Fetal sonographic findings: analysis of the most frequent patterns and their specificity of association

Haemangiomas and associated congenital malformations in a large population-based sample of infants

Haemangiomas are common, benign, vascular tumours, observed in 4-12% of infants during the first year of life. Most cases progress without complication, yet a small proportion experience life-threatening complications. Concomitant congenital malformations have been reported in a small but significant proportion of haemangioma patients. This study aimed to describe haemangioma cases and to identify patterns of congenital malformations associated with these diagnoses in a large population. Diagnoses of haemangiomas and 21 congenital malformations were extracted from electronic medical records of 467 295 singleton infants born to US military families from 1998 to 2003. Cluster analysis was used to group cases according to these diagnoses. Multivariable logistic regression was used to further explore the associations of the 21 congenital malformations with the diagnosis of haemangioma and to assess the adjusted relationships between a number of characteristics of interest and diagnosis of haemangioma. Clusters found to be associated with haemangioma were characterised by anomalies of the cervix, vagina, and external female genitalia, anophthalmia or microphthalmia, hydrocephalus without spina bifida, and reduction deformities of the brain. Logistic regression identified three congenital malformations significantly associated with haemangioma diagnosis: spina bifida without anencephalus, hydrocephalus without spina bifida, and anomalies of the cervix, vagina and external female genitalia. Characteristics significantly associated with haemangioma included female gender, preterm birth, white non-Hispanic race/ethnicity and increasing maternal age. This exploratory study identified a number of important associations between haemangiomas and congenital malformations that may provide insight into the pathogenesis of these disorders and have possible implications for clinical care.

Ultrasound screening in pregnancy: advancing technology, soft markers for fetal chromosomal aberrations, and unacknowledged ethical dilemmas

Fetal ultrasound screening has become routine practice in many western countries. During the last decade, such screening has led to frequent situations characterised by clinical uncertainty due to the disclosure of soft markers in the unborn child. Soft markers are minor anatomical variations indicating a somewhat increased likelihood that the fetus has a chromosomal aberration, most frequently trisomy 21 (Down syndrome). This paper presents the results of a comprehensive literature search of the National Library of Medicine with emphasis on the chronological development of scientific knowledge in relation to soft markers and the link between advancing imaging technology and clinical counselling dilemmas. An analysis of the literature makes evident that many ultrasound examiners have counselled individual pregnant women on the basis of insufficient data. Moral dilemmas have thus emerged as a direct result of advancing medical technology, and healthy fetal lives prove to have been lost due to invasive diagnostic testing aimed at resolving clinical uncertainty. Ultrasound examiners have warned against a policy of disclosing all findings of soft markers to expectant parents, but no exploration of experiential aspects linked to the disclosure of fetal soft markers has yet been published in the medical literature. The emotional reactions of mothers are important to consider given their potential impact on the biological development of the fetus. In conclusion, this paper stresses the need for paying close attention to the crucial distinction between technology development and technology implementation in relation to prenatal testing. Furthermore, it provides strong arguments for scrutinising the interface between prenatal testing and human experience.

Prenatal diagnosis and fetal therapy--what lies in future?

Prenatal diagnosis has traditionally occurred between the 15th and 20th weeks of gestation. However, the capabilities of screening and diagnostic tools have advanced substantially over the past 10 years. Recent advances in the science of prenatal diagnosis allow for the evaluation of an affected embryo or an abnormal cell line prior to gestation within the womb via preimplantation diagnosis. The technique can be used for any genetic condition which can be detected with a chromosome-specific probe. At the current time, noninvasive second trimester maternal serum screening with either 2 or 3 serum analytes is associated with a 60-70% detection rate of Down syndrome. Although these particular serum markers are not useful during the first trimester, the fetoplacental secretory products-free beta-hCG and pregnancy-associated plasma protein-A (PAPP-A) appear to be meaningful clinically when measured between 8 and 13 weeks of gestation, yielding similar first trimester detection rates as the current second trimester screening programme. The addition of nuchal translucency measurements as an independent predictor of fetal aneuploidy may further increase the detection rate of Down syndrome to 80%. Open fetal surgery is now possible under highly selective circumstances in which the fetal condition is considered life-threatening and the prognosis is extremely poor. Surgical intervention may be appropriate for congenital cystic adenomatoid malformation, bronchopulmonary sequestration, congenital diaphragmatic hernia, and possibly for myelomeningocele.