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Objectives: To evaluate the agreement between multiplanar and Virtual Organ Computer-aided AnaLysis (VOCAL()) techniques for the measurement of total fetal thigh volume and to assess the repeatability and reproducibility of measurements performed using these methods; to derive birth weight-predicting models for both methods and to compare their accuracies. Methods: This was a cross-sectional study of 150 singleton pregnancies at 30-42 weeks of gestation in which ultrasound volumes of the fetal thigh were obtained within 48 hours of delivery and measured using multiplanar and VOCAL techniques. Bland-Altman analyses were performed to determine the agreement between the two methods, and to evaluate intraobserver and interobserver variability in a subset of 40 patients. Birth weight-predicting models were derived using total fetal thigh volumes obtained using the VOCAL (ThiV) and multiplanar (ThiM) methods as independent variables. The accuracies of these formulas were compared. Results: The mean percentage difference between measurements performed using the VOCAL technique and the multiplanar technique was -0.04 and the 95% limits of agreement were -8.17 and 8.09. The mean percentage difference and 95% limits of agreement between paired measurements in the assessment of intraobserver and interobserver variability were -1.10 (-7.67 to 5.47) and 0.61 (-7.68 to 8.91) for the VOCAL technique and 1.03 (-6.35 to 8.41) and -0.68 (-11.42 to 10.06) for the multiplanar method, respectively. The best-fit formulas for predicting birth weight (BW) were: BW = 1025.383 + 12.775x ThiV; and BW = 1033.286 + 12.733x ThiM. There was no significant difference between the accuracies of these formulas. Conclusions: There is good agreement between the VOCAL and multiplanar techniques for assessment of total fetal thigh volume. Measurements performed using both methods are repeatable and reproducible. For prediction of birth weight, the formulas generated in this study can be used interchangeably. [ABSTRACT FROM AUTHOR]

Objectives: To identify predictors of outcomes in severe twin oligo-polyhydramnios sequence (TOPS) with or without twin anemia-polycythemia sequence (TAPS) and/or selective fetal growth restriction (SFGR) treated by laser ablation of placental vessels (LAPV)., Methods: Analysis of cases treated from 2011 to 2022. Variables evaluated Prenatal predictors: stages of TOPS, presence of TAPS and/or SFGR; pre-LAPV fetal ultrasound parameters; peri-LAPV variables. Perinatal predictors: GA at birth; birthweight; Apgar scores; transfontanellar ultrasonography (TFUS)., Outcome Variables: fetal death, neonatal survival, infant's neurodevelopment. Binary logistic regression analyses were performed to detect predictors of outcomes., Results: 265 cases were included. Predictors of post-LAPV donor fetus' death were delta EFW (p:0.045) and absent/reverse end-diastolic flow in the umbilical artery (AREDF-UA) (p < 0.001). The predictor of post-LAPV recipient fetus' death was hydrops (p:0.009). Predictors of neonatal survival were GA at birth and Apgar scores. Predictors of infant's neurodevelopment were TFUS and pre-LAPV middle cerebral artery Doppler (MCAD) for the donor twin; and pre-LAPV ductus venosus' flow and MCAD for the recipient twin., Conclusions: Prediction of fetal death, neonatal survival and infant's neurodevelopment is possible in cases of TOPS associated or not with SFGR and/or TAPS that were treated by LAPV., (© 2024 John Wiley & Sons Ltd.)

Background: Preterm labor and delivery is a major concern for patients with twin-to-twin transfusion syndrome undergoing fetoscopic laser surgery. A preoperative short cervix is a risk factor for preterm labor. Pessary placement is a short-acting intervention that may be useful to reduce this adverse event., Objective: This study aimed to investigate the relationship between pessary placement and preterm delivery in monochorionic twin pregnancies with twin-to-twin transfusion syndrome and a short cervix before fetoscopic laser surgery., Study Design: This was a retrospective study in 2 centers, including all pregnancies affected by twin-to-twin transfusion syndrome that underwent fetoscopic laser surgery with the Solomon technique between 2013 and 2022 (center A) and 2014 and 2022 (center B) with a preoperative cervical length below 25 mm. This study explored the correlation between cervical length and fetoscopic laser surgery-to-delivery interval following active or expectant management and compared perinatal outcomes between patients managed expectantly and patients managed with pessary placement, using multivariate analysis to control for potential confounders. Patients with a cervical length below 5 mm were not included in the comparative analysis., Results: Of 685 patients, 134 met the inclusion criteria. Moreover, 21 patients were treated with a cervical cerclage and excluded from the analysis, leaving 113 patients for the final analysis. There was a significant negative correlation between cervical length at fetoscopic laser surgery and the risk of early delivery (adjusted odds ratio, 0.66; 95% confidence interval, 0.49-0.81; P<.001). The use of a pessary correlated with fewer patients delivering before 28 weeks of gestation (adjusted odds ratio, 0.28; 95% confidence interval, 0.09-0.75), fewer double neonatal demise (adjusted odds ratio, 0.2; 95% confidence interval, 0.05-0.75). Posthoc subgroup analysis suggested that these improvements were essentially noticeable for cervical lengths between 5 and 18 mm, where pessary placement was associated with an increased fetoscopic laser surgery-to-delivery interval (+24 days; 95% confidence interval, 0.86-42; P=.042) and later gestational age at delivery (+3.3 weeks; 95% confidence interval, 0.86-42; P=.035)., Conclusion: Patients with a moderately shortened cervix, between 5 and 18 mm, may benefit from pessary placement after fetoscopic surgery for twin-to-twin transfusion syndrome, resulting in a reduction of adverse neonatal outcomes, double neonatal demise, and severe preterm delivery., (Copyright © 2023. Published by Elsevier Inc.)

Objective: To assess the neurodevelopmental functions of survivors of twin-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC), during the first year of life, comparing them to a control group; and to verify the influence of specific variables on neurodevelopment., Method: This was a prospective, longitudinal study. The sample comprised 33 monochorionic diamniotic twins who underwent FLC for treatment of TTTS and 22 full-term infants of single-fetus pregnancies. Bayley Scales of Infant and Toddler Development Screening Test were used for evaluation. Prenatal, perinatal and postnatal information were obtained., Results: There was an increased frequency of infants in the TTTS group with inadequate performance compared to the control group. The identified variables (fetal donor, low economic income and cardiorespiratory disease) negatively impacted expressive communication and fine motor skills., Conclusion: Although through follow-up is recommended in all TTTS survivors, particular attention is required for the high-risk group as defined in this study.

Objective: To assess the neurodevelopmental functions (cognition, language and motor function) of survivors of twin-twin transfusion syndrome (TTTS)., Method: Observational cross-sectional study of a total of 67 monochorionic diamniotic twins who underwent fetoscopic laser coagulation (FLC) for treatment of TTTS. The study was conducted at the Center for Investigation in Pediatrics (CIPED), Universidade Estadual de Campinas. Ages ranged from one month and four days to two years four months. Bayley Scales of Infant and Toddler Development Screening Test-III, were used for evaluation., Results: Most children reached the competent category and were classified as having appropriate performance. The preterm children scored worse than term infants for gross motor subtest (p = 0.036)., Conclusion: The majority of children reached the expected development according to their age. Despite the good neurodevelopment, children classified at risk should be monitored for development throughout childhood.

Objective: The aim of this study is to test the feasibility and reproducibility of diffusion-weighted magnetic resonance imaging (DW-MRI) evaluations of the fetal brains in cases of twin-twin transfusion syndrome (TTTS)., Method: From May 2011 to June 2012, 24 patients with severe TTTS underwent MRI scans for evaluation of the fetal brains. Datasets were analyzed offline on axial DW images and apparent diffusion coefficient (ADC) maps by two radiologists. The subjective evaluation was described as the absence or presence of water diffusion restriction. The objective evaluation was performed by the placement of 20-mm(2) circular regions of interest on the DW image and ADC maps. Subjective interobserver agreement was assessed by the kappa correlation coefficient. Objective intraobserver and interobserver agreements were assessed by proportionate Bland-Altman tests., Results: Seventy-four DW-MRI scans were performed. Sixty of them (81.1%) were considered to be of good quality. Agreement between the radiologists was 100% for the absence or presence of diffusion restriction of water. For both intraobserver and interobserver agreement of ADC measurements, proportionate Bland-Altman tests showed average percentage differences of less than 1.5% and 95% CI of less than 18% for all sites evaluated., Conclusion: Our data demonstrate that DW-MRI evaluation of the fetal brain in TTTS is feasible and reproducible., (© 2014 John Wiley & Sons, Ltd.)

Fetal interventions have been performed for some congenital heart diseases. However, these procedures have not gained wide acceptance due to concerns about their efficacy and safety. The aim of this study was to report on a preliminary experience with fetal cardiac interventions in Brazil. Twenty-two cardiac interventions were performed in 21 fetuses. Thirteen fetuses had critical aortic stenosis (CAS), 4 had hypoplastic left heart syndrome (HLHS) and intact interatrial septum or small patent foramen ovale, 1 had pulmonary atresia with intact ventricular septum (IVS), and 3 had critical pulmonary stenosis (CPS). The main outcome variables evaluated were technical success and procedural complications as well as pregnancy and postnatal outcomes. Success was achieved in 20 of 22 procedures (91%) with 1 failed aortic and 1 failed pulmonary valvuloplasties. There was 1 fetal death. No maternal complications occurred. One patient with CAS, severe mitral regurgitation, and hydrops died postnatally within 5 months of age. All patients with HLHS and restrictive atrial septum died after interventional or surgical procedures and prolonged hospitalizations. All patients with CPS/IVS survived and achieved a biventricular (BV) circulation after neonatal valvuloplasty and ductal stenting. A BV circulation was achieved in 4 of 8 patients with CAS and evolving HLHS (one still in utero), including 2 with initial borderline left ventricles (LV) in whom surgical LV overhaul was performed at 9 months of age. In this preliminary experience, the feasibility of fetal cardiac interventions and their outcomes were similar to those previously reported.

Purpose: To create longitudinal reference intervals for pulsatility index (PI) of the umbilical (UA), middle cerebral (MCA), uterine (UtA) arteries and ductus venosus (DV) in a Brazilian cohort., Methods: A longitudinal observational study performed from February 2010 to May 2012. Low risk pregnancies were scanned fortnightly from 18 to 40 weeks for the measurements of PI of the UA, MCA, DV and UtA. Linear mixed models were used for the elaboration of longitudinal reference intervals (5th, 50th and 95th percentiles) of these measurements. PI obtained for the placental and abdominal portions of the umbilical artery were compared by the t-test for independent samples. Two-sided p values of less than 0.05 were considered statistically significant., Results: A total of 164 patients underwent 1,242 scans. There was significant decrease in PI values of all vessels studied with gestational age (GA). From the 18(th) to the 40(th) week of pregnancy, the median PI values of UA (abdominal and placental ends of the cord), MCA, DV and the mean PI of the UtA ranged from 1.19 to 0.74, 1.33 to 0.78, 1.56 to 1.39, 0.58 to 0.41, and 0.98 to 0.66, respectively. The following equations were obtained for the prediction of the medians: PI-UA=1.5602786 - (0.020623 x GA); Logarithm of the PI-MCA=0.8149111 - (0.004168 x GA) - [0.02543 x (GA - 28.7756)²]; Logarithm of the PI-DV=-0.26691- (0.015414 x GA); PI-UtA = 1.2362403 - (0.014392 x GA). There was a significant difference between the PI-UA obtained at the abdominal and placental ends of the umbilical cord (p<0.001)., Conclusions: Longitudinal reference intervals for the main gestational Doppler parameters were obtained in a Brazilian cohort. These intervals could be more adequate for the follow-up of maternal-fetal hemodynamic modifications in normal and abnormal pregnancies, a fact that still requires further validation.

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.

Fetal interventions for congenital heart disease have become important treatment modalities in the past 10 to 15 years. The basic hypothesis has been that a prenatal intervention may remodel cardiac morphology and function to such an extent that it may favorably alter the in utero natural history, resulting in improved prenatal and postnatal outcomes, including an increased likelihood of achieving biventricular circulation. This review discusses the current indications, techniques, and outcomes of fetal cardiac interventions and provides a glimpse into the future with regard to technical improvements and newer treatment modalities, such as maternal oxygenation and in utero pacemaker implantation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purposes: To elaborate models for the estimation of fetal weight and longitudinal reference intervals of estimated fetal weight (EFW) using a sample of the Brazilian population., Methods: Prospective observational study. Two groups of patients were evaluated: Group EFW (estimation of fetal weight): to elaborate (EFW-El) and validate (EFW-Val) a model for the prediction of fetal weight; Group LRI (longitudinal reference intervals): To elaborate (LRI-El) and validate (LRF-Val) conditional (longitudinal) percentiles of EFW. Polynomial regression analysis was applied to the data from subgroup EFW-El to elaborate a model for the estimation of fetal weight. The performance of this model was compared to those of previously published formulas. Linear mixed models were used for the elaboration of longitudinal reference intervals of EFW using data from subgroup LRI-El. Data obtained from subgroup LRI-Val were used to validate these intervals., Results: Group EFW consisted of 458 patients (EFW-El: 367; EFW-Val: 91) and Group LRI consisted of 315 patients (LRI-El: 265; LRI-Val: 50). The model obtained for EFW was: EFW=-8.277+2.146xBPDxACxFL-2.449xFLxBPD². The performances of other models were significantly worse than those obtained with our formula. Equations for the prediction of conditional percentiles of EFW were derived from the longitudinal observation of patients of subgroup LRI-El and validated with data from subgroup LRI-Val., Conclusions: We described a method for customization of longitudinal reference intervals of EFW obtained using formulas generated from a sample of the Brazilian population.

Objectives: The purpose of this study was to assess whether cyst diameter might contribute to the prediction of malignancy in complex breast masses., Methods: In this cross-sectional study, we identified 48 breast masses that had sonographic features suggestive of benign breast lesions (oval shape, circumscribed margins, parallel axis, and abrupt limits). However, these masses were classified as Breast Imaging Reporting and Data System (BI-RADS) category 4 because of the presence of at least 1 cyst (complex echogenicity). All breast masses were biopsied (25 core needle and 23 core needle and excision). Subsequent histologic analysis was performed, and 12 malignancies (25%) were identified. Mammographic features were reviewed. Different sonographic measurements (largest diameters of the mass and cyst and vascular pattern) were assessed for the detection of malignancy., Results: Among the sonographic features, the vascular pattern, ie, the detection of blood flow (present in the lesion [P >.99] or present immediately adjacent to the lesion [P = .46]), was not associated with malignancy, whereas the largest mass and cyst dimensions had significantly positive correlations (P = .02; P < .001, respectively) with tumor malignancy. In receiver operating characteristic curve analysis, the point with the highest sum of sensitivity and specificity corresponded to a maximum cyst diameter of 8 mm (sensitivity, 67%; specificity, 86%). The positive and negative predictive values at that cutoff point were 61% and 86%, respectively. The area under the curve was 0.772. In this study, all masses with cysts smaller than 3 mm in diameter (7 cases) were benign, and all masses with cysts larger than 13 mm in diameter (4 cases) were malignant., Conclusions: Cyst diameter is a good predictor of malignancy in complex breast masses, which, except for the presence of internal cysts, would be otherwise classified as BI-RADS category 3.

Purpose: To compare postnatal survival to hospital discharge of fetuses with severe isolated left-sided congenital diaphragmatic hernia, who underwent tracheal occlusion, with that of nonrandomized contemporaneous controls., Methods: Experimental nonrandomized controlled study, performed from April 2007 to September 2011. Fetuses with severe isolated left-sided congenital diaphragmatic hernia with liver herniation into the chest and lung area-to-head circumference ratio <1.0, who underwent tracheal occlusion (study group) or expectant management (non-randomized contemporaneous controls), were compared in terms of lung area-to-head circumference ratio and observed/expected lung area-to-head circumference ratio (observed/expected lung area-to-head circumference ratio) at the time of diagnosis, gestational age at birth, and survival to hospital discharge. Modifications in lung area-to-head circumference ratio and o/e lung area-to-head circumference ratio after tracheal occlusion were also analyzed. Fisher's exact test, Mann-Whitney's or Wilcoxon's tests were used for the comparisons., Results: There were no significant differences between the Study Group (TO=28) and Controls (n=13) in terms of the lung area-to-head circumference ratio (p=0.709) and the observed/expected lung area-to-head circumference ratio (p=0.5) at the time of diagnosis and gestational age at birth (p=0.146). The survival to hospital discharge was higher (p=0.012) in the tracheal occlusion group (10/28=35.7%) than in controls (0/13=0.0%). There was a significant increase in lung area-to-head circumference ratio (p<0.001) and observed/expected lung area-to-head circumference ratio (p<0.001) between the diagnosis of the congenital diaphragmatic hernia [lung area-to-head circumference ratio: 0.80 (0.40-0.94); observed/expected lung area-to-head circumference ratio: 27.0 (15.3-45.0)], and the day before retrieval of the balloon [lung area-to-head circumference ratio: 1.2 (0.50-1.80); observed/expected lung area-to-head circumference ratio: 40.0 (17.5-60.0)]., Conclusions: There was a significant improvement in the survival rate to hospital discharge of fetuses with severe isolated left-sided congenital diaphragmatic hernia, who underwent tracheal occlusion in comparison to nonrandomized contemporaneous controls.

Objective: To examine the relationship between observed to expected (o/e) lung to head circumference ratio (LHR) and lung-to-body weight ratio (LBWR) in fetuses with congenital diaphragmatic hernia (CDH)., Methods: All consecutive fetuses with CDH and termination of pregnancy for which a postmortem examination was available, examined at three institutions between 2000 and 2010, were included in the study. Contralateral fetal lung area was measured by two-dimensional ultrasonography using the longest axis method and the o/e-LHR was calculated based on the appropriate normal mean for gestational age (GA). Regression analysis was used to determine the significance of association between the LBWR and the o/e-LHR for left and right-sided cases, and subsequently the predicted LBWR in left-sided CDH was calculated using the regression equation. Regression analysis was used to investigate the effect on the proportional difference between the predicted and observed LBWR of GA at o/e-LHR, time gap between o/e-LHR and LBWR measurement, proportional weight of the ipsilateral compared with total lung weight, presence of associated anomalies and intrathoracic herniation of the liver., Results: There were 23 fetuses with left-sided and seven fetuses with right-sided CDH. In left-sided CDH, the LBWR and the o/e-LHR correlated significantly, following the linear equation: LBWR = 0.0043 + (0.0134 × o/e-LHR) (r = 0.52, P = 0.012), but this was not the case for right-sided CDH, for which LBWR followed the equation: LBWR = 0.0107 - (0.0014 × o/e-LHR) (r = 0.08, P = 0.862), where o/e-LHR is expressed as percentage. Regression analysis showed that the proportional difference between predicted and observed LBWR in left-sided CDH was significantly and independently associated with GA at o/e-LHR measurement and proportional weight of ipsilateral vs. total lung weight., Conclusion: In left-sided CDH, o/e-LHR correlates well with LBWR irrespective of the length of time between o/e-LHR and LBWR measurement, presence of associated anomalies and intrathoracic herniation of the liver. Inconsistencies between the two measurements are mainly attributable to the contribution of the ipsilateral lung to the total lung weight. In right-sided CDH, o/e-LHR does not correlate with LBWR., (Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.)

Congenital diaphragmatic hernia (CDH) is a phenotypically and genetically heterogeneous disorder, with a complex inheritance pattern. Structural abnormalities of almost all chromosomes have been described in association with CDH. We made a molecular analysis through array comparative genomic hybridization (array CGH) of a group of fetuses with prenatal ultrasound diagnosis of CDH and normal G-banded karyotypes. A whole genome BAC-array CGH, composed of approximately 5000 BAC clones, was carried out on blood samples from fetuses with prenatal ultrasound diagnosis of CDH and a normal karyotype (500-band level). All potential cytogenetic alterations detected on the arrays were reported. The array CGH analysis showed copy number gains and losses in 10 of 12 cases. Eighty-five clones showed genomic imbalances, and 29 clones displayed described copy number variations. We identified a recurrent gain in 17q12 in two of 12 cases, which has not been previously described. Our results may contribute to determining the effectiveness and applicability of array CGH for prenatal diagnosis purposes, and also to elucidate the submicroscopic genomic instability of CDH fetuses.

This is a traditional (narrative) review with the objective of highlighting the contribution of obstetric ultrasonography (US) between the 11th and 14th week of pregnancy, commonly called first trimester anomaly scan. In addition to being used for the screening of chromosomal anomalies, US can be employed during this period to confirm or determine gestational age, evaluate fetal anatomy, diagnose malformations, screen major structural abnormalities and genetic syndromes, define the prognosis of pregnancy, diagnose and characterize multiple pregnancies, and screen preeclampsia and intrauterine growth restriction. The most important studies about this subject published between 1990 and 2010 in the Cochrane and PubMed libraries were included. The selected studies can be classified with scientific levels I to III.

Objective: To report on the initial experience in a single Brazilian university clinic of the use of fetoscopic endotracheal occlusion (FETO) to treat severe isolated congenital diaphragmatic hernia (CDH)., Methods: The inclusion criteria for FETO for this prospective study were isolated CDH and intrathoracic herniation of the liver, as well as the lung area to head circumference ratio (LHR) <1.0. The main variables evaluated were LHR and observed to expected (o/e) LHR before and after FETO, gestational age (GA) at FETO, reversal of tracheal occlusion (TO), and birth and discharge of a living child from the hospital., Results: Among 8 isolated left-sided CDH cases with normal karyotypes, the median LHR and o/e LHR before FETO were 0.7 (range: 0.6-0.9) and 0.27 (range: 0.22-0.32), respectively. The median LHR and o/e LHR after FETO were 1.2 (range: 0.9-1.8) and 0.45 (0.31-0.67), respectively. The median GA at FETO, reversal of TO and birth were 26.8 (range: 26-29), 32.5 (range: 31.0-34.0) and 37 weeks (range: 35-37), respectively. Neonatal survival at the time of hospital discharge was 50% (4/8)., Conclusion: FETO is feasible at our institution and may help to improve postnatal survival of children with severe CDH in developing countries., (Copyright © 2011 S. Karger AG, Basel.)

Purpose: To evaluate gestational and neonatal outcomes in pregnancies complicated by fetal hydrocephalus., Methods: Retrospective analysis of 287 cases of fetal hydrocephalus followed at the Fetal Medicine Unit of the University of Campinas in the period of 1996 to 2006., Results: Mean maternal age was 25 years, mean gestational age at diagnosis was 27 weeks. There were 50 cases of isolated ventriculomegaly, 95 cases of Chiari II malformation and 142 cases of ventriculomegaly associated with other malformations. Preterm delivery and vaginal delivery were more frequent in the group of ventriculomegaly associated with other malformations. Cardiac, skeletal and renal malformations were the most common associated malformations. Cesarean section was common (95%) in the Chiari II group. Fetal and neonatal death occurred more frequently (29 and 68%, respectively) in the group of ventriculomegaly associated with other malformations. Chromosomal anomalies were present in 15% of 165 investigated cases., Conclusions: Fetal and neonatal prognosis and outcome are associated with the presence of associated anomalies and aneuploidy.

Purpose: To describe the maternal complications due to therapeutic endoscopic procedures in fetal Medicine performed at an university center in Brazil., Methods: Retrospective observational study including patients treated from April 2007 to May 2010 who underwent laser ablation of placental vessels (LAPV) for severe twin-twin transfusion syndrome (TTTS); fetal tracheal occlusion (FETO) and endoscopic removal of tracheal balloon in cases of severe congenital diaphragmatic hernia (CDH); LAPV with or without bipolar coagulation of the umbilical cord in cases of twin reversed arterial perfusion (TRAP) sequence. The main variables described for each disease/type of surgery were maternal complications and neonatal survival (discharge from nursery)., Results: Fifty-six patients underwent 70 procedures: Severe TTTS (34 patients; 34 surgeries); severe CDH (16 patients; 30 surgeries), and TRAP sequence (6 patients; 6 surgeries). Among 34 women who underwent LAPV for TTTS, two (2/34=5.9%) experienced amniotic fluid leakage to the peritoneal cavity and seven (7/34=20.6%) miscarried after the procedure. Survival of at least one twin was 64.7% (22/34). Among 30 interventions performed in cases of CDH, there was amniotic fluid leakage into the maternal peritoneal cavity in one patient (1/30=3.3%) and premature preterm rupture of membranes after three (3/30=30%) fetoscopies for removal of the tracheal balloon. Infant survival with discharge from nursery was 43.8% (7/16). Among six cases of TRAP sequence, there was bleeding into the peritoneal cavity after surgery in one patient (1/6=16.7%) and neonatal survival with discharge from nursery was 50% (3/6)., Conclusions: In agreement with the available data in literature, at our center, the benefits related to therapeutic endoscopic interventions for TTTS, CDH and TRAP sequence seem to overcome the risks of maternal complications, which were rarely considered severe.

Purpose: To describe the results of laser ablation of placental vessels for the treatment of severe twin-to-twin transfusion syndrome in an university center in Brazil., Methods: Retrospective observational study of patients treated at UNICAMP from 2007 to 2009. Laser ablation of placental vessels was performed in cases of severe twin-twin transfusion syndrome (Quintero stages II, III and IV) diagnosed before 26 complete weeks of gestation. The main variables evaluated in this series were gestational age at delivery, survival (discharge from the nursery) of at least one twin and neurological damage in survivors. Logistic regression was used to investigate the influence of cervical length, gestational age and stage of the disease (before the surgery) on the occurrence of delivery/abortion and fetal death after the intervention, and the influence on severe preterm birth and survival., Results: In the whole series, at least one twin survived in 63.3% of cases (19/30). Among patients who did not have delivery/abortion after surgery, the survival of at least one twin was 82.6% (19/23). In this subgroup (n=23), mean gestational age in delivery was 31.9 weeks and neurological damage was identified in one neonate (1/31; 3.2%). Cervix length influenced the occurrence of delivery/abortion after surgery (p-value=0.008). Among seven patients (7/30; 23.3%) who carried this complication, five (5/7; 71.4%) had cervix length lower than 15 mm. Among the 23 patients who did not have delivery/abortion as a result of the surgery, the highest stages of the disease (III and IV) increased the risk of delivery prior to 32 complete weeks of gestation (p-value=0.025) and decreased the chance of survival of both twins (p-value=0.026)., Conclusions: The results are similar to those available in the literature. In our series, the main factors associated with poorer results were short cervix (lower than 15 mm) and the highest stages of the disease (III and IV) at the time of the treatment.

Objectives: To compare the accuracies of birth-weight predicting models derived from two-dimensional (2D) ultrasound parameters and from total fetal thigh volumes measured by three-dimensional (3D) ultrasound imaging; and to compare the performances of these formulae with those of previously published equations., Methods: A total of 210 patients were evaluated to create a formula-generating group (n = 150) and a prospective-validation group (n = 60). Polynomial regression analysis was performed on the first group to generate one equation based on 2D ultrasound measurements, one based on fetal thigh volume measured by the multiplanar technique (ThiM) and one based on fetal thigh volume obtained by the Virtual Organ Computer-aided AnaLysis (VOCAL()) method (ThiV). Paired-samples t-tests with Bonferroni adjustments were used to compare the performances of these equations in the formula-finding and the prospective-validation groups. The same approach was used to compare the accuracies of the new 2D and 3D formulae with those of both original and modified 2D equations from previous publications, as well as the 3D model reported by Chang et al., Results: The formulae with the best fit for the prediction of birth weight were: estimated fetal weight (EFW) = - 562.824 + 11.962x AC x FDL + 0.009 x BPD(2)x AC(2) (where AC is abdominal circumference, FDL is femur diaphysis length and BPD is biparietal diameter), EFW = 1033.286 + 12.733 x ThiM, and EFW = 1025.383 + 12.775 x ThiV. For both the formula-generating and the prospective-validation groups, there were no significant differences between the accuracies of the new 2D and 3D models in the prediction of birth weight. When applied to our population, the performances of the modified and original versions of the previously published 2D equations and the performance of the original 3D formula reported by Chang et al. were all significantly worse than our models., Conclusions: We believe that the greatest sources of discrepancy in estimation of birth weight are the phenotypic differences among patients used to create each of the formulae mentioned in this study. Our data reinforce the need for customized birth-weight prediction formulae, regardless of whether 2D or 3D measurements are employed., (Copyright 2009 ISUOG. Published by John Wiley & Sons, Ltd.)

Purpose: to verify the association between ultrasonographic signs during gestation and post-delivery evolution in fetuses with bilateral obstructive uropathies, followed up in an expectant way., Methods: fetuses with bilateral obstructive uropathies presenting severe oligoamnios and narrow thorax have been compared with fetuses with bilateral obstructive uropathies without those alterations, concerning the presence or absence of cysts in both kidneys, and the presence or absence of parenchymal hyperechogenicity in both kidneys. Cases of neonatal death were compared with cases of neonatal discharge from the nursery, regarding the same renal echographic aspects mentioned above, the presence of severe oligoamnios and narrow thorax. The sensitivity, specificity, positive and negative predictive value of the presence of bilateral renal cysts, bilateral renal hyperechogenicity, severe oligoamnios and narrow fetal thorax for the neonatal death were calculated., Results: severe oligoamnios and narrow thorax were more frequent (p=0.03; p<0.001) in fetuses with bilateral renal cysts, as compared to those with echographically normal renal parenchyma. Neonatal death was more frequent among cases with severe oligoamnios (p<0.001), narrow thorax (p<0.001) and bilateral renal cysts (p<0.002), when respectively compared with cases without those alterations. The best values of sensitivity, specificity, positive and negative predictive value for the death of neonatal/breastfeeding infants were obtained using the echographic aspect of narrow thorax, and were 81.8, 100, 100 and 79.3%, respectively., Conclusions: in cases of fetuses with bilateral obstructive uropathies followed up in an expectant way, the ultrasonographic signs more associated to bad prognosis are severe oligoamnios, narrow fetal thorax and presence of bilateral renal cysts.

Purpose: to evaluate the evolution of monochorionic-diamniotic twin pregnancies with and without the twin-twin transfusion syndrome (TTTS), followed up in an expectant way., Methods: retrospective study in which the pregnancies with and without TTTS and with mild (Quintero's stage I) and severe (Quintero's stages II, III, IV and V) disease manifestations were compared according to extreme preterm delivery, neurological impairment and the twins' nursery discharge. The extreme preterm twins who had had TTTS, or not, were compared whether they had or not neurological impairment. The chi2 or Fisher's exact test were used., Results: among 149 monochorionic-diamniotic twin pregnancies, 15 presented TTTS, 11 (11/15 - 73.3%) in the severe form and 4 (4/15 - 26.7%) at stage I. The extreme preterm delivery was more frequent (p<0.001) in the cases with the disease (11/15 - 73.3%) than in the cases without it (25/134 - 18.7%), and more common (p=0.033) in severe (10/11 - 91.1%) than in mild cases (1/4 - 25.0%). Neurological impairment in at least one twin was more frequent in cases with (5/8 - 62.5%) than in cases without (9/134 - 6.7%) the disease (p<0.001). Nursery discharge of at least one twin was more common (p<0.001) in cases without (132/134 - 98.5%) than in cases with the disease (8/15 - 53.0%). Neurological impairment in at least one of the twins was more frequent (p=0.04) in the severe (5/5 - 100%) than in the mild (1/4 - 25%) form of the disease. Nursery discharge of both twins was more common (p=0.004) at stage I (4/4 - 100%), than in the severe form of the disease (1/11 - 9.0%). Among the 47 extreme preterm twins, the neurological impairment was more frequent (p=0.001) among the ones who had (6/6 - 100%), than among those who did not have TTTS (11/41 - 26.8%)., Conclusions: cases with twin-twin transfusion syndrome, followed up in an expectant way have bad perinatal prognosis, with high neonatal mortality and high rates of neurological arrest among the survivors.

Objective: The objective of the study was to investigate the volume response of the contralateral lung in the prediction of postnatal outcome in fetuses with congenital diaphragmatic hernia (CDH) treated by fetoscopic endotracheal occlusion (FETO)., Study Design: In 30 fetuses with isolated severe CDH that underwent FETO, the volume of the contralateral lung was measured by 3-dimensional ultrasound the day before and 2 and 7 days after FETO. The measurements of fetuses that subsequently died were compared to those who survived., Results: In all fetuses before FETO, the lung volume was below the 2.5th percentile of the normal range for gestation (60%). Within 2 days after FETO, the lung volume increased to above the 2.5th percentile in 14/21 (66%) that survived, compared with 1/9 (11%) that died. The respective percentages at 7 days after FETO were 95% and 11%, respectively., Conclusion: In fetuses with CDH, the lung responsiveness within 2 and 7 days after FETO provides useful prediction of subsequent survival.

Objectives: To compare prediction of postnatal survival in isolated diaphragmatic hernia by prenatal two-dimensional (2D) versus three-dimensional (3D) sonographic assessment of the contralateral lung., Methods: The lung area to head circumference ratio (LHR) of the contralateral lung was measured and expressed as a percentage of the normal mean for gestation (O/E) in 47 fetuses with isolated diaphragmatic hernia at 26 (range, 21-36) weeks of gestation. The lung area was measured by tracing the limits of the lungs (LHR trace) and by multiplying the longest diameter by its perpendicular (LHR diameters). The contralateral lung volume was measured by the Virtual Organ Computer-Aided anaLysis method and the O/E was calculated. Regression analysis was used to determine the significance of the LHRs and volume in the prediction of postnatal survival., Results: The survival rate was 59.6% (28 of 47). There were significant associations between O/E LHR trace and O/E LHR diameters, and between each O/E LHR and O/E volume, but multiple regression analysis demonstrated that significant prediction of survival was provided only by O/E LHR trace and intrathoracic herniation of the liver., Conclusions: In diaphragmatic hernia prenatal prediction of postnatal outcome is better by 2D measurement of LHR trace than it is by 3D measurement of lung volume.

Purpose: To prospectively compare three-dimensional (3D) ultrasonography (US) and magnetic resonance (MR) imaging in the assessment of lung volumes in fetuses with congenital diaphragmatic hernia., Materials and Methods: Informed consent was obtained for this ethics committee-approved study. Left and right lung volumes were measured by using the 30 degrees virtual organ computer-aided analysis 3D US technique and a transverse multiplanar T2-weighted MR imaging technique in 43 fetuses with isolated congenital diaphragmatic hernia. Regression analysis was used to determine the significance of the association between the two methods., Results: The 43 fetuses were assessed in a total of 78 examinations. Median gestational age at the examinations was 28 weeks (range, 18-38 weeks). In all examinations, it was possible to visualize and measure both the ipsilateral and the contralateral lungs with MR imaging. In contrast, with 3D US, the contralateral lung could be measured in all examinations, but the ipsilateral lung could be measured in only 44 (56%) examinations. For the contralateral lungs, there was a significant association between 3D US and MR imaging measurements (r = 0.86, P < .001). Although the mean lung volume measured with 3D US was 25% lower than that measured with MR imaging, the ratio of observed volume to expected normal mean volume for gestation was not significantly different between the two methods (3D US, 0.48; MR imaging, 0.52). In the 44 examinations in which the ipsilateral lung could be measured with both methods, 3D US volumes were not significantly different from MR imaging volumes, and the association was weaker (r = 0.39, P < .05) in the ipsilateral lungs than in the contralateral lungs., Conclusion: For congenital diaphragmatic hernia, 3D US provides a reliable measurement of the contralateral but not the ipsilateral lung.

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

Objective: To compare the intra- and interobserver agreement of three different methods of measuring lung area in fetuses with congenital diaphragmatic hernia (CDH)., Methods: In 71 fetuses with isolated CDH at 21-33 weeks' gestation, the area of the contralateral lung was assessed by firstly, manual tracing of lung borders, secondly, multiplication of the longest diameter of the lung by its widest perpendicular diameter, and thirdly, multiplication of the anteroposterior (AP) diameter of the lung at the mid-clavicular line by the perpendicular diameter at the midpoint of the AP diameter (AP method). In 30 fetuses the measurements were made by two observers and Bland-Altman analysis was used to compare the measurement agreement and bias for each observer and between the two observers., Results: The area obtained by the AP method was similar to that obtained by the manual tracing method, but the area by the longest diameter approach was bigger by 34.4% (95% CI, - 2.4% to 71.1%). The 95% confidence intervals of the difference in paired measurements of lung areas by the same observer and by two different observers were narrower in the manual tracing method than in the multiplying diameters methods., Conclusions: In CDH the most reproducible measurement of fetal lung area is provided by manual tracing of the limits of the lungs, rather than by multiplication of lung diameters.

Objective: To investigate the mid-facial hypoplasia of fetuses with trisomy 21 at 11 + 0 to 13 + 6 weeks of gestation, by three-dimensional (3D) evaluation of the maxilla and the nasal bones., Methods: A 3D volume of the fetal head was obtained before fetal karyotyping at 11 + 0 to 13 + 6 (median 12) weeks of gestation in 80 fetuses that were subsequently found to have trisomy 21 and in 862 fetuses subsequently found to be chromosomally normal. The multiplanar mode was used to obtain a sequence of transverse views of the fetal face and to demonstrate the maxilla, the adjacent rami of the mandible and the nasal bones. The maxillary depth, defined as the distance between the alveolus of the maxilla in the midline anteriorly and the midpoint of the line joining the rami posteriorly, was measured. Ossification of the nasal bones was considered to be normal if both bones were more echogenic than the overlying skin., Results: In the chromosomally normal group the maxillary depth increased linearly with crown-rump length (CRL) from 3.1 mm at a CRL of 45 mm to 4.8 mm at a CRL of 84 mm, and in the trisomy 21 fetuses the depth was significantly smaller than normal (mean difference = - 0.3 mm, P < 0.001). There was no significant association between the delta maxillary depth and delta nuchal translucency thickness in either the trisomy 21 or the chromosomally normal fetuses. Impaired ossification of the nasal bones was observed in 3.1% of the chromosomally normal fetuses and in 60.0% of those with trisomy 21. The mean maxillary depth was significantly smaller in fetuses demonstrating impaired ossification than in those with normal ossification of the nasal bones (mean difference = -0.2 mm; 95% CI, -0.3 to -0.1, P = 0.001)., Conclusions: In a high proportion of fetuses with trisomy 21 there is sonographic evidence of mid-facial hypoplasia at 11 + 0 to 13 + 6 weeks of gestation., (Copyright 2006 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: To examine the relationship between the fetal lung area and lung area to head circumference ratio (LHR) and lung volume by three-dimensional (3D) ultrasonography in normal fetuses and in fetuses with unilateral congenital diaphragmatic hernia (CDH)., Methods: In 64 fetuses with CDH at median 26 (range, 20-32) weeks of gestation the contralateral lung volume, lung area and LHR were measured and the values were compared to those of 650 normal fetuses at 12-32 weeks. In the normal fetuses both lungs were assessed but in the 64 fetuses with CDH only the contralateral lung was measured because the ipsilateral lung could be visualized adequately in only 40 (62.5%) of the cases. Regression analysis was used to assess the significance of the association between lung volume and lung area or LHR. In the fetuses with CDH, the observed to expected ratios for lung area and LHR were calculated. The expected lung area and LHR were the normal median for a given lung volume. The significance of the differences between the observed to expected lung area and LHR in fetuses with CDH and normal fetuses was determined. In the 64 fetuses with CDH and in 64 normal fetuses, matched for gestational age, the lung length between the apex and the superior aspect of the diaphragm dome was also recorded., Results: In normal fetuses the median lung area and LHR in both the left and right lungs increased significantly with lung volume. In the fetuses with CDH, the lung area and lung volume for gestation were substantially lower than in normal fetuses and the ratios of observed to expected lung area and LHR for a given lung volume were significantly lower than the respective values in normal fetuses. Additionally, the mean lung length was 13% greater and the mean lung area was 44% smaller than the respective values in the normal controls matched for gestational age., Conclusions: The finding of a significant association between LHR and lung volume has validated the use of LHR in the assessment of lung growth. However, the study has also demonstrated that in fetuses with CDH, LHR underestimates the actual lung volume, because the herniated viscera cause a greater lateral, rather than vertical, compression of the contralateral lung., (Copyright 2006 ISUOG)

Objective: To compare the volume of the ipsilateral and contralateral lungs in fetuses with congenital diaphragmatic hernia (CDH)., Methods: Left and right lung volumes were measured using three-dimensional (3D) ultrasonography in 42 fetuses with CDH at median 26 (range, 20-32) weeks of gestation. Each value was then expressed as a difference, in standard deviations, from the normal mean for gestation, previously established from the study of 650 normal fetuses at 12-32 weeks (Z-score). The Mann-Whitney U-test was used to determine the significance of the differences between the measurements in fetuses with CDH and normal fetuses and between the ipsilateral and contralateral lungs in fetuses with left- and right-sided CDH., Results: There were 34 fetuses with left-sided CDH and eight with right-sided CDH. In CDH both the ipsilateral and contralateral lung volumes were substantially lower than in normal fetuses. In left CDH the left lung volume was 4.03 (median; range, 3.11-4.78) SDs below the normal mean for gestation, and the respective values for the right lung were 3.04 (median; range, 1.78-4.31) SDs (P < 0.001 for both). In right CDH, the left lung volume was 2.91 (median; range, 1.62-4.07) SDs below the normal mean for gestation and the respective values for the right lung were 4.35 (median; range, 3.07-4.99) SDs (P < 0.001 for both). In both left and right diaphragmatic hernia the deficit in the volume of the ipsilateral lung was significantly greater than the deficit in the contralateral lung., Conclusions: In fetuses with CDH both the ipsilateral and contralateral lung volumes are substantially lower than in normal fetuses., (Copyright 2006 ISUOG)

Objective: The purpose of this study was to assess the agreement between 3-dimensional ultrasonography (3DUS) and magnetic resonance imaging (MRI) for lung volumetry in fetuses with and without abnormalities associated with lung hypoplasia., Methods: Fifty-nine singleton pregnancies were evaluated. Cases were separated into groups 1 and 2, according to the presence or absence of malformations associated with lung hypoplasia, respectively. Fetal lung volume was calculated by the Virtual Organ Computer-Aided Analysis (VOCAL) program of the 3DUS and the MRI. In both groups, measurements performed with all VOCAL angles were compared among themselves and with those obtained by MRI. Bland-Altman tests and analysis of variance were used for this purpose., Results: In groups 1 and 2, the mean lung volume obtained with each rotation angle of the VOCAL technique was significantly smaller than the mean volume calculated by MRI (P < .001), and the mean volume obtained with the 30 degrees rotation step was significantly smaller than those obtained with the other rotation steps of the VOCAL technique. Bland-Altman tests confirmed this underestimation and showed a broad 95% confidence interval when the VOCAL angles were compared with those of MRI and when the 30 degrees rotation step was compared with the other VOCAL steps., Conclusions: There was a substantial discrepancy between 3DUS and MRI and between the 30 degrees rotation step of the VOCAL technique and the other rotation angles, for lung volume measurement in fetuses with and without abnormalities associated with lung hypoplasia.

Objective: To establish reference intervals for the fetal right, left and total lung volumes and heart volume between 12 and 32 weeks of gestation., Methods: Fetal lung and heart volumes were measured using three-dimensional (3D) ultrasound in 650 normal singleton pregnancies at 12-32 weeks. The VOCAL (Virtual Organ Computer-aided AnaLysis) technique was used to obtain a sequence of six sections of each lung and the heart around a fixed axis, each after a 30 degrees rotation from the previous one. The rotation axis for the lungs extended from the apex to the upper limit of the diaphragm dome, and the rotation axis for the heart extended from its apex to its connection to the great vessels. The contour of each of these organs was drawn manually in the six different rotation planes to obtain the 3D volume measurement. In 60 cases the fetal lungs and heart volumes were measured by the same sonographer twice and also by a second sonographer once in order to compare the measurements and calculate intra- and interobserver agreement., Results: The total lung volume and heart volume increased with gestation, from respective mean values of 1.6 and 0.6 mL at 12 weeks to 10.9 and 4.3 mL at 20 weeks and 49.3 and 26.6 mL at 32 weeks. The right to left lung volume ratio did not change significantly with gestation (median, 0.7), whereas the heart to total lung volume ratio increased with gestation from about 0.3 at 12 weeks to 0.5 at 32 weeks. In the Bland-Altman plot, the difference between paired measurements by two sonographers was, in 95% of the cases, less than 0.05, 0.5 and 1.9 mL for each lung at 12-13, 19-22 and 29-32 weeks, respectively, and the corresponding values for the heart volumes were 0.04, 0.4 and 2.3 mL., Conclusions: In normal fetuses the lung and heart volumes increase between 12 and 32 weeks of gestation. The extent to which in pathological pregnancies possible deviations in these measurements from normal prove to be useful in the prediction of outcome remains to be determined., (Copyright (c) 2005 ISUOG.)

Objectives: To evaluate whether fetal urinary sodium and chloride provide clinically useful information in addition to ultrasound in bilateral obstructive uropathy., Methods: Sonographic features and urinary concentrations of sodium and chloride were evaluated in fetuses with bilateral obstructive uropathy. After a minimum of 12 months of postnatal follow-up, cases that developed increased serum creatinine (greater than 50 micromol/L) were compared with those that did not., Results: Of the cases studied, 16/35 died perinatally, all showing anamnios and markedly elevated urinary electrolytes. Of the survivors, ten maintained normal postnatal serum creatinine, whereas nine did not. The frequency of reduced amniotic fluid/olygohydramnios was higher in cases that developed increased serum creatinine (four out of nine) than in those that did not (nil). Sodium above the 95th percentile was 100% specific and 44% sensitive to predict an increased serum creatinine during early infancy, while chloride above the 95th percentile was 70% specific and 56% sensitive. All seven cases in which urinary sodium was elevated and/or amniotic fluid volume was reduced developed renal failure., Conclusion: Urine sampling slightly improved renal function prediction, but this must be balanced against its fetal risks., (2006 John Wiley & Sons, Ltd.)

Objective: To determine the pattern of early growth disturbance in chromosomally abnormal fetuses by comparing the volume of the fetal head to that of the trunk., Methods: The fetal trunk and head volume was measured using three-dimensional (3D) ultrasound in 145 chromosomally abnormal fetuses at a median gestational age of 12 (range, 11 + 0 to 13 + 6) weeks. The head volume was measured separately and then subtracted from the total head and trunk volume to obtain the volume of the fetal trunk. The head-to-trunk ratios were then calculated and the Mann-Whitney U-test was used to determine the significance of differences from 500 chromosomally normal fetuses., Results: The fetal head volume for crown-rump length (CRL) was significantly smaller than normal in trisomy 21, trisomy 13 and Turner syndrome (P < 0.001, P < 0.001 and P = 0.001, respectively), whereas no significant differences were found in trisomy 18 and triploidy (P = 0.139 and P = 0.070, respectively). The fetal trunk volume for CRL was significantly smaller in all chromosomal abnormalities (P < 0.001) except Turner syndrome (P = 0.134). The head-to-trunk ratio for CRL was significantly larger in trisomy 18, trisomy 13 and triploidy (P < 0.001), but normal in trisomy 21 (P = 0.221) and Turner syndrome (P = 0.768)., Conclusions: In trisomy 21 and Turner syndrome, the growth deficit was symmetrical with the head and trunk being equally affected, whereas in triploidy and trisomies 18 and 13 there was asymmetrical growth restriction with the trunk being more severely compromised than the head.

Objective: To establish reference intervals with gestation for the right and left lung areas and lung area to head circumference ratio (LHR)., Methods: This was a cross-sectional study of 650 normal singleton pregnancies at 12-32 weeks of gestation. We measured the left and right lung areas on the cross-sectional plane of the thorax, used for examination of the four-chamber view of the heart, by three different techniques: firstly, manual tracing of the limits of the lungs; secondly, multiplication of the longest diameter of the lung by its longest perpendicular diameter; thirdly, multiplication of the anteroposterior diameter of the lung at the mid-clavicular line by the perpendicular diameter at the midpoint of the anteroposterior diameter., Results: The respective mean left and right lung areas (manual tracing) increased with gestational age, from 36 and 58 mm(2) at 12 weeks to 220 and 325 mm(2) at 20 weeks and 594 and 885 mm(2) at 32 weeks. This 16-fold increase in lung area was accompanied by a four-fold increase in head circumference. Consequently, the left and right LHR increased with gestational age. The most reproducible way of measuring the lung area was by manual tracing of the limits of the lungs and the least reproducible was by multiplying the longest diameter of the lungs by their longest perpendicular diameter. Furthermore, the method employing the longest diameter, compared with the tracing method, overestimated both the left and the right lung areas by about 45% and the method employing the anteroposterior diameter overestimated the area of the right lung by about 35%, but not that of the left lung., Conclusions: In the antenatal prediction of pulmonary hypoplasia by the assessment of lung area it is important to take gestational age into account. Dividing the lung area by the head circumference does not correct for the gestation-related increase in lung area. Reproducible measurement of the lung area is provided by manual tracing of the limits of the lungs, rather than by multiplication of lung diameters.

Objective: To examine the pattern of growth in chromosomally abnormal fetuses at 11+0 to 13+6 weeks of gestation and compare the trunk and head volume to crown-rump length (CRL) in defining the growth deficit in such fetuses., Methods: The fetal trunk and head volume was measured using three-dimensional (3D) ultrasound in 140 chromosomally abnormal fetuses at 11+0 to 13+6 (median 12) weeks of gestation, and the values were compared to 500 chromosomally normal fetuses. In each chromosomally abnormal fetus, the observed fetal trunk and head volume was subtracted from the expected mean (delta value) of the chromosomally normal fetuses of the same gestational age, and this difference was expressed as a percentage of the appropriate normal mean. The Mann-Whitney U-test was used to determine the significance of differences between the chromosomally normal and abnormal groups., Results: In trisomy 21 (n=72) and Turner syndrome (n=14) fetuses, compared to chromosomally normal fetuses, the CRL for gestation was similar (P=0.335 and P=0.317, respectively), but the fetal trunk and head volume was about 10-15% lower (P<0.001 and P=0.004, respectively). In trisomy 18 (n=29), trisomy 13 (n=14) and triploidy (n=11), the deficit in volume was about 45% (P<0.001), whereas the deficit in CRL was less than 15% (P<0.001)., Conclusions: In the quantification of the degree of early growth impairment in chromosomally abnormal fetuses, measurement of the fetal trunk and head volume using 3D ultrasound may be better than measurement of CRL., (Copyright (c) 2005 ISUOG.)

Objective: To establish the relationship between fetal trunk and head volume measured by three-dimensional (3D) ultrasound and gestational age at 11 + 0 to 13 + 6 weeks of gestation., Methods: The fetal trunk and head volume were measured using 3D ultrasound in 417 chromosomally normal fetuses from singleton pregnancies at 11 + 0 to 13 + 6 (median, 12 + 0) weeks of gestation. Regression analysis was used to determine the significance of the association between fetal volume and gestational age. The Bland-Altman analysis was used to compare the measurement agreement and bias for a single examiner and between different examiners., Results: The fetal trunk and head volume increased linearly with gestation from a mean of 5.8 mL at 11 + 0 weeks to 33.3 mL at 13 + 6 weeks and 1 SD was 4.4 mL. There was also a significant linear association between fetal volume and crown-rump length (CRL), from a mean of 5.1 mL at a CRL of 45 mm to 37.5 mL at a CRL of 84 mm and 1 SD was 2.7 mL. However, within this gestational range, a doubling in CRL, from a mean of 48 mm at 11 + 0 weeks to 79 mm at 13 + 6 weeks, was associated with a 5-6-fold increase in fetal volume. The mean difference in fetal volume between paired measurements by the same sonographer was -0.87 mL (95% limits of agreement, -2.31 to 4.05 mL) and the mean difference between paired measurements by two sonographers was -1.09 mL (-5.49 to 3.32 mL)., Conclusions: 3D ultrasound can provide a reproducible measurement of the fetal trunk and head volume in early pregnancy. At between 11 + 0 and 13 + 6 weeks there is a 5-6-fold increase in fetal volume but only a doubling in CRL.

Objective: To determine the potential value of measuring the placental volume at 11 to 13 + 6 weeks of gestation in screening for chromosomal defects., Methods: The placental volume was measured using three-dimensional ultrasound in 500 consecutive singleton pregnancies immediately before chorionic villus sampling for fetal karyotyping at 11 to 13 + 6 (median, 12) weeks of gestation., Results: The fetal karyotype was normal in 417 pregnancies and abnormal in 83. In the chromosomally normal group the mean placental volume increased significantly with gestation from a mean of 51 mL (5th and 95th centiles: 31.2 and 82.4 mL) at 11 weeks to 91 mL (5th and 95th centiles: 55.7 and 147.2 mL) at 13 + 6 weeks. In the chromosomally abnormal group the mean placental volume for gestational age was not significantly different from normal in trisomy 21 and Turner syndrome, but it was smaller in trisomies 13 and 18., Conclusions: The measurement of the placental volume at 11 to 13 + 6 weeks of gestation is unlikely to be a useful predictor of the major chromosomal defects. In trisomies 13 and 18 the small placental volume may be due to early-onset fetal growth restriction, which could be the consequence of impaired placental function., (Copyright (c) 2005 ISUOG.)

Objective: To determine the potential value of measuring the gestational sac volume (GSV) at 11 to 13 + 6 weeks of gestation in screening for chromosomal defects., Methods: The GSV was measured using three-dimensional (3D) ultrasound in 500 consecutive singleton pregnancies immediately before chorionic villus sampling (CVS) for fetal karyotyping at 11 to 13 + 6 (median 12) weeks of gestation., Results: The fetal karyotype was normal in 417 pregnancies and abnormal in 83. In the chromosomally normal group, the mean GSV increased significantly with gestational age from a mean of 69 mL at 11 weeks to 144 mL at 13 + 6 weeks (the standard deviation was 27 mL). In the chromosomally abnormal group, the mean GSV for gestational age was not significantly different from normal in fetuses with trisomy 21, trisomy 18 and Turner syndrome, but it was smaller in those with triploidy and trisomy 13. However, the mean GSV for crown-rump length (CRL) was significantly larger in trisomy 18, smaller in triploidy and trisomy 13, and not different from normal in trisomy 21 and Turner syndrome. The mean CRL for gestational age was significantly smaller than normal in trisomy 18, triploidy and trisomy 13., Conclusions: The measurement of the GSV at 11 to 13 + 6 weeks of gestation is unlikely to provide useful prediction of the major chromosomal defects. In trisomy 13 and triploidy, the small GSV may be due to early onset fetal growth restriction and reduced amniotic fluid volume. In trisomy 18, the increase in GSV is probably due to the presence of associated fetal abnormalities that interfere with fetal swallowing., (Copyright 2005 ISUOG)

Objective: To detect the presence of a gap between the fetal nasal bones at 11 to 13 + 6 weeks of gestation and to verify if this gap could lead to the erroneous diagnosis of absent nasal bone., Methods: Three-dimensional (3D) ultrasound was used to assess the fetal nose in 450 singleton pregnancies, immediately after two-dimensional (2D) evaluation of the nasal bones and screening for chromosomal defects by a combination of maternal age and the measurement of fetal nuchal translucency at 11 to 13 + 6 (median, 12) weeks of gestation. A 3D volume of the fetal face was acquired and then analyzed using the multiplanar mode. A sequence of transverse views was used to confirm the presence or absence of the nasal bones and when they were present any visible gap between them was measured. A perfectly mid-sagittal plane was then examined to determine if the nasal bone was visible or not., Results: In 421/450 (93.6%) cases the nasal bone was present during 2D ultrasound. Using the multiplanar mode of 3D ultrasound, in 83/421 (19.7%) fetuses a gap between the nasal bones could be demonstrated and in 36/83 (43.4%) cases the nasal bone was found to be absent in the perfect mid-sagittal view. In 29/450 (6.4%) cases the nasal bones were absent during the 2D scan. In the 3D assessment there was absence of both bones in 25/29 (86.2%) cases and absence of one of the two bones in 4/29 (13.8%) cases. Chorionic villus sampling demonstrated that the fetal karyotype was normal in 404 and abnormal in 46 cases, including 31 cases of trisomy 21. There was absence of one or both nasal bones in three (0.7%) of the chromosomally normal fetuses, in 19 (61.3%) with trisomy 21 and in seven (46.7%) with other chromosomal defects., Conclusions: At 11 to 13 + 6 weeks of gestation there is a gap between the nasal bones in about 20% of fetuses, and in about 40% of these cases in the perfect mid-sagittal plane the nasal bone may erroneously be considered to be absent.

This study presents 30 cases of fetal isolated spina bifida aperta (SBA) to identify prenatal ultrasound findings that could predict the prognosis. Comparisons between surviving patients who had normal (group 1) and abnormal (group 2) post-natal neurological outcomes were made for three different prenatal signs, that is, site of vertebral lesion, presence and degree of ventriculomegaly and presence of talipes. The site of the lesion was the most significant outcome predictor, as high spinal dysraphisms were observed in 2 patients (2/7-28.6%) in group 1 and in 15 patients (15/19-79.0%) in group 2 (p = 0.03). The presence of fetal ventriculomegaly was associated with impaired post-natal neurological development, as it occurred in 4 patients (4/7-57.1%) in group 1 and in 18 patients (18/19-94.7%) in group 2 (p = 0.04). The presence of talipes did not significantly differ between the two groups. Patients with abnormal intellectual outcome (8/26-30.8%) had significantly greater (p = 0.018) lateral ventricle/hemisphere ratios (mean = 0.74, standard deviation = 0.13) than those with normal intellectual development (mean = 0.54, standard deviation = 0.18). Mean post-natal follow-up was at 23 months (standard deviation = 15 months)., (Copyright 2003 John Wiley & Sons, Ltd.)