 2.70, 3.21, and 3.66, respectively. Free β-hCG levels did not predict SGA. The investigators believe that, in the presence of a normal fetal karyotype, low maternal serum levels of PAPP-A are associated with an elevated risk of subsequently delivering a SGA infant. Low levels presumably indicate impaired placentation. Present evidence warrants using low PAPP-A to help identify SGA pregnancies.

We are currently witnessing a change in obstetrics. For more than 10 years, obstetric sonography has been the main diagnostic tool available to specialists. Currently, the prediction of conditions such as preeclampsia, preterm labor, or placental insufficiency within the context of intrauterine growth restriction is based on ultrasound use. It is logical to hypothesize that sonography could play a significant, expanded role in labor management and assistance, particularly in situations that require quick obstetric decisions based on clinical explorations that are subjective and have a considerable learning curve.

A simple and specific method was developed for the determination of sulfite in rainwater based on solid-phase spectrophotometry (SPS). Rainwater was collected on morpholine, sulfite was stabilized by forming an adduct that reacted with pararosanil-ine and formaldehyde, and the reaction product was fixed on Dowex 1-X8 resin. The absorbance of the solid phase was measured directly at 565 and 700 nm. The calibration curve was linear in the concentration range of 1-50 μg/L in solution (relative standard deviation = 1.7%); the International Union of Pure and Applied Chemistry detection limit was 0.8 μg/L. In simulated rainwater, the values of the calibration curve slopes were similar to that of the standard calibration curve slope, and recoveries for 40-497 μg/L sulfite ranged from 97 to 105%. Linearity, analytical sensitivity, and precision were better for the SPS method than the solution method, and the detection and quantitation limit values were lower for the SPS method than the solution method based on the similar reaction. The SPS method was subsequently used to determine sulfite in real rainwater.

Resumen Las anomalias cromosomicas son una causa importante de muerte perinatal y discapacidad en la infancia. Entre ellas, la que de forma mas comun es causa de discapacidad a largo plazo es el sindrome de Down. Su diagnostico es la indicacion mas habitual durante el embarazo para realizar procedimientos invasivos (biopsia corial, amniocentesis) con una tasa de aborto del 1%. Durante el embarazo se pueden ofrecer distintos test de cribado de sindrome de Down. Los avances en los ultimos 40 anos nos han demostrado pautas mas eficaces que la edad materna para seleccionar a las pacientes susceptibles de riesgo de esta cromosomopatia. Esto no solo ha aumentado las tasas de deteccion de esta, sino que ademas ha reducido las tasas de falsos positivos del test, y por tanto han disminuido los procedimientos invasivos innecesarios y las tasas de abortos iatrogenicos. En esta revision se aportan evicencias de los distintos test de cribado ofrecidos durante el embazo, la forma de combinar la informacion de estos y la actitud de las embarazadas ante los resultados.

Objective To evaluate detection and false-positive rates of the ultrasound markers—nasal bone (NB), ductus venosus (DV) flow and tricuspid regurgitation (TR)—during the first trimester in a population at high genetic risk, and to study the influence of a two-stage screening policy alter previous combined screening on the rate of invasive procedures. Methods A total of 333 chorionic villus samples were obtained in singleton pregnancies. Before biopsy, the ultrasound markers—NB, DV, and TR—were assessed, although the findings were not used to recalculate the previously determined risk for Down syndrome. Results Detection and false-positive rates for Down syndrome were 63.2% and 3.4% for NB, 65% and 3.1% for DV, and 50% and 2.1% for TR. All three markers were normal in 30% [84/277, 95% confidence interval (CI) 25%–36%] of chorionic villus sampling (CVS) cases performed for abnormal findings at the first trimester genetic screen, with 0% (0/20, 95% CI 0%–17%) false-negative rate for Down syndrome. Conclusion Assessment of secondary ultrasound markers is feasible in clinical practice and their use could reduce the number of unnecessary invasive procedures by 30%. Copyright © 2010 John Wiley & Sons, Ltd.

We report a case of fetal goiter in a pregnant woman with Graves-Basedow disease. It was diagnosed in the third trimester by a routine ultrasound, and the cordocentesis verified increased levels of thyroxine (T4) and increased autoantibodies (antithyroperoxidase antibodies) that were also increased in maternal blood. Fetal goiter got smaller on the follow-up scans, and the newborn presented hypothyroidism. Current notions on the diagnosis and management of fetal goiter are briefly discussed.

Ultrasound may play an important role in the management of labor and delivery. Induction of labor is a common obstetric intervention, performed in about 20% of pregnancies. Pre-induction cervical length, measured by transvaginal sonography, has been shown to have a significant association with the induction-to-delivery interval and the risk for cesarean section. In the management of labor there is extensive evidence that digital pelvic examination does not provide accurate assessment of the position and descend of the fetal head both during the first but also in the second stage of labor. Several recent studies using both two- and three-dimensional ultrasound have now described objective measures of progression of the fetal head during labor. In instrumental deliveries an important determinant of a successful and safe use of vacuum and forceps is the correct determination of the fetal head position and appropriate application of the instrument. However, ultrasound studies have shown that digital examination before instrumental delivery fails to identify the correct fetal position in a high proportion of cases. The use of ultrasound is of crucial importance in performing a safe operative delivery and can help in the prediction of whether a vaginal delivery would be successful.

Objective To investigate an approach for the analysis of samples obtained in screening for trisomy 21 that retains the advantages of quantitative fluorescent polymerase chain reaction (qf-PCR) over full karyotyping and maximises the detection of clinically significant abnormalities. Design Observational study. Setting Tertiary referral centre. Subjects 17 446 pregnancies, from which chorionic villous samples had been taken after assessment of risk for trisomy 21 by measurement of fetal nuchal translucency (NT) thickness at 11 to 13+6 weeks of gestation. Interventions Analysis of chorionic villous samples by full karyotyping and by qf-PCR for chromosomes 13, 18, 21 X and Y. Main outcome measure Detection of clinically significant chromosomal abnormalities. Results The fetal karyotype was normal in 15 548 (89.1%) cases and abnormal in 1898 (10.9%) cases, including 1722 with a likely clinically significant adverse outcome. Karyotyping all cases would lead to the diagnosis of all clinically significant abnormalities, and a policy of relying entirely on qf-PCR would lead to the diagnosis of 97.9% of abnormalities. An alternative strategy whereby qf-PCR is the main method of analysis and full karyotyping is reserved for those cases with a minimum fetal NT thickness of 4 mm would require full karyotyping in 10.1% of the cases, would identify 99.0% of the significant abnormalities, and would cost 60% less than full karyotyping for all. Conclusions In the diagnosis of chromosomal abnormalities after first trimester screening for trisomy 21, a policy of qf-PCR for all samples and karyotyping only if the fetal NT thickness is increased would reduce the economic costs, provide rapid delivery of results, and identify 99% of the clinically significant chromosomal abnormalities.

Objective To examine the prevalence and distribution of all chromosomal defects in fetuses with increased nuchal translucency thickness. Methods Assessment of risk for trisomy 21 was carried out by a combination of maternal age and fetal nuchal translucency thickness at 11-13 + 6 weeks. A search of the database was made to identify, first, all singleton pregnancies in which fetal karyotyping was carried out and, second, the cases where the fetal nuchal translucency was equal to or above the 95th centile for fetal crown-rump length. The prevalence and distribution of chromosomal defects were determined for each nuchal translucency category: between the 95th centile for crown-rump length and 3.4 mm, 3.5-4.4 mm, 4.5-5.4 mm, 5.5-6.4 mm, 6.5-7.4 mm, 7.5-8.4 mm, 8.5-9.4 mm, 9.5-10.4 mm, 10.5-11.4 mm, and 11.5 mm or more. Results The search identified 11,315 pregnancies. The median maternal age was 34.5 (range 15-50) years, and the median fetal crown-rump length was 64 (range 45-84) mm. The fetal karyotype was abnormal in 2,168 (19.2%) pregnancies, and the incidence of chromosomal defects increased with nuchal translucency thickness from approximately 7% for those with nuchal translucency between the 95th centile for crown-rump length and 3.4 mm to 75% for nuchal translucency of 8.5 mm or more. In the majority of fetuses with trisomy 21, the nuchal translucency thickness was less then 4.5 mm, whereas in the majority of fetuses with trisomies 13 or 18 it was 4.5-8.4 mm, and in those with Turner syndrome it was 8.5 mm or more. Conclusion In fetuses with increased nuchal translucency, approximately one half of the chromosomally abnormal group is affected by defects other than trisomy 21. The distribution of nuchal translucency is different for each type of chromosomal defect. Level of evidence II-3.

In pregnancies complicated by fetal trisomy 21, maternal serum levels of free-human chorionic gonadotropin (free β-hCG) are about twice as high as in pregnancies with a euploid fetus, while levels of pregnancy-associated plasma protein-A (PAPP-A) are reduced by about half. Screening for trisomy 21 using these markers in addition to fetal nuchal translucency thickness has been reported to detect about 90% of affected pregnancies at a false-positive rate of 5%. However, currently the only variables for which adjustments are made are maternal weight and gestational age. To determine if other maternal variables influence screening test results, the present multicenter trial prospectively screened women in the first-trimester of pregnancy for trisomy 21, using multiple regression analysis to learn how maternal factors, particularly ethnic origin, influenced measured levels of β-hCG and PAPP-A. Gaussian distributions were fitted to the distribution of log multiples of the median values in 491 cases of trisomy 21 and 96,803 euploid pregnancies. Compared with Caucasian women who were parous, nonsmokers, and conceived spontaneously, PAPP-A levels were 57% higher in women of Afro-Caribbean origin, 3% higher in South Asians, 9% higher in East Asians, 2% higher in nulliparous women, 17% lower in smokers, and 10% lower in women who conceived by in vitro fertilization (IVF). Maternal serum levels of free β-hCG were 12% higher in women of Afro-Caribbean origin, 9% lower in South Asian women, 8% higher in East Asians, 2% higher in nulliparous women, 4% lower in smokers, and 9% higher in women who conceived by IVF. If no adjustments were made for variables other than maternal age and gestational age, integrated first-trimester screening based on maternal age-related risk and serum PAPP-A and free β-hCG levels resulted in the detection of 51% of all cases of trisomy at a false-positive rate of 1.4% in Afro-Carribean women; after adjustment for race, the detection increased to 68% at a false-positive rate of 4.6%. Similar changes in the detection and false-positive rates occurred after adjustment for smoking, conception by IVF, and parity. In addition, screening was considerably more sensitive when carried out at 11-12 weeks' gestation rather than at 13 weeks. These results indicate that numerous maternal and pregnancy-related factors must be taken into account when screening in the first-trimester of pregnancy for trisomy 21.

A multi-scale constitutive model for the nonpregnant cervical tissue is presented. The mechanical response of the cervix is described by a model which takes into account material properties at different structural hierarchies of tissue through a multi-scale coupling scheme. The model introduces the deformation mechanisms of collagen fibrils at the nanoscale into a macroscopic description of the mechanical behavior of tissue continuum. The composition of soft tissues like cervical tissue consists of a distribution of cells embedded in an extracellular matrix (ECM). The microstructure of cervical ECM is composed of dense, hydrated and highly cross-linked collagen network embedded in a viscous proteoglycan ground substance. The mechanical behavior of cervix can be largely due to different constituents of its extracellular matrix, and the collagen fibers are the major responsible for its mechanical strength [M. House, 2009]. So the proposed model considers the stroma as the maximum responsible for the mechanical strength of the cervix.

A solid-phase spectrophotometric method for the determination of sulphite and its application to the determination of atmospheric sulphur dioxide is described. In this method, sulphur dioxide is trapped with morpholine to form an adduct which reacts with pararosaniline and formaldehyde, and the reaction product is sorbed on Dowex 1-X8 resin. The absorbance of the resin phase at 565 and 700 nm is measured directly, allowing for the determination of sulphur dioxide in the range 4–56 µg l–1 in solution, with a relative standard deviation of 2.1%. The method was applied to the determination of sulphur dioxide in air samples from laboratory emissions.