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Objective: The aim of this study was to investigate the performance of screening for open spina bifida (OSB) integrated into the routine first-trimester screening. Method: This is a prospective multicentre study of 4,755 women undergoing first-trimester ultrasound scans over a 4-year period. Measurements of the brainstem (BS) diameter and brainstem-to-occipital-bone (BSOB) distance were performed. The cisterna magna (CM) was measured in the tilted axial view. Results: Pregnancy outcome data were available for 4,658 fetuses included in this study. There were 5 fetuses with OSB, and in all of them, the BS/BSOB ratio and the CM measurements were abnormal. The sensitivity and specificity of a BS/BSOB ratio >1 were 100%. The sensitivity of a CM width Conclusion: Screening for OSB is feasible in routine first-trimester scans. The BS/BSOB ratio shows a very good sensitivity and specificity. In cases with near-normal values for the BS/BSOB ratio, the CM width might be helpful for further assessment.

Objectives To compare the sonographic signs of spina bifida obtained on axial and sagittal views of the fetal head between 11 and 13+6 weeks of gestation. Methods This was a retrospective study including 27 cases of spina bifida and 1003 randomly selected controls. Indirect markers of spina bifida were evaluated on stored ultrasound images. Intracranial translucency (IT), ratio between the brainstem and the brainstem-occipital bone distance (BS/BSOB), and maxillo-occipital (MO) line were assessed on sagittal view, whereas biparietal diameter (BPD), BPD to abdominal circumference ratio (BPD/AC), and aqueduct to occipital bone (aqueduct of Sylvius [AoS]) distance were measured on the axial plane. Reference ranges were developed, and cases of spina bifida were examined in relation to the reference range. Results On the sagittal view, detection rates for IT below the fifth percentile, BS/BSOB above the 95th percentile, and an abnormal MO line were 52.3%, 96.3%, and 96.3%, respectively. On the axial view, detection rates for BPD, BPD/AC, and AoS below the fifth percentile were 66.7%, 70.4%, and 77.8%, respectively. Conclusion The MO line and the BS/BSOB ratio appear to be the best indirect ultrasound markers of spina bifida and can be easily obtained during the routine first-trimester scan.

Introduction The presence of vasa previa carries a high risk for severe fetal morbidity and mortality due to fetal bleeding caused by injury to unprotected fetal vessels when rupture of membranes occurs. Previously, it has been shown that prenatal diagnosis significantly improves the outcome. However, systematic screening for vasa previa is not generally performed, and clinical studies demonstrating the performance of systematic screening for vasa previa in routine clinical practice are rare. The objective of this study was to assess the performance of systematic screening for vasa previa by determining placental cord insertion at the 20-week anomaly scan. Material and methods This is a retrospective study of 6038 pregnant women between 18+0 and 24+0 gestational weeks who were prospectively screened for vasa previa by depiction of the site of placental cord insertion on occasion of the 20-week anomaly scan. Pregnancies with marginal or velamentous cord insertion underwent vaginal sonography for examination for vasa previa. In cases with succenturiate or bilobed placentas, the bridging vessels were depicted, and vaginal sonography was performed if necessary. Results There were 21 cases of vasa previa, and all were diagnosed prenatally. In 18 cases, the cord insertion was marginal or velamentous. The remaining three cases had placental anomalies, which necessitated a detailed examination. All pregnancies with vasa previa were delivered at a mean of 35.2 (SD 1.8) gestational weeks by cesarean section. Among pregnancies affected by vasa previa, all fetuses survived. The median birthweight was 2390 g (range 1200 to 2990 g), and the mean umbilical artery pH was 7.34 (SD 0.04). The median five-minute APGAR score was 9 (range 7-10). None of the fetuses or neonates died or required blood transfusions. In all pregnancies of the whole cohort which were complicated by fetal or neonatal demise and in neonates with a 5-minute APGAR score ≤ 5 and/or an umbilical artery pH ≤ 7.10, fetal blood loss was excluded as a cause for the poor obstetric outcome. Conclusions Screening for vasa previa is feasible and efficient, taking into account the site of placental cord insertion in pregnancies not affected by placenta previa and bilobed and succenturiate placenta.

Objective: The study aimed to describe reference values for structures of the posterior fossa in fetuses with a crown-rump length (CRL) between 45 and 84 mm. Materials and Methods: This was a prospective, cross-sectional study including 216 normal appearing fetuses. In transvaginal acquired 3-dimensional volume blocks, the longest diameter of the vermis (VE), posterior membranous area (PMA), medulla-oblongata-pons angle (MOPA), diameters of the medulla oblongata (MO) and pons (PO), and the area of Blake’s pouch (BP) were measured. Polynomial or linear regression analysis were performed to calculate the mean, 5th and 95th centile according to CRL. In 20 fetuses, intra- and interobserver repeatability were calculated. Results: There is a curvilinear correlation between CRL and PO (PO [mean] = 1.3893 + 0.004356 × CRL + 0.000002610 × CRL3; SD = 1.6818 – 0.03765 × CRL + 0.000003831 × CRL3; R2 = 0.489); CRL and MO (MO [mean] = 1.5959–0.001905 × CRL + 0.000003362*CRL3; SD = –0.1417 + 0.005404 × CRL + 0.0000004988 × CRL3; R2 = 0.525); CRL and VE (VE [mean] = –0.3640 + 0.04302 × CRL+ 0.000001486 × CRL3; SD = 0.5854 – 0.004812 × CRL + 0.0000005896 × CRL3; R2 = 0.643); CRL and PMA (PMA [mean] = 0.6901 + 0.04307 × CRL – 0.0000008459 × CRL3; SD = –0.4232 + 0.02026 × CRL – 0.000001320 × CRL3; R2 = 0.272); CRL and BP (mm2; BP [mean] –12.2067 + 0.3334 × CRL – 0.00001262 × CRL3; SD = –1.6431 + 0.06380 × CRL+ 0.0000003257 × CRL3; R2 = 0.289). The relation between CRL and MOPA (°) is best described by a linear regression (MOPA [mean] = 79.6332 + 0.6122 × CRL; SD = 4.8453 + 0.07333 × CRL; R2 = 0.318). Conclusion: We provide reference values for anatomical structures of the posterior fossa of fetuses between 45 and 84 mm CRL. The established reference values might ease the diagnosis of fetal malformations in early pregnancy.

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is a rare congenital disorder, acknowledged as the most debilitating form of chronic intestinal pseudoobstruction disorders. Because the disease is often fatal in the first years of life and the surviving individuals are dependent on supportive medical or surgical treatment, definite antenatal diagnosis is desirable. We report a case of prenatally diagnosed MMIHS and discuss the suspicious findings and diagnostic criteria that allow a rapid and definite prenatal diagnosis.

Objective To describe the sonographic appearance and temporal changes of the structures of the posterior cranial fossa in fetuses at a crown–rump length (CRL) between 45 and 84 mm in transvaginal acquired three-dimensional volume blocks. Methods This was a prospective, cross-sectional, observational study including 80 fetuses, whose mothers attended Kepler University Hospital Linz or the Ambulatorium fur Fetalmedizin Feldkirch for first-trimester sonography. Three-dimensional volume blocks were acquired in a standardized way and after processing the sonographic characteristics of the brainstem, cerebellar vermis, choroid plexus, anterior membranous area (AMA) and Blake's metapore were described. Measurements of the length of the cerebellar vermis, the length of the AMA and the medulla–oblongata–pons angle (MOPA) were performed. In 20 fetuses the intra- and interobserver repeatability was calculated. Results The sonomorphologic characteristics of posterior fossa structures as cerebellar vermis, AMA, Blake's metapore, choroid plexus, pons and medulla oblongata were described. There is a significant correlation between CRL and vermis length, CRL and MOPA and CRL and AMA. Conclusions Transvaginal three-dimensional sonography allows a detailed depiction of the structures of the posterior fossa and their temporal course in early pregnancy. © 2016 John Wiley & Sons, Ltd. © 2016 John Wiley & Sons, Ltd.

Objective: To demonstrate sonographic detectable abnormalities of the posterior fossa in fetuses with a crown-rump length of 45–84 mm in high-risk pregnancies. Methods: This was a prospective, observational study including 47 fetuses with known outcome, whose mothers attended our centers for first trimester tests and showed an abnormal first trimester ultrasound scan. In these fetuses, we examined transvaginal acquired three-dimensional volume blocks for abnormalities of the fetal posterior fossa. In these fetuses, the measurements of the cerebellar vermis (VE) and of the anterior membranous area (AMA) were compared with published reference ranges. Results: There were 8 fetuses with a ver­mian length below the 5th centile. In 5 of these fetuses, the AMA was also elongated and in 4 of these fetuses, pathology was confirmed. One case with a normal vermian length and normal AMA had a hypoplastic VE later on in the confirmatory test. Conclusion: Pathology of the posterior fossa can be directly diagnosed by assessing the VE and the AMA at the first trimester scan by examining transvaginal acquired volume blocks.

The incidence of fetal portosystemic anastomoses is unknown, and it is presumed that many cases remain undetected, as visualization of the hepatic vasculature is not part of the routine 20-week sonographic scan in pregnancy. However, portosystemic anastomoses are associated with fetal growth restriction due to a diminished oxygen supply to hepatocytes and, hence, downregulation of liver function. In these cases, uteroplacental perfusion might be normal.

Objective To evaluate Doppler parameters of the two segments of the posterior cerebral artery (PCA) in normally grown and growth restricted (IUGR) fetuses. Methods Normal reference values of the pulsatility index (PI), peak systolic velocity, end-diastolic velocity, and time-averaged maximum velocity from the two segments of the PCA (segment one, PCA-S1; segment two, PCA-S2) were constructed in 350 pregnant women from 20 to 40 weeks of gestation. The association of the two PCA segments with the middle cerebral artery (MCA), and with the umbilical artery was evaluated in 50 IUGR fetuses. Results In normal fetuses, Doppler parameters from PCA-S1 and PCA-S2 showed similar behavior throughout gestation. In IUGR fetuses, the PI of the two PCA segments was significantly reduced with no differences between them. PCA-S2 PI showed a higher correlation with the MCA-PI (r = 0.73) than PCA-S1 PI (r = 0.63; p = 0.001). IUGR fetuses showed vasodilatation in the PCA earlier than in the MCA disregarding the umbilical artery-PI value. Conclusion In IUGR fetuses, the two segments of the PCA show signs of vasodilatation earlier than the MCA. As IUGR fetuses deteriorate, the two segments of the PCA and the MCA behave similarly. © 2013 John Wiley & Sons, Ltd.

To describe the sonographic appearance and temporal changes of the structures of the posterior cranial fossa in fetuses at a crown-rump length (CRL) between 45 and 84 mm in transvaginal acquired three-dimensional volume blocks.This was a prospective, cross-sectional, observational study including 80 fetuses, whose mothers attended Kepler University Hospital Linz or the Ambulatorium für Fetalmedizin Feldkirch for first-trimester sonography. Three-dimensional volume blocks were acquired in a standardized way and after processing the sonographic characteristics of the brainstem, cerebellar vermis, choroid plexus, anterior membranous area (AMA) and Blake's metapore were described. Measurements of the length of the cerebellar vermis, the length of the AMA and the medulla-oblongata-pons angle (MOPA) were performed. In 20 fetuses the intra- and interobserver repeatability was calculated.The sonomorphologic characteristics of posterior fossa structures as cerebellar vermis, AMA, Blake's metapore, choroid plexus, pons and medulla oblongata were described. There is a significant correlation between CRL and vermis length, CRL and MOPA and CRL and AMA.Transvaginal three-dimensional sonography allows a detailed depiction of the structures of the posterior fossa and their temporal course in early pregnancy. © 2016 John WileySons, Ltd.

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

Objectives To investigate the posterior fossa of normal fetuses and fetuses with open spina bifida in stored three-dimensional (3D) volumes and to describe signs that might allow early detection of this defect. Methods A prospective study of 3D volumes of the fetal brain obtained from 10 normal fetuses and three fetuses with open spina bifida was undertaken. Measurements of the anteroposterior diameters of the cisterna magna and fourth ventricle were taken in the tilted axial view. In the mid-sagittal plane the brainstem (BS) diameter and the brainstem–occipital bone (BSOB) distance were measured. The BS/BSOB ratio was calculated. All measurements were expressed as Z-scores. Structural analysis of the differences in the posterior fossa between normal fetuses and fetuses with open spina bifida was undertaken. Results In normal fetuses all measurements were within ± 2.5 Z-scores. In three fetuses with open spina bifida the BS Z-scores were 2.7, 2.8 and 2.8; the BSOB scores were − 3.4, − 2.8 and − 2.9; the cisterna magna scores were − 5.6, − 3.7 and − 4.2; and the BS/BSOB ratio scores were 4.1, 9.7 and 8.9. In normal fetuses the cisterna magna was posterior to the fourth ventricle and extended along its entire length. In fetuses with open spina bifida the cisterna magna was partially or completely obliterated. Conclusions Assessment of the cranial posterior fossa is feasible at 11–13 weeks' gestation. There are distinct signs in fetuses with open spina bifida which can be evaluated by ultrasonography. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Please cite this paper as: Strobl I, Windbichler G, Strasak A, Weiskopf-Schwendinger V, Schweigmann U, Ramoni A, Scheier M. Left ventricular function many years after recovery from pre-eclampsia. BJOG 2011;118:76–83. Objective Epidemiological observations have shown that women with pre-eclampsia are at increased risk for subsequent development of cardiovascular disease. We evaluated maternal haemodynamics in asymptomatic women many years after pre-eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. Design Case–control study. Setting University-based department of obstetrics. Population Forty-eight women, 13–18 years after the affected pregnancy: 17 women with a history of HELLP syndrome, 14 women with a history of pre-eclampsia and 17 women following normal pregnancy (control group). Methods Echocardiographic examination was performed in all groups, recording the isovolumetric contraction time and isovolumetric relaxation time (ICT + IVRT), ejection time (ET), myocardial performance index (MPI), transmitral early to atrial filling velocity ratio (MV-E/MV-A), stroke volume (SV) and cardiac output (CO). Main outcome measures Cardiac function. Results Women with previous HELLP syndrome showed a significantly increased MPI (0.34 versus 0.26; P = 0.008) and ICT + IVRT (442.16 versus 415.03; P = 0.01); MV-E/A, SV, ET and CO were not significantly different. Women with a history of pre-eclampsia showed a significantly increased MPI (0.36 versus 0.26; P = 0.006) and decreased ET (317.3 versus 328.93; P = 0.04); ICT + IVRT, MV-E/A, SV and CO were not significantly different. Conclusion This study confirms epidemiological observations that women with pre-eclampsia are at increased risk for subsequent development of cardiovascular disease. Many years after HELLP syndrome or pre-eclampsia, asymptomatic women have an increased risk for impaired cardiac function as shown by an increased MPI.

Objectives To evaluate the feasibility and reproducibility of volume segmentation of fetal intracranial structures using three-dimensional (3D) ultrasound imaging, and to estimate differences in the volume of intracranial structures between intrauterine growth-restricted (IUGR) and appropriate-for-gestational age (AGA) fetuses. Methods Total intracranial, frontal, thalamic and cerebellar volumes were measured using 3D ultrasound imaging and Virtual Organ Computer-aided AnaLysis (VOCAL) in 39 IUGR and 39 AGA fetuses matched for gestational age, at 28-34 weeks of gestation. Volumes of, and ratios between, structures were estimated, and differences between IUGR and AGA fetuses were calculated. Volume measurements were performed by two observers, and interobserver and intraobserver intraclass correlation coefficients (ICCs) were calculated for each structure. Results Volumes were satisfactorily obtained in all fetuses. All net volumes except those for the thalamus(P = 0.23) were significantly smaller (P = 0.001) in IUGR fetuses. After adjusting volumes for biparietal diameter the frontal volume was significantly smaller (P = 0.02) and the thalamic volume significantly greater (P = 0.03) in IUGR fetuses than in AGA fetuses. Significant intergroup differences in the ratios between structures were found only in those involving the frontal region. Interobserver ICCs were as follows: total intracranial 0.97 (95% CI, 0.92-0.98), cerebellar 0.69 (95% CI, 0.44-0.75), frontal 0.66 (95% CI, 0.42-0.79) and thalamic 0.54 (95% CI, 0.37-0.72). Conclusions IUGR fetuses show differences in the volume of intracranial structures compared with AGA fetuses, with the largest difference found in the frontal region. These differences might be explained by in-utero processes of neural reorganization induced by chronic hypoxia. © 2009 ISUOG., This study was supported by research grants from Cerebra, Foundation for the Brain-Injured Child (Carmarthen, Wales, UK); The Thrasher Research Fund (Salt Lake City, UT, USA); Marie Curie Host Fellowships for Early Stage Researchers (FETAL-MED-019707-2); and Fondo de Investigación Sanitaria PI060347 (Spain). E.H.-A. was supported by grants from the Ministry of Education and Science (SB2003-0293), ‘Juan de la Cierva’ program for the development of Research Centers, Spain.

BACKGROUND: A prospective study to evaluate long-term pregnancy outcome and childhood development of chromosomally normal foetuses with increased nuchal translucency thickness (NT) at 10-14 weeks of gestation. METHODS: Between Jan 1, 1997 and Dec 31, 2001 78 foetuses with increased NT but normal karyo-type were identified from the database of the Department of Obstetrics and Gynaecology at Innsbruck Medical University. To evaluate long term cognitive abilities and social skills standardized questionnaires ("Elternfragebogen zur erganzenden Entwicklungsbeurteilung bei den kinderarztlichen Vorsorgeuntersuchungen U6 bis U9” EEE U6-U9 ; "Kognitive Probleme bei Kindern und Jugendlichen - Vorstellung eines Fragebogens” KOPKIJ ) were used. 41 children with increased nuchal translucency were compared with 41 control children matched for date of birth, gestational and maternal age. RESULTS: Follow-up data could be collected in 44 cases. 2 out of 78 foetuses died intrauterine, one infant died after birth. Two out of the 41 surviving infants showed genetic disorders. There was no significant difference in cognitive delay between children with increased NT and controls (9.8% vs. 2.4%, p=0.361). CONCLUSION: Our findings suggest that chromosomally normal foetuses with increased nuchal translucency in the first-trimester scan do not have an increased risk for a significant cognitive developmental delay in an observation period of up to six years.

Objective To define the impact of nuchal cord on the measurement of fetal nuchal translucency thickness (NT). Methods Between December 2004 and June 2006, we examined prospectively 53 fetuses that were observed on routine first-trimester ultrasound examination between 11 + 3 and 13 + 6 weeks of gestation to have nuchal cord causing an indentation in the skin in the nuchal region. The fetuses were re-examined after a median interval of 132 min, when the cord was no longer around the neck and indentation of the skin had resolved. Various NT measurements (highest, lowest, mean) with the cord located around the neck (nuchal cord) were compared with NT measurements in the absence of nuchal cord (‘true’ NT) in the same fetuses. Measurements were considered to be equal when they were within mean ± 1.96 SD, defined by our own intraobserver repeatability according to the method of Bland and Altman. Results The mean of the largest and the smallest of six measurements in the presence of nuchal cord fell within the mean ± 1.96 SD of our own intraobserver repeatability, i.e. gave a correct estimate of the true NT, in 80% of fetuses, while the NT was overestimated in 10% and underestimated in 10% of fetuses. The largest and the smallest of six measurements in the presence of nuchal cord gave an underestimate of the true NT in 2% of fetuses and an overestimate in 4% of fetuses, respectively. Conclusion There is a wide scattering of measurements in fetuses with nuchal cord in comparison to the same fetuses in the absence of nuchal cord. This prevents accurate prediction of the true NT, although the largest and smallest of repeat measurements with nuchal cord can allow calculation of the highest and lowest possible risks, respectively. These facts must be taken into consideration in counseling patients. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.

Objective This study was undertaken to determine the detection of fetal anemia and false-positive rates by fetal middle cerebral artery peak systolic velocity (MCA-PSV) and the estimated daily decrease of hemoglobin (Hb) in red blood cell alloimmunized pregnancies that had previous fetal transfusions. Study design We examined the relation between MCA-PSV measured before cordocentesis, and fetal Hb at the time of the second (n = 42) and third (n = 31) intrauterine blood transfusions. In addition, the daily Hb drop between the transfusions was calculated. Results The MCA-PSV provided significant prediction of severe anemia (Hb deficit ≥6 g/dL) for the second but not for the third transfusion. Detection of 95% of severely anemic fetuses was achieved with a false-positive rate of 37% for the second transfusion and 90% for the third, compared with 14% in our previous study for the first transfusion. In patients who had received 2 previous transfusions, the only significant predictor of fetal anemia was the estimation of the Hb from the measured posttransfusion Hb after the second transfusion and the assumption that the rate of decrease in fetal Hb is 0.3 g/dL per day. Conclusion Prediction of severe fetal anemia after one transfusion is less accurate than in nontransfused fetuses. The MCA-PSV is not useful in predicting severe anemia in fetuses that already had 2 previous transfusions.

Objective In red blood cell (RBC) isoimmunized pregnancies fetal anemia is associated with a hyperdynamic circulation. The aim of the present study was to examine further the possible value of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the management of affected pregnancies. Methods A reference range of fetal MCA-PSV with gestation was constructed from the study of 813 normal singleton pregnancies at 20–40 weeks' gestation. Fetal MCA-PSV was also measured in 58 fetuses from RBC isoimmunized pregnancies, with maternal hemolytic antibody concentration of >15 IU/mL at 19–38 weeks' gestation and within 10 days of measurement of fetal hemoglobin concentration in blood obtained either by cordocentesis (n = 43) or at delivery (n = 15). In the RBC isoimmunized pregnancies each of the measured MCA-PSV and hemoglobin concentrations was expressed as a delta value (difference in SDs from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA-PSV and delta fetal hemoglobin concentration. Results In the normal pregnancies there was a significant increase in fetal MCA-PSV with gestation (mean MCA-PSV = 100.0223 × GA + 0.963). In RBC isoimmunized pregnancies the fetal MCA-PSV was increased and there was a significant association between delta MCA-PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA-PSV + 0.093)/−0.356; R2 = 0.638, P < 0.0001). An MCA-PSV of mean + 1.5 SDs detected 96% of severely anemic fetuses, with a hemoglobin deficit of at least 6 SDs, for a false-positive rate of 14%. Conclusion Measurement of fetal MCA-PSV is a useful method of assessing fetal anemia. In the clinical management of isoimmunized pregnancies a cut-off in MCA-PSV of mean + 1.5 SDs can identify nearly all severely anemic fetuses with a low false-positive rate. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Objective In some cases of non-immune hydrops there is congenital or acquired fetal anemia. The aim of this study was to investigate the potential value of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the assessment and management of non-immune hydrops due to anemia. Methods Fetal MCA-PSV and fetal hemoglobin concentration, in blood obtained by cordocentesis, were measured in 16 singleton pregnancies referred to our unit for further investigations because of a diagnosis of non-immune hydrops fetalis. In all cases a detailed ultrasound examination demonstrated moderate or severe ascites, with or without skin edema, and pericardial or pleural effusions. Furthermore, there were no obvious malformations to account for the hydrops. In each fetus the measured MCA-PSV and hemoglobin concentration were expressed as delta values (the difference in SD from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA-PSV and delta fetal hemoglobin concentration. In addition, we searched our database to identify the sonographic features and hemoglobin concentration of fetuses with congenital infection. Results In the 16 cases of non-immune hydrops there were seven with parvovirus B19 infection, one each of α-thalassemia and primary cardiomyopathy and seven with no obvious explanation for the hydrops. There was a significant association between delta MCA-PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA-PSV + 0.1437)/−0.4154; R2 = 0.7202; P < 0.0001). In 10 of the cases the fetal hemoglobin concentration was more than 4 SD below the normal mean for gestation and in all these cases the MCA-PSV was more than 2 SD above the normal mean for gestation. Our computer search identified an additional nine fetuses with parvovirus B19 infection and in all cases the predominant sonographic finding was ascites and the hemoglobin concentration was more than 4 SD below the normal mean. In contrast, only 3/14 fetuses with cytomegalovirus, toxoplasmosis, coxsackie B or Treponema infection had ascites and only 2/14 had a hemoglobin deficit of 4–6 SD. Conclusion In the management of non-immune hydrops, measurement of fetal MCA-PSV can help identify the subgroup with fetal anemia. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

To evaluate Doppler parameters of the two segments of the posterior cerebral artery (PCA) in normally grown and growth restricted (IUGR) fetuses.Normal reference values of the pulsatility index (PI), peak systolic velocity, end-diastolic velocity, and time-averaged maximum velocity from the two segments of the PCA (segment one, PCA-S1; segment two, PCA-S2) were constructed in 350 pregnant women from 20 to 40 weeks of gestation. The association of the two PCA segments with the middle cerebral artery (MCA), and with the umbilical artery was evaluated in 50 IUGR fetuses.In normal fetuses, Doppler parameters from PCA-S1 and PCA-S2 showed similar behavior throughout gestation. In IUGR fetuses, the PI of the two PCA segments was significantly reduced with no differences between them. PCA-S2 PI showed a higher correlation with the MCA-PI (r = 0.73) than PCA-S1 PI (r = 0.63; p = 0.001). IUGR fetuses showed vasodilatation in the PCA earlier than in the MCA disregarding the umbilical artery-PI value.In IUGR fetuses, the two segments of the PCA show signs of vasodilatation earlier than the MCA. As IUGR fetuses deteriorate, the two segments of the PCA and the MCA behave similarly.

Objective: To investigate the impact of advanced maternal age on the rate of perinatal mortality. Design: Retrospective cohort study including all 56,517 singleton hospital deliveries between 1999 and 2008. Methods: Data were analyzed according to maternal age at delivery in 3 groups of women, 25-34 years, 35-39 years and ≥40 years, using the youngest as the reference group. Results: Odds ratios (ORs) for antenatal deaths were 0.98 (CI: 0.67-1.43) and 2.57 (CI: 1.57-4.22) for age groups 35-39 years and ≥40 years, respectively. Significant differences in neonatal mortality rates between the age groups were not found. Significant amendable risk factors were attendance of Conclusions: Women older than 40 years carry an increased risk for stillbirth. Important amendable risk factors are obesity and poor antenatal care.

Objective To determine the number of ultrasound examinations necessary for training sonographers to examine accurately the fetal nasal bone at 11–14 weeks' gestation. Methods Fifteen sonographers with experience in measuring nuchal translucency were asked to examine the nasal bone during the routine 11–14-week scan. The supervising doctor recorded if the sonographer succeeded in obtaining the correct image. Each sonographer performed a total of 140 examinations, and the data were analyzed in seven groups of 20 examinations. In a second study, two sonographers with extensive experience in examining the nasal bone examined independently 100 consecutive patients at a median fetal crown–rump length of 65 (45–84) mm and median gestational age of 12 (11–14) weeks and recorded whether the nasal bone was absent or present. Results In the first group of 20 examinations, there was failure to obtain the correct image of the fetal profile in 1–5 (median, 4) cases. In the subsequent three groups, there was failure to obtain the correct image in 0–3 (median, 1) cases. In the fifth and sixth groups failure occurred in 0–2 (median, 0) cases and in the seventh group all sonographers obtained successful images of the fetal profile in all cases. One sonographer obtained successful images of all cases after the first 40 scans, four after the first 60 scans, six after the first 80 and two each after the first 100 and 120 scans. In the second study, there was agreement between the two sonographers that the nasal bone was absent in two and present in 98 of the 100 consecutive patients examined. Conclusion The minimum number of scans required for an experienced sonographer to become competent in examining the fetal nasal bone is on average 80, with a range of 40–120. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

Objectives To describe the sonographic appearance of the structures of the posterior cranial fossa in fetuses at 11 + 3 to 13 + 6 weeks of pregnancy and to determine whether abnormal findings of the brain and spine can be detected by sonography at this time. Methods This was a prospective study including 692 fetuses whose mothers attended Innsbruck Medical University Hospital for first-trimester sonography. In 3% (n = 21) of cases, measurement was prevented by fetal position. Of the remaining 671 cases, in 604 there was either a normal anomaly scan at 20 weeks or delivery of a healthy child and in these cases the transcerebellar diameter (TCD) and the anteroposterior diameter of the cisterna magna (CM), measured at 11 + 3 to 13 + 6 weeks, were analyzed. In 502 fetuses, the anteroposterior diameter of the fourth ventricle (4V) was also measured. In 25 fetuses, intra- and interobserver repeatability was calculated. Results We observed a linear correlation between crown–rump length (CRL) and CM (CM = 0.0536 × CRL − 1.4701; R2 = 0.688), TCD (TCD = 0.1482 × CRL − 1.2083; R2 = 0.701) and 4V (4V = 0.0181 × CRL + 0.9186; R2 = 0.118). In three patients with posterior fossa cysts, measurements significantly exceeded the reference values. One fetus with spina bifida had an obliterated CM and the posterior border of the 4V could not be visualized. Conclusions Transabdominal sonographic assessment of the posterior fossa is feasible in the first trimester. Measurements of the 4V, the CM and the TCD performed at this time are reliable. The established reference values assist in detecting fetal anomalies. However, findings must be interpreted carefully, as some supposed malformations might be merely delayed development of brain structures. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Objective: To evaluate changes in central and peripheral circulation, including new and standard parameters of the fetal brain and heart in fetuses with intrauterine growth restriction (IUGR) in relation to progressive deterioration of the umbilical artery (UA). Methods: Seventy-two IUGR fetuses were studied longitudinally. IUGR was defined as an estimated fetal weight Results: A total of 263 scans were performed (median, 3 (range: 1–23) per patient). There were 6 intrauterine and 2 neonatal deaths. Although all cerebral arteries showed a reduction in the PI, ACA1 showed the earliest vasodilatation. From group 2 onwards, all cerebral vessels had a similar pattern of vasodilatation. Mod-MPI became abnormal at group 1 with no further changes. IFI and DV became constantly abnormal starting from group 2. No changes in the RA-PI or FA-PI were documented. Conclusion: The process of hemodynamic deterioration in IUGR fetuses seems to be earlier represented by the ACA1 and the Mod-MPI. Signs of further deterioration were observed in the DV, IFI and MCA. The peripheral blood in the RA and FA did not show any change. AFI showed a late deterioration process.

Aims: To evaluate the arteriovenous (AV) pH difference in cord blood as a possible indicator of fetal O 2 -utilization at delivery. Furthermore to examine which maternal, fetal and obstetrical factors lead to elevated O 2 -utilization. Methods: In this retrospective study all singleton live births, delivered within a four-month period at the University Hospital in Innsbruck, Austria, were analyzed. In total 491 deliveries were evaluated. Arterial and venous cord blood samples were collected at birth and analyzed by using a Radiometer ABL 510. Results: Spontaneous deliveries showed a highly significant elevation in AV-difference (pH 0.10) as compared to cesarean sections (pH 0.05). In spontaneous births, the AV-difference was high in the case of low arterial cord blood pH (P < 0.01), as well as in nuchal cord (P < 0.01), high parity (P < 0.01), very short labor (P < 0.05) and elevated birth size and weight (P < 0.05). Conclusions: As a result of increased fetal stress at birth, spontaneous delivery leads to higher O 2 -utilization than cesarean section, which is detectable in an elevated AV-difference. The AV-difference in combination with absolute pH-values can be used for the objective evaluation of fetal O 2 -utilization and consecutively the fetal stress at birth.

We report a case of spontaneous intrauterine fracture of the right tibia and fibula in an otherwise healthy fetus at 20 weeks of gestation. The fracture healed in utero in an abnormal position. Postnatal development of the baby was normal with spontaneous correction of the angulation, and no underlying disease could be discovered. Spontaneous isolated fetal fractures are rare and need to be differentiated from fractures that occur due to trauma or underlying skeletal diseases.

Aim: To construct normal reference values for Doppler parameters in 2 anatomical segments of the fetal anterior cerebral artery (ACA) throughout pregnancy. Methods: The ACA was evaluated in 373 normally growing fetuses from 20 to 40 weeks of gestation. The first segment of the ACA (ACA-S1) was recorded just after its origin from the internal carotid artery in the same plane as the middle cerebral artery (MCA). The second segment (ACA-S2) was recorded distal to the outlet of the anterior communicating artery. Results: The ACA pulsatility index (PI) behaved similarly in both segments, with a constant increase until 28 weeks followed by a decrease until the end of pregnancy [ACA-S1 PI = 3.49 – 0.37 × gestational age (GA) – (0.0063 × GA2), SD = 0.6 – 0.061 × GA – (0.001 × GA2); ACA-S2 PI = 1.54 – 0.22 × GA – (0.0037 × GA2), SD = 0.206 + (0.0037 × GA)]. Peak systolic velocities in both segments showed a constant increase from 20 to 40 weeks of gestation. No significant differences were found between the 2 segments with regard to any Doppler parameter. However, the angle of insonation and the time spent on examination were significantly lower and reproducibility was better for ACA-S1. Conclusion: Despite showing similar Doppler values, ACA-S1 has a higher reliability than ACA-S2 and can be recorded in the same anatomical projection as the MCA.

Objectives: To discuss diagnosis and management of a case of a rare fetal tumor complicated by fetal anemia due to intratumoral hemorrhage. Case Report: We report on a 29-week-old fetus with a tumor in the posterior left shoulder region. The morphologic aspect of the tumor, lack of fetal movements and an increased middle cerebral artery (MCA) peak systolic velocity (PSV) were indicative of fetal anemia caused by intratumoral bleeding. Following intravascular blood transfusion the pregnancy was safely prolonged for 15 days, during which lung maturity was induced. After delivery the neonate underwent surgical excision. Histological examination revealed an infantile congenital fibrosarcoma. Conclusion: Anemia must be ruled out in cases with fetal tumors. MCA PSV is useful in diagnosis and surveillance in these fetuses.