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The review article analyses the practical application of 3D/4D ultrasound in modern obstetrics. The basic terms applied with this method are introduced including their equivalents in Bulgarian. The main volume rendering modes are described. The advantages of 3D/4D ultrasound in obstetrics are outlined including: 1) improved understanding of normal fetal anatomy and fetal anomalies by the parents; 2) improved maternal-fetal bonding; 3) enhanced diagnosis of fetal anomalies; 4) precise identification of the nature, size and location of certain fetal defects; 5) precise volume measurement of organs with irregular shape; 6) retrospective analysis, data exchange and education. Some specific advantages of 3D/4D sonography are listed regarding its application in the first trimester, for the diagnosis of fetal anomalies and for fetal growth assessment. Some myths about 3D/4D ultrasound popular among patients and medical professionals are discussed. The ethical aspects of 3D/4D ultrasound in obstetrics as well as the future perspectives of the method are also outlined.

The aim of the study is to investigate the possibilities of three- and four-dimensional ultrasound in the prenatal diagnosis of structural fetal anomalies. We present our first experience with this relatively new diagnostic modality and discuss its implementation into clinical practice.

Unlabelled: The most of European registries of congenital anomalies (CA) collected information of CA in livebirths, stillbirths and terminated pregnancies following prenatal/ultrasound diagnosis., Objectives: to assess terminated pregnancies after prenatal/ ultrasound diagnosis of CA as a part of register of CA performed in University Hospital-Pleven. Among 21 202 births monitored during the study period (1996-2005), 679 CA were detected. The total prevalence of CA was 32/ 1000 births. The outcome of pregnancy for all cases of selected CA by register was 620 livebirths (91.3%), 36 stillbirths (5.3%), 23 terminated pregnancies (TP) (3.4%). The percentage of pregnancy termination was higher in the case of isolated anomalies, mainly lethal and CA associated with a low survival rate (61%), than with multiple ones. The most common CA detected after prenatal/ ultrasound diagnosis were neural tube defects (NTD) - the main reason for TP (52% of cases). The low proportion of these CA in TP (1/3) compared to their proportion in livebirths (50%) demonstrated an insufficiency of prenatal diagnosis of NTD as a part of register of CA performed in University Hospital-Pleven. Prenatal diagnosis of CA allows an early genetic counseling of mother presenting information on neonatal prognosis and recurrence risk for subsequent pregnancies. It helps family to take an adequate decision for termination of pregnancy with bad prognosis about heavy fetal CA.

Purpose: To evaluate the correlation between maternal hyperglycemia in early pregnancy and the risk of fetal abnormalities in pregnant women with type 1 diabetes mellitus., Study Design: A retrospective study over 124 pregnant women with diabetes mellitus type 1 hospitalized in High Risk Pregnancy Department--SHATOG "Maichin dom" has been done from January. 1998 to January 2004. The diabetic pregnant women were divided in two groups: first group pregnant women without malformations n = 105 and second group pregnant women with malformations n = 19. The pregnant women with fetal malformations were divided into two subgroups: with major malformations n = 13 and with minor malformations n = 6. The diabetic pregnant women were divided in classes according to Whites Classification: Class B - 38, Class C - 35; Class D - 39 and Class R/F - 12. The values of preprandial glucose, postprandial glucose and glycosilated hemoglobin has been measured at 13 week of gestation., Results: 104 pregnancies of total 124 pregnancies were without abnormalities. The fetal malformations were observed in 19 (15.3%) of total 124 pregnancies. The rate of major abnormalities were - 13 (10.4%) and minor abnormalities were - 7 (5.6%). The highest rate of abnormalities there has been within the complicated diabetic women of class D - n = 7 (17.9 %) and class R/F n = 3 (25%). The initial values of preprandial glucose 9.54 (SD +/- 3.59) mmol/l and postprandiai glucose 10.52 (SD +/- 1.81) mmol/l between the women whit pregnancies with abnormalities were significantly higher then those values of preprandial glucose 7.39 (SD +/- 2.82) mmol/l (P - 0.021) and values of postprandial glucose 10.52 (SD +/- 1.81) mmol/l (P = 0.014) between the women without fetal malformations. The mean values of glycosilated hemoglobin were significantly higher HbA 1 c = 9. 01% (SD +/- 1.53) in pregnancies complicated with malformations than those values measured in pregnancies without fetal malformations 8.06% (SD +/- 1.64, P = 0.022). A positive correlation between the observed abnormalities and metabolic control in the early pregnancy exist. The values of Hbeta A1-c is significantly higher Hbeta A1-c - 9.9% (SD +/- 1.2) in pregnancies complicated with fetal malformations than those measured in pregnancies without malformations. Hbeta A1-c 8.2% (SD +/- 1.5) n = 125. Significant differences in the value of Hbeta A1-c between pregnancies with mild and those with severe abnormalities have not been established. A correlation between the levels of Hbeta A1-c in early pregnancy and the rate of the observed abnormalities exist. Within the values of Hbeta A1-c < 7.9%, the rate of malformations is 6.9%, Hbeta A1-c > 8.0% < 10%, the rate of malformations is 19.0% and within the values of Hbeta A1-c > 10%, the rate of the observed abnormalities is 31.5%. A logistic regression between the higher values of postprandial glucose and Hbeta A1-c values and the relative risk of congenital malformations has been observed. The relative risk is evaluated by odds ratio (OR) When the levels of Hbeta A1-c rise with 1% the relative risk of congenital malformations is evaluated by odds ratio OR = 2.02 (limited in 1.46 - 2.81 by 95% conf. interval) and when the levels of postprandial glucose rise with 1 mmol/l the relative risk OR = 1.21 (limited in 1.06 - 1.37: 95% conf. interval)., Conclusion: Fetal abnormalities are more frequent in pregnant women with long lasting diabetes complicated with vasculopathy. Fetal abnormalities are associated with higher levels of Hbeta A1-c in the first trimester of pregnancy. In diabetic women who planed their pregnancy an optimal metabolic control must been established.

Aim: The aim of the present survey is to analyze the attitude of pregnant women towards the possibilities of prenatal screening and diagnosis between 11-14 weeks of gestation (w.g.)., Material and Methods: Overall 109 pregnant women, hospitalized in SBALAG "Maichin dom", received written information about the possibilities for prenatal screening and diagnosis between 11-14 w.g. and 16-20 w.g., as well as a comprehensive description of the potential advantages and disadvantages of the different approaches/methods of screening/diagnosis. Consequently, the patients were asked to answer 13 closed and semi-closed questions in an anonymous enquiry., Results: Overall 97,2% (106/109) of the women agreed to perform an ultrasound examination for fetal nuchal translucency measurement as a screening tool for chromosomal anomalies between 11-14 w.g. Furthermore, 82,6% (90/109) preferred the option of first trimester biochemical screening, rather than screening in the second trimester. On the other hand only 62,4% (68/109) accepted chorionic villous sampling between 11-14 w.g. in comparison to 83,5% (91/109) who agreed to perform an amniocentesis between 16-20 w.g., Conclusion: The vast majority of women prefer prenatal screening programs to be scheduled in the first, rather than in the second trimester. However, most women would still choose for a relatively safer second trimester invasive procedure instead of the option of earlier prenatal diagnosis.

Aim of the Study: To assess the feasibility of first trimester ultrasound screening for structural and chromosomal fetal anomalies in multiple gestations., Methods: An observational prospective follow up study was carried out in 32 cases of multiple pregnancies. Two scans were scheduled in each case--the first, between 6-9 weeks of gestation (w.g.) and the second, between 11-14 w.g. The aim was assessment of fetal number, viability, chorionicity/amnionicity and fetal biometry. In addition, nuchal translucency [NT] measurement, assessment of risk for chromosomal anomalies and fetal anatomy survey were always performed. Increased NT > or = 95 percentile and/or detection of structural anomaly were considered indications for invasive prenatal diagnosis and fetal karyotyping. Selective fetocide was considered in cases of chromosomal or structural anomalies and in high-order multiple gestations (> or = 3 fetuses). Pregnancy outcome was ascertained by the physical examination of the fetuses, placentas and membranes postpartum, the hospital records, the referring physicians or the parents., Results: From 32 cases of multiple pregnancies included in the study, 28 were twins, and 4--triplets. 68% (19/28) of the twin pregnancies were bichorionic-biamniotic [Bi-Bi], 25% (7/28)--monochorionic-biamniotic [Mo-Bi] and 7% (2/28)--monochorionic-monoamniotic [Mo-Mo]. 4 cases of increased NT in one of the twins (1--associated with trisomy 21) were observed, as well as 2 cases of structural fetal anomalies (1--discordant for exencephaly, and 1--with conjoint twins), 2 cases of feto-fetal transfusion syndrome that developed in the second trimester (1--associated with increased NT between 11-14 w.g.), 1 case of TRAP syndrome [twin-reversed arterial perfusion] and 1 case of cord entanglement in monoamniotic twins. In addition, there were 4 cases of a vanishing twin in the first trimester, and in 2 other cases spontaneous miscarriage of both twins occurred before 24 w.g. In two of the triplet pregnancies selective fetocide was performed, one was successfully delivered at 33 w.g. and in the last case the parents chose to terminate the pregnancy., Conclusions: First trimester ultrasound is a method of choice for detection of major structural fetal anomalies in multiple gestations. Increased NT between 11-14 w.g. in multiple pregnancies is a useful screening tool for detection of chromosomal fetal anomalies, while in monochorionic twins its presence might predict the development of fetofetal transfusion syndrome. First trimester selective fetocide in high-order multiple gestations or in affected twins is one of the options in pregnancy management.

Aim of the Study: To assess the feasibility of ultrasound screening and diagnosis of structural fetal anomalies at the 11-14 week scan., Methods: An observational prospective follow up study from March 2000 till May 2003 was performed at three referral centers by seven experienced sonographers with high-resolution ultrasound equipment. 1135 singleton pregnancies between 11+0 and 14+6 weeks gestation (w.g.) participated in the study. The first trimester scan included assessment of fetal number, viability and biometry, nuchal translucency [NT] measurement and fetal anatomy survey performed according to standardized published protocols. Increased NT > or = 95th centile and/or diagnosis of structural fetal anomaly was considered as indication for invasive prenatal diagnosis, early fetal echocardiogram and follow-up scans, including a detailed fetal anomaly scan at 18-22 w.g. and a third scan at 28-32 w.g. Pregnancy outcome was ascertained from hospital records, referring physicians or the patients themselves., Results: The overall prevalence of structural fetal anomalies in the present study was 4.6% (53/1135). 22% (12/53) of the structural anomalies were detected between 11-14 w.g. 9 of those had normal karyotype, and 3 were associated with chromosomal anomalies. Furthermore, 10 cases of increased NT, with or without non-immune hydrops fetalis, were associated with congenital heart disease, rare genetic syndromes and adverse pregnancy outcome later in gestation. The ultrasound detection rate of structural fetal anomalies in the present study increased from 22% (12/53), to 69% (37/53) and 79% (42/53) for the first trimester scan, the first and second trimester scans, and the combination of all three scans, respectively. 21% (11/53) of all structural fetal anomalies were missed by prenatal ultrasound., Conclusions: The first trimester scan is a method of choice for the diagnosis of major structural fetal anomalies. NT measurement is a useful screening test for chromosomal anomalies. In cases with increased NT subsequent development of congenital heart disease, rare genetic syndromes or adverse pregnancy outcome should be ruled out. At present, the second trimester scan constitutes an indispensable tool for the detection of most structural abnormalities. Even in advanced gestation the prenatal diagnosis of certain anomalies is difficult and often unfeasible.