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Sepulveda W, Wong AE, Ranzini AC. Improving prenatal detection of abdominal supraumbilical anomalies: The sonographic examination of fetal anechoic spaces of upper abdomen revisited. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:326-345. [PMID: 36785497 DOI: 10.1002/jcu.23427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/07/2023] [Indexed: 06/18/2023]
Abstract
Visualization of the axial plane of the fetal abdomen is mandatory to obtain abdominal biometry in the assessment of fetal growth in the second and third trimesters. The main anatomic landmarks that must be identified in this view include the fetal stomach and the intrahepatic portion of the umbilical vein, which are easily identifiable as they appear anechoic on ultrasound. The gallbladder is the other prominent anechoic structure in this plane. Focused study of the morphological characteristics of, and spatial relationship among, these three anechoic spaces is a simple technique to detect anomalies involving fetal upper abdominal organs. In this review, the sonographic features of those conditions that can be detected using this technique, which was termed the Fetal Examination of the Anechoic Spaces of upper abdomen Technique (FEAST), are classified and illustrated.
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Affiliation(s)
- Waldo Sepulveda
- FETALMED-Maternal-Fetal Diagnostic Center, Fetal Imaging Unit, Santiago, Chile
| | - Amy E Wong
- Department of Maternal-Fetal Medicine, Palo Alto Medical Foundation, Mountain View, California, USA
| | - Angela C Ranzini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, Ohio, USA
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Zhang H, Zhu X, Kang J, Sun Y, Yang H. Pregnancy Outcomes of Non-Visualization of the Fetal Gallbladder from a Chinese Tertiary Single Centre and Literature Review. CHILDREN 2022; 9:children9091288. [PMID: 36138596 PMCID: PMC9497519 DOI: 10.3390/children9091288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/12/2022] [Accepted: 08/24/2022] [Indexed: 12/02/2022]
Abstract
Objection: To explore the clinical features and prognosis of non-visualization of the fetal gallbladder (NVFGB). Methods: Sixty-five cases diagnosed with NVFGB in the Peking University First Hospital were collected retrospectively from January 2019 to December 2020. Results: Forty-nine cases were successfully followed up. Among them, the gallbladder of 21 fetuses (42.9%) was present in the later pregnancy. In the rest 28 cases (57.1%), the gallbladders were absent during the whole pregnancy. Eleven of twenty-eight fetuses (39.3%) with NVFGB were complicated with other structural anomalies. In the remaining 17 cases of isolated NVFGB (60.7%) during the whole pregnancy, there was one case of congenital biliary atresia, three cases of a small gallbladder, one case of gallstone and one case of the gallbladder with several septa inside. A total of nine cases (18.4%) underwent prenatal diagnosis, four of which revealed abnormal copy number variant (CNV) results. Conclusion: Nearly half of NVFGB could be noted during the later pregnancy. The persistent NVFGB during the pregnancy has a higher risk to complicate gallbladder abnormality, other structural anomalies and abnormal CNV results. Other structures, especially the heart, gastrointestinal and urinary system, should be carefully examined when NVFGB is suspected.
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Affiliation(s)
- Huijing Zhang
- Department of Obstetrics and Gyanaecology, Peking University First Hospital, Beijing 100034, China
| | - Xiaoying Zhu
- Department of Ultrasound, Hengshui Renmin Hospital, Hengshui 053000, China
| | - Jinling Kang
- Department of Ultrasound, Dezhou Women and Children’s Hospital, Dezhou 251500, China
| | - Yu Sun
- Department of Obstetrics and Gyanaecology, Peking University First Hospital, Beijing 100034, China
| | - Huixia Yang
- Department of Obstetrics and Gyanaecology, Peking University First Hospital, Beijing 100034, China
- Correspondence:
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Mekki C, Aissat A, Mirlesse V, Mayer Lacrosniere S, Eche E, Le Floch A, Whalen S, Prud’Homme C, Remus C, Funalot B, Castaigne V, Fanen P, de Becdelièvre A. Prenatal Ultrasound Suspicion of Cystic Fibrosis in a Multiethnic Population: Is Extensive CFTR Genotyping Needed? Genes (Basel) 2021; 12:genes12050670. [PMID: 33946859 PMCID: PMC8145404 DOI: 10.3390/genes12050670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/23/2022] Open
Abstract
In families without a Cystic Fibrosis (CF) history, fetal ultrasound bowel abnormalities can unexpectedly reveal the disease. Isolated or in association, the signs can be fetal bowel hyperechogenicity, intestinal loop dilatation and non-visualization of fetal gallbladder. In these cases, search for CF transmembrane conductance regulator (CFTR) gene mutations is part of the recommended diagnostic practices, with a search for frequent mutations according to ethnicity, and, in case of the triad of signs, with an exhaustive study of the gene. However, the molecular diagnosis remains a challenge in populations without well-known frequent pathogenic variants. We present a multiethnic cohort of 108 pregnancies with fetal bowel abnormalities in which the parents benefited from an exhaustive study of the CFTR gene. We describe the new homozygous p.Cys1410* mutation in a fetus of African origin. We did not observe the most frequent p.Phe508del mutation in our cohort but evidenced variants undetected by our frequent mutations kit. Thanks to the progress of sequencing techniques and despite the difficulties of interpretation occasionally encountered, we discuss the need to carry out a comprehensive CFTR study in all patients in case of fetal bowel abnormalities.
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Affiliation(s)
- Chadia Mekki
- Departement de Genetique, DMU Biologie-Pathologie, GH Mondor-Chenevier, AP-HP, F-94010 Creteil, France; (C.M.); (A.A.); (A.L.F.); (B.F.); (P.F.)
| | - Abdel Aissat
- Departement de Genetique, DMU Biologie-Pathologie, GH Mondor-Chenevier, AP-HP, F-94010 Creteil, France; (C.M.); (A.A.); (A.L.F.); (B.F.); (P.F.)
- INSERM, IMRB, Paris Est Creteil University, F-94010 Creteil, France
| | - Véronique Mirlesse
- Service D’echographie Gynecologique et Obstetricale, GH Bichat-C Bernard, AP-HP, F-75018 Paris, France; (V.M.); (E.E.)
- Service Medecine Fœtale, Centre Hospitalo Universitaire de Geneve (HUG), S-1205 Geneve, Switzerland
| | - Sophie Mayer Lacrosniere
- Département de Gastro-Enterologie, Pneumologie, Mucoviscidose et Nutrition Pediatrique, CRCM, Université Paris 7, Hopital Robert Debre, AP-HP, F-75019 Paris, France;
| | - Elsa Eche
- Service D’echographie Gynecologique et Obstetricale, GH Bichat-C Bernard, AP-HP, F-75018 Paris, France; (V.M.); (E.E.)
| | - Annick Le Floch
- Departement de Genetique, DMU Biologie-Pathologie, GH Mondor-Chenevier, AP-HP, F-94010 Creteil, France; (C.M.); (A.A.); (A.L.F.); (B.F.); (P.F.)
| | - Sandra Whalen
- Service de Genetique, Hopital Trousseau, AP-HP, F-75012 Paris, France; (S.W.); (C.P.)
| | - Cecile Prud’Homme
- Service de Genetique, Hopital Trousseau, AP-HP, F-75012 Paris, France; (S.W.); (C.P.)
| | - Christelle Remus
- Service de Genetique, Centre Hospitalier Intercommunal de Creteil, F-94010 Creteil, France;
| | - Benoit Funalot
- Departement de Genetique, DMU Biologie-Pathologie, GH Mondor-Chenevier, AP-HP, F-94010 Creteil, France; (C.M.); (A.A.); (A.L.F.); (B.F.); (P.F.)
- INSERM, IMRB, Paris Est Creteil University, F-94010 Creteil, France
- Service de Genetique, Centre Hospitalier Intercommunal de Creteil, F-94010 Creteil, France;
| | - Vanina Castaigne
- Service d’Obstetrique et Gynecologie, Centre Hospitalier Intercommunal de Creteil, F-94010 Creteil, France;
| | - Pascale Fanen
- Departement de Genetique, DMU Biologie-Pathologie, GH Mondor-Chenevier, AP-HP, F-94010 Creteil, France; (C.M.); (A.A.); (A.L.F.); (B.F.); (P.F.)
- INSERM, IMRB, Paris Est Creteil University, F-94010 Creteil, France
| | - Alix de Becdelièvre
- Departement de Genetique, DMU Biologie-Pathologie, GH Mondor-Chenevier, AP-HP, F-94010 Creteil, France; (C.M.); (A.A.); (A.L.F.); (B.F.); (P.F.)
- INSERM, IMRB, Paris Est Creteil University, F-94010 Creteil, France
- Correspondence:
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Wang Y, Zhou J, Deng M, Xiang X, Zhu X. Utility of Magnetic Resonance Imaging in Diagnosis of Prenatal Non-Visualization of the Fetal Gallbladder: A Case-Series Study. Med Sci Monit 2021; 27:e927474. [PMID: 33397840 PMCID: PMC7796068 DOI: 10.12659/msm.927474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This study aimed to assess the utility of magnetic resonance imaging (MRI) in the diagnosis of prenatal non-visualization of the fetal gallbladder (PNVGB). MATERIAL AND METHODS The clinical data of 32 pregnant women with PNVGB who underwent MRI examination during the second and third trimester of pregnancy were collected and their outcomes were analyzed. RESULTS MRI showed that 26 patients (81.3%) had isolated PNVGB and 6 (18.8%) had additional malformations. In 26 patients with isolated PNVGB, 7 were found in the gallbladder on MRI and 4 were found on subsequent ultrasonography. One patient had termination of pregnancy (TOP) and 1 patient was lost to follow-up; the remaining 24 patients were known to deliver a healthy child. Among the 6 patients with additional malformations, 3 terminated their pregnancies due to combined severe abnormalities: 1 patient with horseshoe kidney and 1 with fetal echogenic bowel both had a healthy child, while 1 with fetal growth restriction (FGR) delivered a child who walked on tiptoe. CONCLUSIONS MRI contributes to identifying PNVGB detected or suspected by ultrasonography.
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Affiliation(s)
- Yuanhe Wang
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Jinling Zhou
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Meixiang Deng
- Department of Radiology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Xiaomiao Xiang
- Ultrasonic Department, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Xiaojun Zhu
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
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AIUM Practice Parameter for the Performance of Detailed Second- and Third-Trimester Diagnostic Obstetric Ultrasound Examinations. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:3093-3100. [PMID: 31736130 DOI: 10.1002/jum.15163] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Di Pasquo E, Kuleva M, Rousseau A, Vitucci A, Sonigo P, Chardot C, Salomon LJ, Ville Y. Outcome of non-visualization of fetal gallbladder on second-trimester ultrasound: cohort study and systematic review of literature. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:582-588. [PMID: 30809885 DOI: 10.1002/uog.20252] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 01/20/2019] [Accepted: 02/07/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To investigate the ultrasound characteristics and outcome of fetuses with non-visualization of the fetal gallbladder (NVFGB) followed in our tertiary university hospital, and to provide a comprehensive review of the literature on prenatal findings and outcome of NVFGB. METHODS NVFGB was defined as non-visualization of the gallbladder on two targeted ultrasound examinations performed within a 1-week period. First, we reviewed the medical records of NVFGB cases managed in our center over a 9-year period. Then, we performed a systematic review of the literature to identify studies on NVFGB. The incidence of chromosomal anomalies, later visualization of the gallbladder, gallbladder agenesis, cystic fibrosis and biliary atresia was assessed in fetuses with isolated and non-isolated NVFGB. The role of hepatic enzyme measurements in the diagnosis of cystic fibrosis and biliary atresia in fetuses with NVFGB was also reviewed. RESULTS Sixteen cases of NVFGB were followed in our center, in 10 (62.5%) of which it was an isolated finding. The incidence of biliary atresia was 12.5% and that of gallbladder agenesis was 12.5%, while no case of cystic fibrosis was reported. The gallbladder was visualized later in pregnancy or postnatally in 43.8% and 25.0% of cases, respectively. A total of seven studies, including our cohort, involving a total of 280 NVFGB cases, met the inclusion criteria for the systematic review. Overall, 20.5% of fetuses had an associated ultrasound anomaly, and the incidence of chromosomal anomaly in this group was 20.4%. In cases with isolated NVFGB, the incidence of chromosomal anomaly was 1.9%. In fetuses with normal karyotype and isolated NVFGB, the gallbladder was later visualized in 70.4% of cases, while the incidence of gallbladder agenesis, cystic fibrosis and biliary atresia was 25.2%, 3.1% and 4.8%, respectively. In fetuses with non-isolated NVFGB, the incidence of cystic fibrosis and biliary atresia was 23.1% and 18.2%, respectively. The negative predictive value of amniotic fluid enzyme levels for the prediction of severe disease (including biliary atresia or cystic fibrosis) ranged between 94% and 100% when evaluated before 22 weeks' gestation, and dropped to 88% after 22 weeks. CONCLUSIONS In cases with persistent NVFGB, the risk of a severe postnatal condition should be considered. A detailed ultrasound scan should be offered and parents tested for cystic fibrosis gene mutation. An invasive procedure for karyotyping and measurement of liver enzyme concentrations before 22 weeks constitutes a reasonable work-up. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Di Pasquo
- Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - M Kuleva
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - A Rousseau
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - A Vitucci
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - P Sonigo
- Radiologie Pédiatrique, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - C Chardot
- Chirurgie Pédiatrique, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - L J Salomon
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
- Société Française pour l'Amélioration des Pratiques Echographiques, Paris, France
| | - Y Ville
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
- Société Française pour l'Amélioration des Pratiques Echographiques, Paris, France
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Prenatal diagnosis of biliary atresia: A case series. Early Hum Dev 2017; 111:16-19. [PMID: 28531808 DOI: 10.1016/j.earlhumdev.2017.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 05/08/2017] [Accepted: 05/13/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Biliary atresia is a progressive disease presenting with jaundice, and is the most common indication for liver transplantation in the pediatric population. Prenatal series have yielded conflicting results concerning a possible association between BA and prenatal nonvisualization of the gallbladder. AIMS This retrospective case series was performed to assess the association between biliary atresia, prenatal nonvisualization of the gallbladder and other sonographic signs. STUDY DESIGN/SUBJECTS We identified biliary atresia patients who underwent a Kasai procedure by a single pediatric surgeon and/or follow up by a single pediatric gastroenterologist. Axial plane images and/or video recordings were scrutinized for sonographic signs of biliary atresia on the second trimester anomaly scan. OUTCOME MEASURES Proportion of biliary atresia cases with prenatal sonographic signs. RESULTS Twenty five charts of children with biliary and high quality prenatal images were retrieved. 6/25 (24%) of cases analyzed had prenatal nonvisualization of the gallbladder or a small gallbladder on the prenatal scan. Two cases had biliary atresia splenic malformation syndrome. None of the cases had additional sonographic markers of biliary atresia. CONCLUSIONS Our study suggests that in addition to the well-established embryonic and cystic forms, an additional type can be suspected prenatally, which is characterized by prenatal nonvisualization of the gallbladder in the second trimester. This provides additional evidence that some cases of BA are of fetal rather than perinatal onset and may have important implications for prenatal diagnosis, for counseling and for research of the disease's etiology and pathophysiology.
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Muller F, Bernard P, Salomon LJ, Dreux S, Allaf B, Czerkiewicz I, Ville Y. Role of fetal blood sampling in cases of non-visualization of fetal gallbladder. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:743-744. [PMID: 25914176 DOI: 10.1002/uog.14888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/20/2015] [Accepted: 04/22/2015] [Indexed: 06/04/2023]
Affiliation(s)
- F Muller
- Department of Biochemistry-Hormonology, Robert Debré Hospital, AP-HP, 48 Boulevard Sérurier, 75019, Paris, France
- University Paris Ile de France Ouest, Versailles Saint-Quentin, France
| | - P Bernard
- Department of Obstetrics and Maternal Fetal Medicine, Saint Luc Academic Hospital, Brussels, Belgium
| | - L J Salomon
- Department of Obstetrics and Maternal Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP, Paris, France
- University Paris Descartes and Sorbonne Paris-Cité, Paris, France
| | - S Dreux
- Department of Biochemistry-Hormonology, Robert Debré Hospital, AP-HP, 48 Boulevard Sérurier, 75019, Paris, France
| | - B Allaf
- Department of Biochemistry-Hormonology, Robert Debré Hospital, AP-HP, 48 Boulevard Sérurier, 75019, Paris, France
| | - I Czerkiewicz
- Department of Biochemistry-Hormonology, Robert Debré Hospital, AP-HP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Y Ville
- Department of Obstetrics and Maternal Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP, Paris, France
- University Paris Descartes and Sorbonne Paris-Cité, Paris, France
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Bardin R, Ashwal E, Davidov B, Danon D, Shohat M, Meizner I. Nonvisualization of the Fetal Gallbladder: Can Levels of γ-Glutamyl Transpeptidase in Amniotic Fluid Predict Fetal Prognosisγ. Fetal Diagn Ther 2015; 39:50-5. [DOI: 10.1159/000430440] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/10/2015] [Indexed: 11/19/2022]
Abstract
Objective: In cases of nonvisualization of the fetal gallbladder (NVFGB), we investigated whether amniotic fluid levels of γ-glutamyl transpeptidase (GGTP) can distinguish normal development or benign gallbladder agenesis from severe anomaly such as biliary atresia. Methods: This is a retrospective cohort study of pregnancies in which the gallbladder was not visualized in the second-trimester fetal anatomy scan. Levels of GGTP in amniotic fluid were analyzed prior to 22 weeks of gestation by amniocentesis. Data were collected regarding other fetal malformations, fetal karyotype, and screening results for cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations. Results: Of 32 cases of NVFGB, 27 (84%) had normal GGTP levels and a normal CFTR gene screening, and 1 of them had an abnormal karyotype. Three of the 5 cases with low GGTP were diagnosed with extrahepatic biliary atresia, proven by histopathological examination following termination of pregnancy. The fourth case had hepatic vasculature abnormality and the fifth isolated gallbladder agenesis. In 22 of 32 cases (68.7%), the gallbladder was detected either later in pregnancy or after delivery. Conclusion: The findings support low levels of GGTP in amniotic fluid, combined with NVFGB, as a sign of severe disease, mainly biliary atresia. Normal GGTP levels, concomitant with isolated NVFGB, carry a good prognosis.
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Wax J, Minkoff H, Johnson A, Coleman B, Levine D, Helfgott A, O’Keefe D, Henningsen C, Benson C. Consensus Report on the Detailed Fetal Anatomic Ultrasound Examination. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2014. [DOI: 10.1177/8756479314532221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Beverly Coleman
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Andrew Helfgott
- University of South Carolina School of Medicine, Columbia, SC, USA
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Wax J, Minkoff H, Johnson A, Coleman B, Levine D, Helfgott A, O'Keeffe D, Henningsen C, Benson C. Consensus report on the detailed fetal anatomic ultrasound examination: indications, components, and qualifications. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:189-195. [PMID: 24449720 DOI: 10.7863/ultra.33.2.189] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Joseph Wax
- MMC Ob/Gyn Associates, 887 Congress St, Suite 200, Portland, ME 04102 USA.
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