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These practice guidelines follow the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world, with the goal of improving the ultrasound assessment of the fetal Central Nervous System (CNS) anatomy. In fact, this document provides further guidance for healthcare practitioners for the evaluation of the fetal CNS during the mid-trimester ultrasound scan with the aim to increase the ability in evaluating normal fetal anatomy. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world, and serves as a guideline for use in clinical practice.

Abnormal fetal tongue size is a phenotypic feature of various syndromes including Beckwith-Wiedemann, Pierre-Robin, oromandibular limb hypoplasia, chromosomal aberrations, etc. Current data regarding normal fetal tongue size are limited. Hence, micro/macroglossia are subjectively determined. The aim of the study was to construct a contemporary fetal tongue nomogram and to assess its clinical contribution.A prospective cross-sectional study was performed in well dated, low risk, singleton pregnancies. Fetal tongues were measured by 5 trained sonographers. Highest quality images were selected. Intra- and interobserver variability was assessed. Tongue length, width, area, and circumference 1st to 99th centiles were calculated for each gestational week. Based on the normal tongue size charts, we created a Tongue Centile Calculator.Over 18 months, 664 tongue measurements were performed. A cubic polynomial regression model best described the correlation between tongue size and gestational age. The correlation coefficient (rWe present novel fetal tongue size charts from 13 to 40 weeks of gestation. Clinical application of these nomograms may be beneficial in the prenatal diagnosis of syndromes or malformations associated with abnormal fetal tongue size.

To evaluate the long-term outcome of fetuses with a diagnosis of isolated short long bones. A retrospective review was conducted of all cases diagnosed with short long bones above 20 weeks of gestation during 2010–2017 in a single tertiary center. Exclusion criteria included abnormal sonographic findings other than short long bones, suspected genetic syndromes, chromosomal abnormalities, and abnormal Doppler flow indices. Follow-up was carried out by telephone questionnaire. During the study period, 54 (24.32%) women met inclusion criteria. Mean gestational age at delivery was 38.05 years (± 2.42 SD). Mean birth weight was 12–19th percentile according to the local fetal growth charts [2645 g (± 684 SD) 95% CI 2173–2980]. Median time for post-natal follow-up was 9.3 years (IQR 6.6–10.75). Growth below the 10th percentile was demonstrated in 27 (50%) children. 11 (20.37%) children were followed up by endocrinological clinics, of them 7 (12.96%) were treated with growth hormone. Three (5.6%) of the children were diagnosed with attention deficit hyperactivity disorder, an incidence that is considered lower than that of the general population (± 9%). Prenatal fetal isolated short long bones diagnosed during the late second and third trimester is associated with short stature. No neurodevelopmental impact was observed in our study group.

Purpose: To assess the value of pre-labor maternal and fetal sonographic variables to predict an unplanned operative delivery.Methods: In this prospective study, nulliparous women were recruited at 37.0-42.0 weeks of gestation. Sonographic measurements included estimated fetal weight, maternal pubic arch angle, and the angle of progression. We performed a descriptive and comparative analysis between two outcome groups: spontaneous vaginal delivery (SVD) and unplanned operative delivery (UOD) (vacuum-assisted, forceps-assisted and cesarean deliveries). Multivariate logistic regression with ROC analysis was used to create discriminatory models for UOD. Results: Among 234 patients in the study group, 175 had a spontaneous vaginal delivery and 59 an unplanned operative delivery. Maternal height and pubic arch angle (PAA) significantly correlated with UOD. Analysis of Maximum Likelihood Estimates revealed a multivariate model for the prediction of UOD, including the parameters of maternal age, maternal height, sonographic PAA, angle of progression (AOP), and estimated fetal weight, with an area under the curve of 0.7118. Conclusion: Sonographic parameters representing maternal pelvic configuration (PAA) and maternal-fetal interface (AOP) improve the prediction ability of pre-labor models for a UOD. These data may aid the obstetrician in the counseling process before delivery.

An aberrant right subclavian artery (ARSA) can be overlooked by the conventional method as described by Chaoui et al., due to acoustic shadowing. The aim of this study was to evaluate the feasibility and accuracy of a novel screening method for ARSA by demonstrating the brachiocephalic artery bifurcation, referred to as the &ldquo, No ARSA&rdquo, sign. A prospective study conducted at a tertiary care center between 2018 and 2019 included unselected pregnant patients at a median gestational age of 15.1 (14.2&ndash, 22.1, IQR (inter-quartile range)) weeks, who had been referred for a routine or targeted anomaly scan. All participants were scanned for the presence or absence of ARSA using both the conventional and the novel &ldquo, methods for validation purposes. A total of 226 unselected patients were enrolled in the study. The &ldquo, sign was visualized in 218 fetuses (96.5%). In the remaining 8 cases (3.5%), the &ldquo, sign was not demonstrated. In these fetuses, an ARSA was visualized by the conventional method. The new method exhibited 100% feasibility and was in complete agreement with the conventional method. Intra- and inter-observer agreement was excellent (&kappa, = 1). The results of the study suggest that the &ldquo, sign is an efficient and reliable screening tool for ARSA.

Objective Fetal isolated ventricular asymmetry (IVA) is a relatively common finding in pregnancy, but data regarding its effect on neurodevelopmental outcome are scarce and founded principally on ultrasound-based studies. The purpose of this study was to assess the neurodevelopmental outcome of IVA cases in a magnetic resonance imaging (MRI)-based study. Methods Cases referred for fetal brain MRI as part of the assessment of IVA without ventriculomegaly (lateral ventricular atrial diameter ≤ 10 mm), identified during routine ultrasound examination, were assessed for possible inclusion. Asymmetry was defined as a difference in width of ≥ 2 mm between the two lateral ventricles. Forty-three cases were included in the study group and compared with a control group of 94 normal cases without IVA. Children were assessed at ages 13-74 months using the Vineland-II Adaptive Behavior Scales (VABS-II). Results VABS-II scores were within normal range. There was no significant difference in composite VABS-II score between the study and control groups (106.5 vs 108.0; P = 0.454). VABS-II scores did not differ between the groups when matched for gender and age at VABS-II interview (109.6 in study group vs 107.8 in control group; P = 0.690). Conclusion In cases of IVA without ventriculomegaly on MRI, neurodevelopmental test scores were normal and did not differ from cases without IVA. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Congenital heart defects (CHD) may be associated with neurodevelopmental abnormalities mainly due to brain hypoperfusion. This defect is attributed to the major cardiac operations these children underwent, but also to hemodynamic instability during fetal life. Advances in imaging techniques have identified changes in brain magnetic resonance imaging (MRI)in children with CHD.To examine the correlation between CHD and brain injury using fetal brain MRI.We evaluated 46 fetuses diagnosed with CHD who underwent brain MRI. CHD was classified according to in situs anomalies, 4 chamber view (4CV), outflow tracts, arches, and veins as well as cyanotic or complex CHD. We compared MRI results of different classes of CHD and CHD fetuses to a control group of 113 healthy brain MRI examinations.No significant differences were found in brain pathologies among different classifications of CHD. The anteroposterior percentile of the vermis was significantly smaller in fetuses with abnormal 4CV. A significantly higher biparietal diameter was found in fetuses with abnormal arches. A significantly smaller transcerebellar diameter was found in fetuses with abnormal veins. Compared to the control group, significant differences were found in overall brain pathology in cortex abnormalities and in extra axial findings in the study group. Significantly higher rates of overall brain pathologies, ventricle pathologies, cortex pathologies, and biometrical parameters were found in the cyanotic group compared to the complex group and to the control group.Fetuses with CHD demonstrate findings in brain MRI that suggest an in utero pathogenesis of the neurological and cognitive anomalies found during child development.

To evaluate the long-term outcome of fetuses with a diagnosis of isolated short long bones.A retrospective review was conducted of all cases diagnosed with short long bones above 20 weeks of gestation during 2010-2017 in a single tertiary center. Exclusion criteria included abnormal sonographic findings other than short long bones, suspected genetic syndromes, chromosomal abnormalities, and abnormal Doppler flow indices. Follow-up was carried out by telephone questionnaire.During the study period, 54 (24.32%) women met inclusion criteria. Mean gestational age at delivery was 38.05 years (± 2.42 SD). Mean birth weight was 12-19th percentile according to the local fetal growth charts [2645 g (± 684 SD) 95% CI 2173-2980]. Median time for post-natal follow-up was 9.3 years (IQR 6.6-10.75). Growth below the 10th percentile was demonstrated in 27 (50%) children. 11 (20.37%) children were followed up by endocrinological clinics, of them 7 (12.96%) were treated with growth hormone. Three (5.6%) of the children were diagnosed with attention deficit hyperactivity disorder, an incidence that is considered lower than that of the general population (± 9%).Prenatal fetal isolated short long bones diagnosed during the late second and third trimester is associated with short stature. No neurodevelopmental impact was observed in our study group.

To evaluate the added value of fetal MRI to ultrasound in detecting and specifying callosal anomalies, and its impact on clinical decision making.Fetuses with a sonographic diagnosis of an anomalous corpus callosum (CC) who underwent a subsequent fetal brain MRI between 2010 and 2015 were retrospectively evaluated and classified according to the severity of the findings. The findings detected on ultrasound were compared to those detected on MRI. An analysis was performed to assess whether fetal MRI altered the group classification, and thus the management of these pregnancies.78 women were recruited following sonographic diagnoses of either complete or partial callosal agenesis, short, thin or thick CC. Normal MRI studies were obtained inµ19 cases (24 %). Among these, all children available for follow-up received an adequate adaptive score in their Vineland II adaptive behavior scale assessment. Analysis of the concordance between US and MRI demonstrated a substantial level of agreement for complete callosal agenesis (kappa: 0.742), moderate agreement for thin CC (kappa: 0.418) and fair agreement for all other callosal anomalies. Comparison between US and MRI-based mild/severe findings classifications revealed that MRI contributed to a change in the management for 28 fetuses (35.9 %), mostly (25 fetuses, 32.1 %) in favor of pregnancy preservation.Fetal MRI effectively detects callosal anomalies and enables satisfactory validation of the presence or absence of callosal anomalies identified by ultrasound and adds valuable data that improves clinical decision making.Feten mit sonografischer Diagnose von Corpus callosum (CC) Anomalien und anschließender fetaler Schädel-MRT zwischen 2010 und 2015 wurden retrospektiv evaluiert und nach dem Schweregrad der Befunde klassifiziert. Die im Ultraschall erhobenen Befunde wurden mit denen der MRT verglichen. Um zu beurteilen, ob die fetale MRT die Gruppenklassifikation und somit auch das Management dieser Schwangerschaften ändert, wurde eine Analyse durchgeführt.Es wurden 78 Frauen mit sonografischer Diagnose einer kompletten oder partiellen Corpus-callosum-Agenesie rekrutiert, mit kurzem, dünnem oder dickem CC. Normale MRT- Ergebnisse lagen in 9 Fällen (24 %) vor. Von diesen erreichten alle Kinder, die zur Nachuntersuchung zur Verfügung standen, einen zufriedenstellenden Score bezüglich des Anpassungsverhaltens im „Vineland-II-Adaptive Behaviour Scales“. Die Analyse der Konkordanz zwischen US und MRT zeigte, dass der Grad der Übereinstimmung bei kompletter Balkenagenesie erheblich (kappa: 0,742), bei dünnem CC moderat (kappa: 0,418) und für alle anderen Balkenanomalien gut war. Der Vergleich zwischen den Befundklassifikationen basierend auf US und MRT zeigte, dass die MRT zu einer Veränderung im Management von 28 Feten (35,9 %) beigetragen hat, in den meisten Fällen (25 Feten; 32,1 %) zu Gunsten der Fortsetzung der Schwangerschaft.Die fetale MRT erkennt effektiv Corpus-callosum-Anomalien und ermöglicht eine zufriedenstellende Bewertung bei Verdacht auf Balkenagenesie im Ultraschall und liefert wertvolle Informationen, die zu einer besseren klinische Entscheidungsfindung beitragen.

Sonographic assessment of the fetal kidneys is an integral part of the prenatal anatomical survey.To evaluate the fetal renal to abdominal (RTA) ratio throughout pregnancy and to investigate whether this ratio can be a potential diagnostic landmark for congenital anomalies of the kidney and urinary tract (CAKUT).Measurements of the anterior-posterior diameters of the fetal kidney and fetal abdomen (APAD) were obtained prospectively. The RTA was calculated as the ratio between them in in two groups: normal population vs. CAKUT cases. RTA in CAKUT cases was compared to RTA in a normal population.The study group was comprised of 210 women. The mean gestational age for the fetuses was 31 ± 5.6 weeks (range 14-40 weeks). Fetal RTA ratio was found to be 0.28 ± 0.03 throughout pregnancy from early second trimester to term, with high reproducibility of measurements. During the study period the RTA was evaluated in nine cases referred for suspected CAKUT. All cases demonstrated a different ratio according to the renal anomaly. High ratio was observed in one case of overgrowth syndrome (Beckwith Wiedenmann syndrome; 0.47), three cases of infantile polycystic kidney (0.45-0.47), and three cases of a solitary kidney (0.31-0.35), while cases of dysplastic kidneys revealed a low ratio (0.14-0.18).Prenatal RTA ratio is constant throughout gestation. An abnormal ratio should lead to meticulous renal investigation to rule out kidney disease.

BACKGROUND AND PURPOSE: One of the perplexing findings of fetal brain MR imaging is white matter T2 hyperintense signal. The aims of our study were initially to determine the main etiologies associated with white matter T2 hyperintense signal, then to examine whether the different etiologies have different ADC values, and, last, to assess the association of white matter T2 hyperintense signal with developmental outcome. MATERIALS AND METHODS: This was a prospective cohort study of 44 MR imaging scans of fetal brains obtained for suspected brain pathologies at a tertiary medical center during 2011–2015. Clinical data were collected from electronic medical charts. ADC values were measured and averaged in the frontal, parietal, occipital, and temporal lobes. Neurodevelopmental assessments were performed with the Vineland Adaptive Behavior Scales II. RESULTS: Half of the cases of MRI hyperintense T2 signal of the fetal brain were associated with congenital cytomegalovirus infection. The other half were mainly idiopathic. Thus, the study group was divided to subgroups positive and negative for cytomegalovirus. Both groups had hyperintense signal in the temporal lobe. The group positive for cytomegalovirus had involvement of the parietal lobe. Only this group had increased ADC values in the temporal and parietal lobes. There was no association between the neurodevelopment outcome and the etiologies or ADC values. CONCLUSIONS: T2 hyperintense signal in fetal brain MRI associated with positive cytomegalovirus infection has increased ADC values in the temporal and parietal lobes, suggestive of brain edema in these areas. However, the association between this finding and neurodevelopment outcome requires further evaluation.

Progress in the fields of fetal cardiology and fetal surgery have been seen not only in singleton pregnancies but also in multiple pregnancies. Proper interpretation of prenatal echocardiography is critical to clinical decision making, family counseling and perinatal management for obstetricians, maternal fetal medicine specialists, neonatologists and pediatric cardiologists. Fetal echocardiography is one of the most challenging and time-consuming prenatal examinations to perform, especially in multiple gestations. Performing just the basic fetal exam in twin gestations may take an hour or more. Thus, it is not practical to perform this exam in all cases of multiple gestations. Therefore our review and recommendations are related to fetal echocardiography in twin gestation.

Background Methods available for assessing the learning curve, such as a predefined number of procedures or direct mentoring are lacking. Our aim was to describe the use of a statistical method to identify the minimal training length of an experienced sonographer, newly trained in deep infiltrating endometriosis (DIE) mapping by evaluating the learning curve of transvaginal ultrasound (TVUS) in the preoperative assessment of endometriosis. Methods A retrospective study in a tertiary referral center for endometriosis. Reports and stored data from TVUS scans performed by one operator with training in general gynecological ultrasound, but not in endometriosis mapping, were analyzed retrospectively for patients who subsequently underwent laparoscopy, which served as a reference standard. The performance of TVUS was assessed for the following sites: endometriomas, bladder, vagina, pouch of Douglas, bowel and uterosacral ligaments, and correlated with laparoscopic findings. Sensitivity, specificity, PPV, NPV, and accuracy were calculated, and the operator’s diagnostic performance was assessed using the learning curve cumulative summation test (LC-CUSUM). Results Data from 94 women were available for analysis. The learning curve using the LC-CUSUM graph showed that the sonographer reached the predefined level of proficiency in detecting endometriosis lesions after 20, 26, 32, 31, 38, and 44 examinations for endometriomas, bladder nodules, vaginal nodules, pouch of Douglas obliteration, bowel nodules, and uterosacral ligament nodules, respectively. Conclusions LC-CUSUM allows monitoring of individual performance during the learning process of new methodologies. This study shows that a sonographer trained in general gynecologic ultrasonography, who devotes time to learn TVUS for DIE mapping, can achieve proficiency for diagnosing the major types of endometriotic lesions after examining less than 50 patients who subsequently undergo surgery in a training setting.

Sonographic finding of a soft tissue mass in the fetal scalp poses a diagnostic challenge. We present the workup of a fetus with a mass in the scalp with abnormal course of the dural sinuses.

In recent years, the role of intrapartum sonography has expanded in childbirth management, in subjective clinical situations such as arrested deliveries, or prior to instrumental deliveries.To assess the current use of intrapartum ultrasound by obstetricians in Israel.An anonymous questionnaire was completed by 79 obstetricians in second- and third level- hospitals in Israel. The results were analyzed according to main subspecialty (sonography, delivery), experience and gender.A questionnaire was completed by 56 senior obstetricians and 23 interns with an average experience of 14.3 and 2.4 years, respectively. All obstetricians performed ultrasound examinations in the delivery room for basic indications such as fetal presentation during twin delivery and to rule out placenta previa. Sonographers consistently reported advanced indications as compared to senior members of delivery teams and interns in the assessment of prolonged first (52% vs. 14% vs. 14%) and second stage of labor (88% vs. 52% vs. 62%) and in assessment of fetal head station (60% vs. 30% vs. 22%), head progression during descent (48% vs. 23% vs. 11%), diagnosis of head position (88% vs. 68% vs. 60%), spine direction (92% vs. 59% vs. 53%) and asynclytism (41% vs. 20% vs. 29%).Ultrasound is currently used by all physicians in the delivery room for basic indications. However, obstetric teams report a low use of advanced intrapartum ultrasound and prefer to rely on their clinical experience. Advanced intrapartum sonographic imaging should be an integral part of obstetric qualifications. A steep learning curve, along with high reproducibility, suggests that ultrasound devices will become a common tool in labor and delivery management.

Aim: To evaluate an innovative sonopelvimetry method for early prediction of obstructed labour. Methods: A prospective study was conducted in two centers.GPS-based sonopelvimetry, laborProTM (Trig Medical Inc., Yoqneam Ilit, Israel) devise, was used prior to labour in nulliparous women at 39 - 42 weeks gestation remote from labor. Maternal pelvic parameters, including inter-iliac transverse diameter, obstetric conjugate and interspinous diameter were evaluated. Fetal parameters included head station, biparietal diameter and occipitofrontal diameter. Data on delivery and outcome were collected from the electronic files. Results: The innovative use of sonopelvimetry was applied to 154 consecutive women, none of the participants complained of discomfort or complications observed. The mean time of examination was 15 + 2 minutes. Mean time of examination to delivery interval was 4.8 days (range 0 - 16 days). Small interspinous diameter and high head station were the best predictors for obstructed labour. Analysis indicated 87% sensitivity and 61% specificity for birth weight fetal head station and ISD combined in predicting obstructed labour with an area under the curve of 0.77. Conclusions: Our results indicate that GPS-based sonopelvimetry combined with fetal estimated weight is a valuable tool in the risk assessment of obstructed labour. Parameters obtained by sonopelvimetry combined with birth weight may be useful.

BACKGROUND AND PURPOSE: Fetal lateral ventriculomegaly is a relatively common finding with much debate over its clinical significance. The purpose of this study was to examine the association between ventriculomegaly and asymmetry and concomitant CNS findings as seen in fetal brain MR imaging. MATERIALS AND METHODS: Fetal brain MR imaging performed for various indications, including ventriculomegaly, with or without additional ultrasound findings, was assessed for possible inclusion. Two hundred seventy-eight cases found to have at least 1 lateral ventricle with a width of ≥10 mm were included in the study. Ventriculomegaly was considered mild if the measurement was 10–11.9 mm; moderate if, 12–14.9 mm; and severe if, ≥15 mm. Asymmetry was defined as a difference of ≥2 mm between the 2 lateral ventricles. Fetal brain MR imaging findings were classified according to severity by predefined categories. RESULTS: The risk of CNS findings appears to be strongly related to the width of the ventricle (OR, 1.38; 95% CI, 1.08–1.76; P = .009). The prevalence of associated CNS abnormalities was significantly higher ( P = .005) in symmetric ventriculomegaly compared with asymmetric ventriculomegaly (38.8% versus 24.2%, respectively, for all CNS abnormalities and 20% versus 7.1%, respectively, for major CNS abnormalities). CONCLUSIONS: In this study, we demonstrate that the rate of minor and major findings increased with each millimeter increase in ventricle width and that the presence of symmetric ventricles in mild and moderate ventriculomegaly was a prognostic indicator for CNS abnormalities.

Objective To discern whether plasma levels of microparticles (MPs) measured at 24 weeks of gestation predict late complications of pregnancy. Design Secondary analysis of samples obtained prospectively. Setting Large academic medical center. Patient(s) Two hundred sixty-two healthy women selected from 642 nulliparous women with singleton pregnancies. Intervention(s) Sampling for blood cell MPs and thrombophilias at 24 weeks of gestation and measurements of blood flow resistance in uterine, placental, and umbilical arteries at 24 and 31 to 33 weeks of gestation. Main Outcome Measure(s) Relationship between levels of MPs and late pregnancy complications, thrombophilias, and blood flow resistance. Result(s) Flow cytometry only detected MPs derived from endothelial cells (CD31 + ) and platelet (CD41 + ). No statistically significant correlation was found between levels of CD31 + or CD41 + MPs and subsequent occurrence of pregnancy-induced hypertension, preeclampsia, intrauterine growth restriction, or small for gestational age infants. Nor was there a statistically significant correlation with blood flow resistance parameters at 24 weeks of gestation (except for the left uterine artery) or at 31 to 33 weeks of gestation. Levels of these MPs in thrombophilic and nonthrombophilic women were similar. Conclusion(s) Levels of circulating MPs at 24 weeks of gestation had no predictive value for subsequent development of pregnancy-induced hypertension, preeclampsia, intrauterine growth restriction, or small for gestational age infants.

BACKGROUND AND PURPOSE: Normal biometry of the fetal posterior fossa rules out most major anomalies of the cerebellum and vermis. Our aim was to provide new reference data of the fetal vermis in 4 biometric parameters by using 3 imaging modalities, 2D ultrasound, 3D ultrasound, and MR imaging, and to assess the relation among these modalities. MATERIALS AND METHODS: A retrospective study was conducted between June 2011 and June 2013. Three different imaging modalities were used to measure vermis biometry: 2D ultrasound, 3D ultrasound, and MR imaging. The vermian parameters evaluated were the maximum superoinferior diameter, maximum anteroposterior diameter, the perimeter, and the surface area. Statistical analysis was performed to calculate centiles for gestational age and to assess the agreement among the 3 imaging modalities. RESULTS: The number of fetuses in the study group was 193, 172, and 151 for 2D ultrasound, 3D ultrasound, and MR imaging, respectively. The mean and median gestational ages were 29.1 weeks, 29.5 weeks (range, 21–35 weeks); 28.2 weeks, 29.05 weeks (range, 21–35 weeks); and 32.1 weeks, 32.6 weeks (range, 27–35 weeks) for 2D ultrasound, 3D ultrasound, and MR imaging, respectively. In all 3 modalities, the biometric measurements of the vermis have shown a linear growth with gestational age. For all 4 biometric parameters, the lowest results were those measured by MR imaging, while the highest results were measured by 3D ultrasound. The inter- and intraobserver agreement was excellent for all measures and all imaging modalities. Limits of agreement were considered acceptable for clinical purposes for all parameters, with excellent or substantial agreement defined by the intraclass correlation coefficient. CONCLUSIONS: Imaging technique–specific reference data should be used for the assessment of the fetal vermis in pregnancy.

Objectives Dandy‐Walker complex is a continuum of developmental anomalies of the posterior fossa which includes vermian rotation. However, vermian rotation alone may be benign. The aim of this study was to describe our experience with sagittal-plane prenatal ultrasound in thediagnosis ofrotationofthe vermisincasesof suspected enlarged cisterna magna on routine antenatal imaging, and to describe the follow-up of these patients. Methods Seven women, who were referred to our ultrasound unit for evaluation of an enlarged fetal cisterna magna and suspected agenesis of the vermis on axialplane imaging, underwent further multiplanar studies of the posterior fossa and measurements of the vermis. Results The mean maternal age was 27 (range, 20‐33) years and the mean gestational age at diagnosis was 19.5 (range, 18‐31) weeks. The standard axial plane image showed a ‘direct communication’ between the cisterna magna and the fourth ventricle. In the midsagittal plane, the vermis was clearly delineated, with posterosuperior rotation. Vermis size was within normal limits for gestational age in all cases. Findings were confirmed by prenatal magnetic resonance imaging (MRI) in two cases and postnatal MRI and/or sonography infive. During a mean follow-up of 4.5 (range, 1‐7.5) years, all children developed normally, with no neurological complications. Conclusion The finding of an enlarged cisterna magna on standard- (axial-)plane ultrasound should be evaluated further inthe sagittal planeto determinewhether thecause is rotation of a normal vermis. This may spare patients unnecessary tests, anxiety and, in some cases, pregnancy termination. Copyright  2006 ISUOG. Published by John Wiley & Sons, Ltd.

Congenital heart defects (CHD) are the most frequent malformation in the human fetus and are the leading cause of mortality due to malformations in the first year of life. Despite its clinical importance screening performed by ultrasonographic examination during the second trimester of pregnancy has shown disappointingly low detection rates mainly due to the difficulties in obtaining an adequate examination of the fetal heart. Four-dimensional (4D) ultrasound of the fetal heart has been recently suggested as a tool to improve the detection rate of CHD by decreasing the dependency on operator skills required in two-dimensional ultrasound scans but up to now no practical manuals are available in describing its application in clinical practice for the study of fetal heart. The objective of this Ebook is to explain the role of 4D during second trimester examination and in fetuses with CHD. The technique of obtaining 4D volume of the fetal heart, how to navigate in the volume to obtain diagnostic planes and how to use semiautomatic and automatic software of analysis are described. We believe that after reading this book the standard fetal cardiac anatomy survey can be performed in the second trimester fetus by 4D in both normal and abnormal hearts. This approach may reduce the operator dependency in diagnosis CHD. This Ebook should prove to be a valuable resource for obstetricians, sonographers and pediatric cardiologists.

Objective To evaluate the outcome of infants born to mothers with varicella zoster virus (VZV) infection in pregnancy who had second trimester amniocentesis for detection of placental transfer. Methods We interviewed women who had had VZV infection in pregnancy and who underwent diagnostic amniocentesis to detect transplacental infection using both polymerase chain reaction (PCR) and cell culture methods to characterize their children's clinical and psychomotor development. Results Twenty women who had a diagnosis of primary VZV during pregnancy were available for interview. The mean gestational age at which primary VZV was acquired was 11±3.5 weeks. One infant had hypospadias and developmental delay. He was born to an epileptic mother who had been treated during pregnancy with sodium valproate and clonazepam. Another infant had abnormal brainstem auditory-evoked potentials. All other infants were reported to have normal clinical and psychomotor development. Conclusion In cases of varicella infection during pregnancy, negative studies of amniotic fluid using PCR may contribute to decision making.

The objective of this study was to determine if transvaginal ultrasound (TVUS) examination of cervical length correlates to digital pelvic examination and if it can predict time to and mode of delivery in term pregnancies.We conducted a prospective cohort study of 726 consecutive non-laboring, term pregnant women presenting to University-based antenatal testing unit between 1 July 2001 and 31 March 2002. Subjects underwent a TVUS for cervical length followed by a digital cervical examination by a physician blinded to the results of the ultrasound. Linear regression analysis was used to correlate the findings of cervical length by ultrasound with cervical dilatation and effacement by digital examination.In 726 women, the relationship between TVUS cervical length and cervical dilatation and effacement measured digitally were found to be significantly related (p0.001), but weak, with a 15 and 23% goodness of fit, respectively, based on the linear model. Using multivariate logistic and linear regression, respectively, TVUS cervical length predicted mode of delivery but did not predict time to spontaneous labor. Digital measurement of cervical dilatation was predictive of time to spontaneous labor.There is a statistically significant correlation between TVUS measurement of cervical length and digital cervical exam though the correlation is weak. TVUS measurement of cervical length was predictive of mode of delivery while controlling for digital cervical examination, parity and time to spontaneous labor. Digital cervical dilatation was predictive of time to spontaneous delivery.

Since its introduction in the mid-1980s sonographic evaluation of the human fetal venous system has advanced dramatically. The venous system is well-recognized as a target for investigation in cases of circulatory compromise, and a broad spectrum of malformations affecting this system has been described. Appreciation of the normal embryology, anatomy and physiology of this system is essential to an understanding of structural anomalies and the sequential changes encountered in intrauterine growth restriction or other developmental disorders. We review the normal embryology, anatomy, and hemodynamics of the human fetal venous system, and provide an overview of Doppler investigation, as well as three- and four-dimensional ultrasound modalities and their application to this system.

We describe our experience with prenatal diagnosis of sex differentiation disorders, with focus on the role of ultrasound scans for coherent assessment of prenatal diagnosis. Over a 5-yr period all cases suspected of sexual ambiguity based on abnormal ultrasonographic scans (US) or US/genotype US discrepancy were evaluated prenatally by three modalities: 1) repeated fetal US; 2) genetic studies, primarily karyotype and fluorescence in situ hybridization analysis of sex-determining region on the Y gene (SRY); and 3) hormonal assays of amniotic fluid. Of approximately 10,000 gestations, 16 fetuses underwent prenatal evaluation. Twelve were referred because of an abnormal US and 4 because of genotype-phenotype discrepancy. Five fetuses were diagnosed with female pseudohermaphroditism (21-hydroxylase deficiency in 3 and urorectal septum malformation sequence in 2). Four fetuses were diagnosed with male pseudohermaphroditism (1 with steroid sulfatase deficiency, 1 with presumed camptomelic dysplasia, and 2 undetermined). Five cases had chromosomal abnormalities, and 2 had 46,XX+SRY sex reversal. In all genetic females the uterus was observed on US. In 11 cases initial US scan was performed at 13-15 wk; in 7 of 11, although the initial scan was normal, a repeated scan later in gestation revealed an abnormality. Repeated US scans performed at 13-15 and 22-24 wk gestation are a helpful tool in prenatal diagnosis of sex differentiation disorders. Our data suggest that both size and structure anomalies of the reproductive structures may evolve throughout pregnancy, and that they represent a developmental biological process rather than a single nonprogressive pathological event. US scan after approximately 19 wk enables detection of the uterus and provides pivotal information in cases of ambiguity. If the uterus appears normal, the most likely diagnosis is a virilized karyotypic female. Prenatal diagnosis allows for early parental counseling and anticipation of medical management postnatally.

Objective To evaluate pregnancy outcome after either transabdominal or transvaginal multifetal pregnancy reduction. Design A study of 72 consecutive multifetal pregnancy reductions. Setting Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center Tel Hashomer, Israel. Patients Seventy-two patients with multifetal pregnancies: 2 twins, 27 triplets, 26 quadruplets, 10 quintuplets, 3 sextuplets, 1 septuplet, 2 nontuplets, and one pregnancy with 12 fetuses. Intervention Multifetal pregnancy reduction was performed at 9 to 13 weeks’ gestation by either transabdominal or transvaginal potassium chloride injection. Main Outcome Measures Early and late complications related to the procedure, outcome of pregnancy, and comparison of two periods. Results Procedures performed between 1984 and 1989 (36 patients) were associated with a 33.3% pregnancy loss, whereas those performed between 1990 and 1992 (36 patients) were associated with no pregnancy loss. Of the 17 patients with quintuplets or more, 10 (59%) delivered live and healthy newborns. No difference was found when comparing the transabdominal and the transvaginal approaches. Conclusions Both transvaginal and transabdominal approaches are comparable. There is a remarkable decrease in pregnancy loss with experience.

Objective To compare the effect of fertility drugs and IVF on the outcome of triplet pregnancies. Design Prospective clinical study. Setting A single university medical center. Patients One hundred six consecutive triplet pregnancies treated from 1984 through 1992. Main Outcome Measures The frequency of pregnancy loss, livebirths, and antenatal and neonatal complications was compared in spontaneous, clomiphene citrate (CC), menotropins, and IVF triplet pregnancies. Results Eighty-one of the 106 (76.4%) triplet pregnancies progressed beyond 25weeks, comprising 6 of 7 (85.7%) spontaneous pregnancies, 13 of 16 (81.2%) CC induced, 44 of 56 (78.6%) menotropin induced, and 18 of 27 (66.6%) IVF gestations. There were no significant differences in the stillbirth and neonatal mortality rates according to the mode of conception. The mean gestational ages and the mean birth weights were similar in the four groups. The frequency of premature contractions, premature rupture of membranes, cesarean section, and neonatal complications were similar in the ovulation induction and IVF pregnancies. Conclusion Triplet pregnancies after ovulation induction and IVF have a similar outcome.

Uteroplacental thrombosis has been implicated in the pathogenesis of fetal loss, intrauterine growth restriction (IUGR) and preeclampsia. The role of inherited and acquired thrombophilias in such pregnancy complications is controversial. Recently, increased levels of circulating procoagulant microparticles (MPs) were related to fetal loss and preeclampsia (Laude et al. Thromb Haemost2001;85:18, Gonzalez-Quintero et al. Am J Obstet Gynecol2004;191:1418)). In this study, we measured the level of MPs derived from endothelial cells, platelets, and monocytes by flow cytometry using monoclonal antibodies against CD31, CD41 and CD14, respectively in 262 healthy unrelated primipara with a spontaneous singleton pregnancy. Expression of tissue factor by a monoclonal antibody and phosphatidyl serine by annexin 5 on MPs were also measured. All women were followed from the 24th week of gestation until delivery and IUGR, small for gestational age (SGA) at birth, pregnancy induced hypertension (PIH) or preeclampsia (PE) or none of the above were recorded. Blood sampling was carried out at 24th week of gestation. The levels of CD31 and CD41- positive MPs in women with and without the above pregnancy complications are presented in the table. Not shown are values of CD14, annexin 5 or tissue factor on MPs since their median levels were negligible in all study groups. There was no statistically significant difference in CD31 and CD41- positive MPs between women who developed or not the indicated pregnancy complications. Also, there was no significant difference in levels of these MPs between women with and without the common inherited thrombophilias, factor V Leiden and or prothrombin mutation (28 patients) and lupus anticoagulant (10 patients). These data indicate that measurement of the level of MP at the 24th week of gestation has no predictive value for development of PIH, PE, IUGR or SGA. CD31 CD41 Number Median % p Median % p PIH or PE No 226 1.50 0.22 1.80 PIH Yes 13 1.57 3.07 0.53 PE Yes 22 0.62 1.87 IUGR No 207 1.53 0.13 1.95 0.08 IUGR Yes 32 1.30 1.71 SGA No 232 1.48 0.64 1.85 0.81 SGA Yes 26 1.27 2.24

Summary Background To compare maternal and neonatal outcomes of term macrosomic and adequate for gestational age (AGA) pregnancies. Material/Methods A retrospective analysis was performed on all term singleton macrosomic (birth weight ≥4000 g) and AGA (birth weight >10th percentile and 4500 g (OR=5.23) but not for birth weight between 4000–4500 g. No differences were found in the rates of extensive perineal lacerations between AGA and the different macrosomic groups. Conclusions Macrosomia is associated with increased rate of cesarean section, shoulder dystocia, neonatal hypoglycemia, and longer hospitalization, but not associated with excessive perineal tears. Increased risk of PPH was found in the >4500g group.