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Sun L, Yu J, Yao J, Cao Y, Sun N, Chen K, Lin Y, Ji C, Zhang J, Ling C, Yang Z, Pan Q, Yang R, Yang X, Ni D, Yin L, Deng X. A novel artificial intelligence model for measuring fetal intracranial markers during the first trimester based on two-dimensional ultrasound image. Int J Gynaecol Obstet 2024. [PMID: 38944698 DOI: 10.1002/ijgo.15762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 05/30/2024] [Accepted: 06/17/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE To establish reference ranges of fetal intracranial markers during the first trimester and develop the first novel artificial intelligence (AI) model to measure key markers automatically. METHODS This retrospective study used two-dimensional (2D) ultrasound images from 4233 singleton normal fetuses scanned at 11+0-13+6 weeks of gestation at the Affiliated Suzhou Hospital of Nanjing Medical University from January 2018 to July 2022. We analyzed 10 key markers in three important planes of the fetal head. Based on these, reference ranges of 10 fetal intracranial markers were established and an AI model was developed for automated marker measurement. AI and manual measurements were compared to evaluate differences, correlations, consistency, and time consumption based on mean error, Pearson correlation analysis, intraclass correlation coefficients (ICCs), and average measurement time. RESULTS The results of AI and manual methods had strong consistency and correlation (all ICC values >0.75, all r values >0.75, and all P values <0.001). The average absolute error of both only ranged from 0.124 to 0.178 mm. AI achieved a 100% detection rate for abnormal cases. Additionally, the average measurement time of AI was only 0.49 s, which was more than 65 times faster than the manual measurement method. CONCLUSION The present study first established the normal standard reference ranges of fetal intracranial markers based on a large Chinese population data set. Furthermore, the proposed AI model demonstrated its capability to measure multiple fetal intracranial markers automatically, serving as a highly effective tool to streamline sonographer tasks and mitigate manual measurement errors, which can be generalized to first-trimester scanning.
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Affiliation(s)
- Lingling Sun
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Junxuan Yu
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Jiezhi Yao
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Yan Cao
- Shenzhen RayShape Medical Technology Co., Ltd, Shenzhen, Guangdong, China
| | - Naimin Sun
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Keqi Chen
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Yujia Lin
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Chunya Ji
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Jun Zhang
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Chen Ling
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Zhong Yang
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Qi Pan
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Ronghao Yang
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Xin Yang
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Dong Ni
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Linliang Yin
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Xuedong Deng
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
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De Robertis V, Sen C, Timor-Tritsch I, Volpe P, Galindo A, Khalil A, Volpe N, Gil MDM, Birnbaum R, Villalain C, Malinger G. Clinical Practice Guidelines and Recommendations by the World Association of Perinatal Medicine and Perinatal Medicine Foundation: Reporting Suspected Findings from Fetal Central Nervous System Examination. Fetal Diagn Ther 2024; 51:203-215. [PMID: 38310852 DOI: 10.1159/000535917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/04/2023] [Indexed: 02/06/2024]
Abstract
These guidelines follow the mission of the World Association of Perinatal Medicine, in collaboration with the Perinatal Medicine Foundation, which brings together groups and individuals worldwide, with the aim to improve prenatal detection of central nervous system anomalies and the appropriate referral of pregnancies with suspected fetal anomalies. In addition, this document provides further guidance for healthcare practitioners with the goal of standardizing the description of ultrasonographic abnormal findings.
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Affiliation(s)
| | - Cihat Sen
- Perinatal Medicine Foundation, Istanbul, Turkey
| | - Ilan Timor-Tritsch
- Obstetrics and Gynecology, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Paolo Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - Alberto Galindo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Maternal and Child Health and Development Network, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Asma Khalil
- Fetal Medicine Unit, St George University Hospital NHS Foundation Trust, London, UK
| | - Nicola Volpe
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Maria Del Mar Gil
- Hospital Universitario de Torrejón, Madrid, Spain
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Roee Birnbaum
- OB-GYN Ultrasound Unit, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, and School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cecilia Villalain
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Maternal and Child Health and Development Network, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Gustavo Malinger
- OB-GYN Ultrasound Unit, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, and School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Volpe P, De Robertis V, Fanelli T, Volpe G, Olivieri C, Boito S, Persico N. Impact of choroid plexus size in prenatal diagnosis of normal and abnormal closure of fourth ventricle. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:875-881. [PMID: 37266920 DOI: 10.1002/uog.26278] [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: 03/16/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess the role of the choroid plexus (CP) of the fourth ventricle (4V) in fetuses with an open 4V and a normal cerebellar vermis. METHODS Two groups of patients were recruited in two fetal medicine referral centers. The prospectively collected control group included singleton pregnancies with a normal sonographic examination after first-trimester combined screening for chromosomal abnormalities and normal outcome, recruited in the period between 2019 and 2022. The study group was selected retrospectively by searching our databases to identify all cases with an isolated open 4V and normal anatomy and size of the cerebellar vermis. The inclusion criteria of the study group were: (1) gestational age between 20 and 22 weeks; (2) a brainstem-vermis angle ≥ 18° in the midsagittal plane with an otherwise normal cerebellum and vermis; (3) 4V-CP visible and seen separately from the vermis; (4) absence of other intra- and extracranial anomalies; and (5) available prenatal and/or postnatal magnetic resonance imaging (MRI) data. RESULTS In 169 cases of the control group, the 4V-CP was seen separately from the cerebellar vermis and was noticed to progressively fill the space caudal to the 4V, between the vermis and brainstem. From 12 to 22 weeks, the surface areas of the vermis and medial portion of the 4V-CP increased progressively with advancing gestation (P < 0.0001). Intra- and interobserver correlation analysis showed good reproducibility for the measurements. Among the cases with an open 4V and a normal vermis, it was retrospectively feasible to visualize the 4V-CP separately from the inferior part of the vermis in 41 fetuses. In five of these cases, the open 4V was due to a small CP. In all 41 fetuses, the diagnosis on MRI was isolated upward rotation of the cerebellar vermis, and no additional anomaly was found. CONCLUSIONS Closure of the 4V is dependent on the 4V-CP and not only the cerebellar vermis. In fact, a small CP may represent another cause of an open 4V. Therefore, separate visualization of the 4V-CP and cerebellar vermis is crucial to improve discrimination between the different causes of an open 4V at the anomaly scan and its clinical implications. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- P Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - V De Robertis
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - T Fanelli
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - G Volpe
- Fetal Medicine and Surgery Service, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - C Olivieri
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - S Boito
- Fetal Medicine and Surgery Service, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - N Persico
- Fetal Medicine and Surgery Service, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
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Montaguti E, Diglio J, Petrachi B, Arosio V, Fiorentini M, Cavalera M, Pellegrino A, Amodeo S, Lenzi J, Pilu G. Identification of Fetuses at Increased Risk of Trisomies in the First Trimester Using Axial Planes. Fetal Diagn Ther 2023; 51:1-6. [PMID: 37778343 DOI: 10.1159/000533879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION The measurement of nuchal translucency (NT) is crucial for assessing risk of aneuploidies in the first trimester. We investigate the ability of NT assessed by a transverse view of the fetal head to detect fetuses at increased risk of common aneuploidies at 11-13 weeks of gestation. METHODS We enrolled a nonconsecutive series of women who attended our outpatient clinic from January 2020 to April 2021 for aneuploidy screening by means of a first trimester combined test. All women were examined by operators certified by the Fetal Medicine Foundation. In each patient, NT measurements were obtained both from the median sagittal view and transverse view. We calculated the risk of aneuploidy using NT measurements obtained both with sagittal and axial scans, and then we compared the results. RESULTS A total of 1,023 women were enrolled. An excellent correlation was found between sagittal and transverse NT measurements. The sensitivity and specificity of the axial scan to identify fetuses that were deemed at risk of trisomy 21 using standard sagittal scans were 40/40 = 100.0% (95% confidence interval [CI]: 91.2-100.0) and 977/983 = 99.4% (95% CI: 98.7-99.7), respectively. The sensitivity and specificity of the axial scan to identify fetuses at risk of trisomy 13 or 18 were 16/16 = 100.0% (95% CI: 80.6-100.0) and 1,005/1,007 = 99.8% (95% CI: 99.3-99.9). CONCLUSIONS When the sonogram, a part of combined test screening, is performed by an expert sonologist, axial views can reliably identify fetuses at increased risk of trisomies without an increase in false negative results.
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Affiliation(s)
- Elisa Montaguti
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Josefina Diglio
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benedetta Petrachi
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Viola Arosio
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marta Fiorentini
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marta Cavalera
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Anita Pellegrino
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Amodeo
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Feng L, Sun L, Wang J, Sun C, Lu L, Zhang Z, Hu Y, Wu Q. Qualitative and quantitative study of fetal posterior fossa during the first trimester in a Chinese population. BMC Pregnancy Childbirth 2022; 22:760. [PMID: 36217104 PMCID: PMC9552477 DOI: 10.1186/s12884-022-05086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/28/2022] [Indexed: 11/23/2022] Open
Abstract
Background To establish the normal reference ranges for parameters related to the fetal posterior fossa in the first trimester (11 ~ 13+6 weeks of gestation) and to analyze the relationship between them and crown-rump length (CRL) among the Chinese population. Methods Singleton pregnancies of 11 ~ 13+6 weeks (CRL:45 ~ 84 mm) with both parents from China were randomly selected from January 2021 to November 2021. The related parameters of the posterior fossa including cisterna magna (CM), intracranial translucency (IT), brain stem (BS), brain stem to the occipital bone (BSOB), and brain stem/brain stem to occipital bone (BS/BSOB) were evaluated and measured in nuchal translucency (NT) mid-sagittal section clearly by an experienced sonographer (operator 1). To assess the reproducibility of the measurements, we randomly selected 50 pregnant women. According to the blind method, operators 1 and 2 respectively screened and measured relevant parameters. In addition, operator 1 examined and measured relevant parameters again 2 h after the first. Results This study included 1663 fetuses. All fetuses can clearly show the three spaces of the fetal posterior fossa. The ICCs (95% CI) of intra-operator reproducibility of CM, IT, BS, BSOB, BS/BSOB were 0.981 (0.952 ~ 0.991, P < 0.001), 0.929 (0.866 ~ 0.961, P < 0.001), 0.970 (0.946 ~ 0.983, P < 0.001), 0.991 (0.974 ~ 0.996, P < 0.001), 0.939 (0.892 ~ 0.965, P < 0.001), respectively; The ICCs (95% CI) of inter-operator reproducibility 0.926 (0.860 ~ 0.960, P < 0.001), 0.810 (-0.083 ~ 0.940, P < 0.001), 0.820 (0.645 ~ 0.904, P < 0.001), 0.804 (0.656 ~ 0.888, P < 0.001), 0.772 (0.599 ~ 0.871, P < 0.001), respectively. There was a linear correlation between CRL and the parameters related to the posterior fossa (CM, IT, BS, BSOB, BS/BSOB). CM (mm) = -1.698 + 0.532 × CRL (cm) (r = 0.829, P < 0.001); IT (mm) = 0.701 + 0.179 × CRL (cm) (r = 0.548, P < 0.001); BS (mm) = 0.403 + 0.349 × CRL (cm) (r = 0.716, P < 0.001); BSOB (mm) = -0.277 + 0.719 × CRL (cm) (r = 0.829, P < 0.001); BS/BSOB = 0.747—0.021 × CRL (cm) (r = 0.196, P < 0.001). Conclusions Qualitative and quantitative assessment of the fetal posterior fossa structure was feasible in the first trimester. We constructed the normal reference ranges of CM, IT, BS, BSOB, and BS/BSOB. Furthermore, CM, IT, BS, and BSOB were positively correlated with CRL, but BS/BSOB was negatively correlated with CRL.
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Affiliation(s)
- Li Feng
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P. R. China.,Beijing Maternal and Child Health Care Hospital, Beijing, P. R. China
| | - Lijuan Sun
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P. R. China.,Beijing Maternal and Child Health Care Hospital, Beijing, P. R. China
| | - Jingjing Wang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P. R. China.,Beijing Maternal and Child Health Care Hospital, Beijing, P. R. China
| | - Congxin Sun
- Shijiazhuang Obstetrics and Gynecology Hospital, Shijiazhuang, P. R. China
| | - Lijuan Lu
- Kunming Maternity and Child Care Hospital, Kunming, P. R. China
| | - Zhikun Zhang
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, P. R. China
| | - Yu Hu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P. R. China.,Beijing Maternal and Child Health Care Hospital, Beijing, P. R. China
| | - Qingqing Wu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P. R. China. .,Beijing Maternal and Child Health Care Hospital, Beijing, P. R. China. .,Department Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, No. 251 Yaojiayuan Road, Chaoyang District, 100026, Beijing , P. R. China.
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Volpe N, Sen C, Turan S, Sepulveda W, Khalil A, Rolnik DL, De Robertis V, Volpe P, Gil MM, Chaveeva P, Dagklis T, Pooh R, Kosinski P, Cruz J, Huertas E, D' Antonio F, Rodriguez Calvo J, Daneva Markova A. First trimester examination of fetal anatomy: clinical practice guideline by the World Association of Perinatal Medicine (WAPM) and the Perinatal Medicine Foundation (PMF). J Perinat Med 2022; 50:863-877. [PMID: 35452577 DOI: 10.1515/jpm-2022-0125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/15/2022]
Abstract
This recommendation document follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation. We aim to bring together groups and individuals throughout the world for precise standardization to implement the ultrasound evaluation of the fetus in the first trimester of pregnancy and improve the early detection of anomalies and the clinical management of the pregnancy. The aim is to present a document that includes statements and recommendations on the standard evaluation of the fetal anatomy in the first trimester, based on quality evidence in the peer-reviewed literature as well as the experience of perinatal experts around the world.
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Affiliation(s)
- Nicola Volpe
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Azienda Ospedaliero-Universitaria Ospedale Maggiore di Parma, Parma, Italy
| | - Cihat Sen
- Perinatal Medicine Foundation and Department of Perinatal Medicine,Memorial BAH Hospital Istanbul, Turkey
| | - Sifa Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland USA
| | - Waldo Sepulveda
- FETALMED Maternal-Fetal Diagnostic Center, Fetal Imaging Unit, Santiago, Chile
| | - Asma Khalil
- Fetal Medicine Unit, St George University Hospital NHS Foundation Trust, London, United Kingdom
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Paolo Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL BA, Bari, Italy
| | - Mar M Gil
- Hospital Universitario de Torrejón, Madrid, Spain.,School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Petya Chaveeva
- Fetal Medicine Unit, Dr Shterev hospital, Bulgaria and Medical University of Pleven, Sofia, Bulgaria
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynaecology, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki/ Greece GR
| | - Ritsuko Pooh
- Fetal Diagnostic Center, CRIFM, Prenatal Medical Clinic, Osaka, Japan
| | - Przemyslaw Kosinski
- Department of Obstetrics, Perinatology and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Jader Cruz
- Fetal Medicine Unit, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | | | - Francesco D' Antonio
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | | | - Ana Daneva Markova
- Department of Obstetrics and Gynecology, Medical Faculty, Skopje University, Skopje, North Macedonia
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Birnbaum R, Barzilay R, Brusilov M, Acharya P, Malinger G, Krajden Haratz K. Early second-trimester three-dimensional transvaginal neurosonography of fetal midbrain and hindbrain: normative data and technical aspects. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:317-324. [PMID: 34002885 DOI: 10.1002/uog.23691] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/11/2021] [Accepted: 05/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To provide a detailed description of the sonographic appearance and development of various fetal structures of the midbrain and hindbrain (MBHB) during the early second trimester, and to evaluate the impact of the frequency of the transvaginal sonography (TVS) transducer on the early recognition of these structures. METHODS This was a retrospective analysis of three-dimensional volumetric datasets of the MBHB from apparently normal fetuses at 14-19 gestational weeks, acquired by TVS in the midsagittal view through the posterior fontanelle. Using a multiplanar approach, we measured the tectal thickness and length, aqueductal thickness, tegmental thickness and width and height of the Blake's pouch (BP) neck. In addition, we assessed the existence of early vermian fissures, the linear shape of the brainstem and the components of the fastigium. The correlation between gestational age according to last menstrual period and sonographic measurements of MBHB structures was evaluated using Pearson's correlation (r). A subanalysis was performed to assess the performance of a 5-9-MHz vs a 6-12-MHz TVS transducer in visualizing the MBHB structures in the early second trimester. RESULTS Sixty brain volumes were included in the study, obtained at a mean gestational age of 16.2 weeks (range, 14.1-19.0 weeks), with a transverse cerebellar diameter range of 13.0-19.8 mm. We found a strong correlation between gestational age and all MBHB measurements, with the exception of the tectal, tegmental and aqueductal thicknesses, for which the correlation was moderate. There was good-to-excellent intraobserver and moderate-to-good interobserver correlation for most MBHB measurements. We observed that the BP neck was patent in all fetuses between 14 and 18 weeks with decreasing diameter, and that the aqueductal thickness was significantly smaller at ≥ 18 weeks compared with at < 16 weeks. The early vermian fissures and the linear shape of the brainstem were present in all fetuses from 14 weeks. We found that, in the early second trimester, the horizontal arm of the presumed 'fastigium' evolves from the fourth ventricular choroid plexus and not the posterior vermis, indicating that this is not the fastigium. Standard- and high-resolution TVS transducers performed similarly in the assessment of MBHB anatomy. CONCLUSION Detailed early second-trimester assessment of the MBHB is feasible by transvaginal neurosonography and provides reference data which may help in the early detection of brain pathology involving the MBHB. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Birnbaum
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Barzilay
- Lifespan Brain Institute, Penn Medicine and Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
| | - M Brusilov
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - P Acharya
- Paras Advanced Center for Fetal Medicine, Ahmedabad, India
| | - G Malinger
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Krajden Haratz
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Volpe P, De Robertis R, Fanelli T, Boito S, Volpe G, Votino C, Persico N, Chaoui R. Low torcular Herophili position and large brainstem-tentorium angle in fetuses with open spinal dysraphism at 11-13 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:49-54. [PMID: 34125985 DOI: 10.1002/uog.23697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/03/2021] [Accepted: 05/21/2021] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To evaluate whether in fetuses with open spina bifida (OSB) the tentorium can be seen to be displaced downwards and vertically oriented by the time of the 11-13-week scan and whether this is reflected in an alteration of the brainstem-tentorium (BST) angle. METHODS The study population was recruited between 2015 and 2020 from three fetal medicine referral centers and comprised a control group and a study group of pregnancies with OSB. The control group was recruited prospectively and included singleton pregnancies with a normal sonographic examination after first-trimester combined screening for chromosomal abnormalities and normal outcome. The study group was selected retrospectively and included all cases with OSB between 2015 and 2020. All cases underwent detailed ultrasound assessment at 11 + 0 to 13 + 6 weeks' gestation. The position of the torcular Herophili (TH) was identified in the midsagittal view of the fetal brain with the use of color Doppler and was considered as a proxy for the insertion of the tentorium on the fetal skull. The BST angle was calculated in the same view and was compared between the two groups. RESULTS Sixty normal fetuses were included in the control group and 22 fetuses with OSB in the study group. In both groups, the BST angle was found to be independent of gestational age or crown-rump length (P = 0.8815, R2 = 0.0003861 in the controls, and P = 0.2665, R2 = 0.00978 in the OSB group). The mean BST angle was 48.7 ± 7.8° in controls and 88.1 ± 1.18°, i.e. close to 90°, in fetuses with OSB. Comparison of BST-angle measurements between the control group and cases with OSB showed a statistically significant difference (P = 0.0153). In all fetuses with OSB, the downward displacement of the TH and tentorium was clearly visible at the 11-13-week scan. CONCLUSIONS In fetuses with OSB, the BST angle is significantly larger than in normal controls, with the tentorium being almost perpendicular to the brainstem. This sign confirms the inferior displacement of the tentorium cerebelli with respect to its normal insertion on the occipital clivus as early as the first trimester of pregnancy and is useful in the diagnosis of Chiari-II malformation at this early stage. In fetuses with OSB, the low position of the tentorium and TH is clearly visible, even subjectively, at the 11-13-week scan. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- P Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL, BA, Bari, Italy
| | - R De Robertis
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL, BA, Bari, Italy
| | - T Fanelli
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL, BA, Bari, Italy
| | - S Boito
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - G Volpe
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - C Votino
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL, BA, Bari, Italy
| | - N Persico
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - R Chaoui
- Center for Prenatal Diagnosis and Human Genetics, Berlin, Germany
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Eric Ozdemir M, Demirci O, Ayvaci Tasan H, Ohanoglu K, Akalin M. The importance of first trimester screening of cranial posterior fossa in predicting posterior fossa malformations which may be identified in the following weeks of gestation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:958-962. [PMID: 34403530 DOI: 10.1002/jcu.23057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE We aimed to investigate the value of posterior fossa ultrasonography measurements in predicting fetal posterior fossa anomaly at 11-14 weeks of gestation. METHODS The study was performed at Zeynep Kamil Women and Children's Diseases Training and Research Hospital. Measurements were made in two groups: the control group consisted of 328 fetuses with normal postnatal outcome and the study group consisted of 22 fetuses with enlarged 4th ventricle. In the study group, we questioned the value of intracranial translucency (IT) and brainstem (BS) measurements and the BS/brainstem-to-occipital bone (BSOB) ratio in order to predict possible posterior fossa anomalies that may be identified in advanced gestational weeks. The differences of ultrasonographic measurements between groups with p < 0.05 were considered statistically significant. RESULTS IT value, BSOB value, and BS/BSOB ratio were determined as ultrasonographic variables in predicting normal development of the fetal posterior fossa, with cutoff values of 2.7, 5.1, and 0.3. Negative predictive values of these three measurements for posterior fossa abnormalities were 100%. There was no statistically significant difference between the three variables for other diagnostic accuracy values (specifities and positive predictive values) (p > 0.05). CONCLUSION IT, BSOB, and BS/BSOB ratio can be used as ultrasonographic markers to predict the normal development of the fetal posterior fossa.
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Affiliation(s)
- Mucize Eric Ozdemir
- Perinatology Department, Health Science University, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Oya Demirci
- Perinatology Department, Health Science University, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Habibe Ayvaci Tasan
- Perinatology Department, Health Science University, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Karolin Ohanoglu
- Obstetrics and Gynaecology Department, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Munip Akalin
- Perinatology Department, Health Science University, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
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10
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Jackson DN. "Is my baby all right?" Commentary on "The importance of first trimester screening of cranial posterior fossa in predicting posterior fossa malformations which may be identified in the following weeks of gestation" by Ozdemir et al. David N Jackson, MD. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:963-965. [PMID: 34695240 DOI: 10.1002/jcu.23076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 06/13/2023]
Affiliation(s)
- David N Jackson
- Maternal-Fetal Medicine, University of Nevada Reno and Las Vegas, Las Vegas, Nevada, USA
- High Risk Pregnancy Center, Las Vegas, Nevada, USA
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11
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Volpe P, De Robertis V, Volpe G, Boito S, Fanelli T, Olivieri C, Votino C, Persico N. Position of the choroid plexus of the fourth ventricle in first- and second-trimester fetuses: a novel approach to early diagnosis of cystic posterior fossa anomalies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:568-575. [PMID: 33847428 DOI: 10.1002/uog.23651] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/09/2021] [Accepted: 03/17/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To describe the sonographic appearance and position of the choroid plexus of the fourth ventricle (4V-CP) between 12 and 21 weeks' gestation in normal fetuses and in fetuses with Dandy-Walker malformation (DWM) or Blake's pouch cyst (BPC). METHODS The study population comprised 90 prospectively recruited normal singleton pregnancies and 41 pregnancies identified retrospectively from our institutional database that had a suspected posterior fossa anomaly at 12-13 weeks' gestation based on the ultrasound finding of abnormal hindbrain spaces. In all cases the final diagnosis was confirmed by prenatal and/or postnatal magnetic resonance imaging or postmortem examination. All pregnancies underwent a detailed ultrasound assessment, including a dedicated examination of the posterior fossa, at 12-13 weeks, 15-16 weeks and 20-21 weeks of gestation. Two-dimensional ultrasound images of the midsagittal and coronal views of the brain through the posterior fontanelle and three-dimensional volume datasets were obtained. Multiplanar orthogonal image correlation with volume contrast imaging was used as the reference visualization mode. Two independent operators, blinded to the fetal outcome, were asked to classify the 4V-CP as visible or not visible in both normal and abnormal cases, and to assess if the 4V-CP was positioned inside or outside the cyst in fetuses with DWM and BPC. RESULTS Of the 41 fetuses with apparently isolated cystic posterior fossa anomaly in the first trimester, eight were diagnosed with DWM, 29 were diagnosed with BPC and four were found to be normal in the second trimester. The position of the 4V-CP differed between DWM, BPC and normal cases in the first- and second-trimester ultrasound examinations. In particular, in normal fetuses, no cyst was present and, in the midsagittal and coronal planes of the posterior fossa, the 4V-CP appeared as an echogenic oval-shaped structure located inside the 4V apparently attached to the cerebellar vermis. In fetuses with DWM, the 4V-CP was not visible in the midsagittal view because it was displaced inferolaterally by the cyst. In contrast, in the coronal view of the posterior brain, the 4V-CP was visualized in all cases with DWM at 12-13 weeks, with a moderate decrease in the visualization rate at 15-16 weeks (87.5%) and at 20-21 weeks (75%). In the coronal view, the 4V-CP was classified as being outside the cyst in all DWM cases at 12-13 weeks and in 87.5% and 75% of cases at 15-16 and 20-21 weeks, respectively. In fetuses with BPC, the 4V-CP was visualized in all cases in both the midsagittal and coronal views at 12-13 weeks and in 100% and 96.6% of cases, respectively, at 15-16 weeks. In the coronal view, the 4V-CP was classified as being inside the cyst in 28 (96.6%), 27 (93.1%) and 25 (86.2%) cases at 12-13, 15-16 and 20-21 weeks, respectively. The medial segment of the 4V-CP was visualized near the inferior part of the vermis. CONCLUSIONS Our study shows that longitudinal ultrasound assessment of the 4V-CP and its temporal changes from 12 to 21 weeks is feasible. The 4V-CP is located inside the cyst, just below the vermis, in BPC and outside the cyst, inferolaterally displaced and distant from the vermian margin, in DWM, consistent with the pathogenesis of the two conditions. The position of the 4V-CP is a useful sonographic marker that can help differentiate between DWM and BPC as early as in the first trimester of pregnancy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- P Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - V De Robertis
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - G Volpe
- Maternal Infant Department SC, Obstetrics and Gynecology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - S Boito
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - T Fanelli
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - C Olivieri
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - C Votino
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - N Persico
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Salsi G, Volpe G, Montaguti E, Fanelli T, Toni F, Maffei M, Votino C, Pompilii E, Pilu G, Volpe P. Isolated Upward Rotation of the Fetal Cerebellar Vermis (Blake's Pouch Cyst) Is a Normal Variant: An Analysis of 111 Cases. Fetal Diagn Ther 2021; 48:485-492. [PMID: 34182549 DOI: 10.1159/000516807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 04/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The objective of the study was to provide more detailed data about fetal isolated upward rotation of the cerebellar vermis rotation (Blake's pouch cyst) in particular regarding pregnancy outcome. METHODS This is a retrospective study of all cases of fetal isolated upward rotation of the cerebellar vermis (URCV) diagnosed in 3 referral centers in Italy from January 2009 to November 2019. Whenever possible, prenatal magnetic resonance imaging (MRI) was performed and a fetal karyotype was obtained. A detailed follow-up was obtained by consultation of medical records, interview with the parents, and the pediatricians. RESULTS Our study population included 111 patients with a prenatal diagnosis of isolated URCV made at a median gestational age of 21 weeks +3 days (interquartile range (IQR) 21 + 0-22 + 2). The median brain stem-vermis (BV) angle was 27° (IQR 24-29°). In 37.9% of the cases, a regression of the finding with restoration of normal anatomy was noted at a follow-up scan or at postnatal checks. A BV angle of 25° or less predicted regression with a probability in excess of 90%. MRI was performed in utero or at birth in 101 patients and always confirmed sonographic diagnosis. Fetal CGH array and/or karyotype was available in 97 cases and was always normal, but in 1 case. A postnatal follow-up was available in 102 infants (mean 7 months, range 0-10 years of age) and documented a normal neurologic development in all the cases. CONCLUSIONS Isolated URCV is most likely a normal variant of fetal anatomy without clinical consequences, at least at an early follow-up. A BV angle of 25° or less predicts intrauterine regression of the finding, but the outcome is good in all the cases. When a confident sonographic diagnosis is made, MRI is not mandatory. The risk of a chromosomal anomaly in these cases is probably low.
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Affiliation(s)
- Ginevra Salsi
- Department of Medical and Surgical Sciences, Obstetric Unit, University of Bologna, Bologna, Italy
| | - Grazia Volpe
- Maternal Infant Department SC, Obstetrics and Gynecology, ASST, Grande Ospedale Metropolitano, Niguarda, Milan, Italy
| | - Elisa Montaguti
- Department of Medical and Surgical Sciences, Obstetric Unit, University of Bologna, Bologna, Italy
| | - Tiziana Fanelli
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - Francesco Toni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UDC Neuroradiologia, Bologna, Italy
| | - Monica Maffei
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UDC Neuroradiologia, Bologna, Italy
| | - Carmela Votino
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
| | - Eva Pompilii
- Department of Medical and Surgical Sciences, Obstetric Unit, University of Bologna, Bologna, Italy.,Gynepro Medical, Bologna, Italy
| | - Gianluigi Pilu
- Department of Medical and Surgical Sciences, Obstetric Unit, University of Bologna, Bologna, Italy
| | - Paolo Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, Bari, Italy
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Zhu X, Zhao S, Yang X, Feng Q, Zhang X, Yang F, Chen X. First-Trimester Cranial Ultrasound Markers of Open Spina Bifida. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1155-1162. [PMID: 32951226 DOI: 10.1002/jum.15496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/21/2020] [Accepted: 08/08/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To evaluate cranial ultrasound markers during a first-trimester routine ultrasound examination for screening for open spina bifida (OSB). METHODS Midsagittal and axial images of the fetal head obtained from fetuses with spina bifida and unaffected control fetuses at 11 weeks to 13 weeks 6 days were analyzed retrospectively. The observed markers of the posterior brain included the 4- versus 3-line view, the brain stem (BS)-to-brain stem-occipital bone (BSOB) distance ratio (BS/BSOB), the position relationship between the maxillo-occipital (MO) line and the midbrain-BS junction, and the crash sign status. RESULTS This study included 9 OSB cases, 2 closed spina bifida (CSB) cases, and 200 unaffected controls. Eight of 9 OSB cases had informative midsagittal views of the head. The 3-line view (abnormal) and BS/BSOB greater than 1 (abnormal) were observed in 87.5% (7 of 8) and 100% (8 of 8), respectively. The midbrain-BS junction was below or nearly on the MO line (abnormal) in 100% (8 of 8). Seven of the cases had informative axial views of the head. The crash sign (abnormal) was observed in 85.7% (6 of 7). A 3-line view was seen in all of the cases that had a positive crash sign. Neither of the 2 cases of CSB and none of the controls had any of the 4 first-trimester intracranial ultrasound markers of OSB. CONCLUSIONS The 4 first-trimester intracranial ultrasound markers investigated in this study appear to be very good markers of OSB, especially a BS/BSOB greater than 1 and an abnormal MO line. The crash sign and 3-line view were observed in the same fetus. In our study, these ultrasound findings were not helpful in CSB.
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Affiliation(s)
- Xia Zhu
- Department of Ultrasonography, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Sheng Zhao
- Department of Ultrasonography, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Xiaohong Yang
- Department of Ultrasonography, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Qian Feng
- Department of Ultrasonography, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Xiaoyan Zhang
- Department of Ultrasonography, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Fan Yang
- Department of Ultrasonography, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Xinlin Chen
- Department of Ultrasonography, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
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14
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AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 Weeks 0 Days and 13 Weeks 6 Days. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:E1-E16. [PMID: 32852128 DOI: 10.1002/jum.15477] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 06/11/2023]
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15
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Macé P, Ville Y, Bessière B, Quarello E. Early diagnosis of rhombencephalosynapsis: the limits of intracranial translucency at first-trimester screening and a plea for assessment of aqueduct of Sylvius. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:846-848. [PMID: 32349173 DOI: 10.1002/uog.22064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 06/11/2023]
Affiliation(s)
- P Macé
- Institut Méditerranéen d'Imagerie Médicale Appliquée à la Gynécologie, la Grossesse et l'Enfance IMAGE2, Marseille, France
- Unité de Dépistage et de Diagnostic Prénatal, Hôpital Privé Marseille Beauregard, Marseille, France
| | - Y Ville
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - B Bessière
- Unité d'Embryofœtopathologie, Service d'Histologie-Embryologie-Cytogénétique, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - E Quarello
- Institut Méditerranéen d'Imagerie Médicale Appliquée à la Gynécologie, la Grossesse et l'Enfance IMAGE2, Marseille, France
- Unité de Dépistage et de Diagnostic Prénatal, Hôpital Saint-Joseph, Marseille, France
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16
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Volpe N, Dall'Asta A, Di Pasquo E, Frusca T, Ghi T. First-trimester fetal neurosonography: technique and diagnostic potential. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:204-214. [PMID: 33049801 DOI: 10.1002/uog.23149] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/04/2020] [Indexed: 06/11/2023]
Abstract
Most brain abnormalities are present in the first trimester, but only a few are detected so early in gestation. According to current recommendations for first-trimester ultrasound, the fetal head structures that should be visualized are limited to the cranial bones, the midline falx and the choroid-plexus-filled ventricles. Using this basic approach, almost all cases of acrania, alobar holoprosencephaly and cephalocele are detected. However, the majority of other fetal brain abnormalities remain undiagnosed until the midtrimester. Such anomalies would be potentially detectable if the sonographic study were to be extended to include additional anatomic details not currently included in existing guidelines. The aim of this review article is to describe how best to assess the normal fetal brain by first-trimester expert multiplanar neurosonography and to demonstrate the early sonographic findings that characterize some major fetal brain abnormalities. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- N Volpe
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - A Dall'Asta
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - E Di Pasquo
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - T Frusca
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - T Ghi
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
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Mace P, Mancini J, Gorincour G, Quarello E. Accuracy of qualitative and quantitative cranial ultrasonographic markers in first-trimester screening for open spina bifida and other posterior brain defects: a systematic review and meta-analysis. BJOG 2020; 128:354-365. [PMID: 32966672 DOI: 10.1111/1471-0528.16530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The significant number of qualitative and quantitative ultrasound markers described for first-trimester screening of open spina bifida (OSB) and other posterior brain defects (oPBD) has resulted in their complex implementation and interpretation for a widespread screening and in a lack of consensus regarding diagnostic accuracy. OBJECTIVES To assess and compare the accuracy of qualitative and quantitative cranial sonographic markers at 11-14 weeks of gestation for the detection of OSB and oPBD. SEARCH STRATEGY A systematic literature search was performed in MEDLINE and COCHRANE from 2009 to April 2020. SELECTION CRITERIA Studies assessing the diagnostic accuracy of quantitative and/or qualitative ultrasound signs to predict OSB and oPBD were included. Cohort studies and case-control studies were also considered. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed the risk of bias. The overall pooled estimate and a summary receiver operating characteristic curve was estimated for each subgroup (qualitative and quantitative assessment). MAIN RESULTS Twenty-three studies were included in our meta-analysis. The pooled sensitivity and specificity for qualitative assessment were 76.5% and 99.6%, and for quantitative assessment were 84.5% and 96.3%, respectively; specificity for the qualitative ultrasound signs was significantly higher (P = 0.001). The overall sensitivity of cranial sonographic markers for the screening of oPBD was 76.7% and specificity was 97.5%. CONCLUSIONS The qualitative approach demonstrated greater specificity, so this would appear to be more appropriate for daily screening, as a first-line tool, whereas the quantitative approach should be reserved for expert ultrasound. TWEETABLE ABSTRACT This study highlights the relevance of first-trimester qualitative ultrasound signs in the screening of open spina bifida.
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Affiliation(s)
- P Mace
- Institut méditerranéen d'imagerie médicale appliquée à la gynécologie, la grossesse et l'enfance IMAGE2, Marseille, France.,Unité de dépistage et de diagnostic prénatal, Hôpital Privé Marseille Beauregard, Marseille, France
| | - J Mancini
- Public Health Department (BIOSTIC), APHM, INSERM, IRD, SESSTIM, Hop Timone, Aix Marseille Univ, Marseille, France
| | - G Gorincour
- Institut méditerranéen d'imagerie médicale appliquée à la gynécologie, la grossesse et l'enfance IMAGE2, Marseille, France.,Elsan, Clinique Bouchard, Marseille, France
| | - E Quarello
- Institut méditerranéen d'imagerie médicale appliquée à la gynécologie, la grossesse et l'enfance IMAGE2, Marseille, France.,Elsan, Clinique Bouchard, Marseille, France
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Zvanca ME, Munteanu A, Bot M, Petca A, Nemescu D. Posterior fossa assessment in the axial view of the head at 11-14 weeks of gestation in normal and aneuploid fetuses. Exp Ther Med 2020; 20:2470-2474. [PMID: 32765736 PMCID: PMC7401706 DOI: 10.3892/etm.2020.8793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/11/2020] [Indexed: 11/05/2022] Open
Abstract
Posterior fossa ultrasound appearance may offer clues for brain anomalies as early as the first trimester. The purpose of the study was to find an easy, reproducible method to examine the posterior fossa. From January 2017 to March 2018, 132 consecutive pregnancies presenting for first-trimester screening, were selected at 11-14 weeks' gestation. An oblique axial view of the fetal head was routinely achieved with visualization of the posterior fossa, wherein the cisterna magna (CM) and the fourth ventricle (V4) anteroposterior diameter was measured. Moreover, 81 patients had a follow-up scan at 19-24 weeks, and the CM and transverse cerebellar diameter (TCD) were measured. Normal ranges were established at 11-14 weeks for CM and V4 according to crown-rump length (CRL). The 50th centile for CM ranges from 1.2 mm to 2.3 mm at a CRL between 45 and 85 mm. The V4 50th centile ranges from 1.8 to 2.4 mm. A positive correlation was found between the first-trimester and second-trimester CM diameter and between the first-trimester V4 and second-trimester TCD. There is an inverse correlation between the first-trimester CM and second-trimester TCD. The measurements of different components of the posterior fossa in the first trimester cannot predict the size of CM and TCD in the second trimester. The presence of the three hypoechoic structures (cerebral peduncles, V4, and CM) separated by two hyperechoic lines is easy to see and measure.
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Affiliation(s)
- Mona Elena Zvanca
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, Elias University Hospital, 011461 Bucharest, Romania
| | - Alexandra Munteanu
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, Elias University Hospital, 011461 Bucharest, Romania
| | - Mihaela Bot
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, Elias University Hospital, 011461 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, Elias University Hospital, 011461 Bucharest, Romania
| | - Dragos Nemescu
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
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Altmann R, Schertler C, Scharnreitner I, Arzt W, Dertinger S, Scheier M. Diagnosis of Fetal Posterior Fossa Malformations in High-Risk Pregnancies at 12–14 Gestational Weeks by Transvaginal Ultrasound Examination. Fetal Diagn Ther 2019; 47:182-187. [DOI: 10.1159/000501500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 06/12/2019] [Indexed: 11/19/2022]
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Lombardi S, Scola E, Ippolito D, Zambelli V, Botta G, Cuttin S, Triulzi F, Lombardi CM. Micro-computed tomography: a new diagnostic tool in postmortem assessment of brain anatomy in small fetuses. Neuroradiology 2019; 61:737-746. [PMID: 30693410 DOI: 10.1007/s00234-019-02168-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/11/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of our study was to evaluate the postmortem micro-CT anatomy of early fetal human fetal brains, either in situ or isolated. METHODS We studied 12 ex vivo specimens, 9 whole human fetuses (9-18 GW), and 3 isolated samples (16-26 GW). Specimens were fixed in formalin, then immersed in Lugol solution. Images were evaluated by two neuroradiologists. The depiction of CNS structures was defined based on the comparison between micro-CT images and a reference histologic anatomical Atlas of human brain development. RESULTS Micro-CT provided informative high-resolution brain images in all cases, with the exception of one case (9 weeks) due to advanced maceration. All major CNS structures (i.e., brain hemispheres, layering, ventricles, germinal neuroepithelium, basal ganglia, corpus callosum, major cranial nerves, and structures of the head and neck) were recognizable. CONCLUSIONS Micro-CT imaging of the early fetal brain is feasible and provides high-quality images that correlate with the histological Atlas of the human brain, offering multiplanar and volumetric images that can be stored and shared for clinical, teaching, and research purposes.
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Affiliation(s)
- Sophie Lombardi
- Department of Neuroradiology, Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Elisa Scola
- Neuroradiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Vanessa Zambelli
- Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy
| | - Giovanni Botta
- Azienda Ospedaliera Città della Salute e delle Scienze di Torino, Presidio Ospedaliero OIRM-Sant'Anna, Turin, Italy
| | - Serena Cuttin
- Department of Pathology, San Gerardo Hospital, Monza, Italy
| | - Fabio Triulzi
- Neuroradiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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21
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First Trimester Neurosonogram-Our Experience. CURRENT HEALTH SCIENCES JOURNAL 2019; 45:167-173. [PMID: 31624643 PMCID: PMC6778289 DOI: 10.12865/chsj.45.02.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 06/27/2019] [Indexed: 11/18/2022]
Abstract
Central nervous system (CNS) malformations represent 1% of all births. For this reason, efforts are being made to increase detection of such anomalies prenatally. Consequently, a detailed assessment of the fetal nervous system in the first trimester of pregnancy is no longer a utopia as this kind of evaluation can detect severe malformation such as acrania, neural tube defects, holoprosencephaly or can draw attention regarding to anomalies currently detected in the second trimester due to certain markers of diagnosis. Material and methods: The study included 1376 pregnant women with gestational ages between 11 and 14 weeks, who were referred to our unit for sonographic evaluation. We analyzed in all patients the fetal brain in axial and mid-sagittal views, assessing markers like intracranial translucency, brainstem/brainstem-occipital bone (BS/BSOB) ratio, choroid plexus (CP/HA) ratio, the octopus sign in order to detect as many anomalies in the first trimester of pregnancy. Results: We detected 6 CNS anomalies during our search. All markers assessed were abnormal in all pathological cases. Conclusion: A detailed assessment of the fetal brain is recommended at 11-14 weeks because the earlier the diagnosis is confirmed, the lower the chances of obstetrical, psychological complications to supervene.
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22
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Volpe P, Persico N, Fanelli T, De Robertis V, D'Alessandro J, Boito S, Pilu G, Votino C. Prospective detection and differential diagnosis of cystic posterior fossa anomalies by assessing posterior brain at 11-14 weeks. Am J Obstet Gynecol MFM 2019; 1:173-181. [PMID: 33345823 DOI: 10.1016/j.ajogmf.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/31/2019] [Accepted: 06/04/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The role of the first-trimester scan has expanded from aneuploidy screening to the diagnosis of fetal malformations. Abnormal appearance of the posterior brain at 11-14 weeks gestation is a marker of cerebral anomalies; in fact an increased amount of fluid, particularly when the choroid plexus of the fourth ventricle is not visible and only 2 brain spaces instead of 3 are seen, may indicate the presence of cystic or cyst-like posterior fossa anomalies, such as Blake's pouch cyst or Dandy-Walker malformation. OBJECTIVE The purpose of this study was to assess the role of ultrasound scanning in the identification of cystic posterior fossa anomalies at 11-14 weeks gestation. STUDY DESIGN A prospective cohort study of fetuses with cystic appearance of the posterior fossa at 11-14 weeks gestation was performed. In all cases and in a control group of 40 normal fetuses, the brainstem-tentorium angle was also measured. The presence or absence of cystic posterior anomalies was determined at birth or at postmortem evaluation. RESULTS In the period 2014-2018, 32 fetuses with an increased brainstem-occipital bone distance and/or failure to visualize the choroid plexus of fourth ventricle (2 brain spaces) were seen. Of these, 18 fetuses were terminated in the first trimester because of associated anomalies and were excluded from the study because of unavailable autoptic findings. The remaining 14 fetuses eventually were found to have a Dandy-Walker malformation in 4 cases, a Blake's pouch cyst in 8 cases, and normal brain anatomy in 2 cases. Two brain spaces were seen in all cases with Dandy-Walker malformation and in 2 of 8 cases with Blake's pouch cyst. Both brainstem-occipital bone measurement and brainstem-tentorium angle were significantly different in fetuses with Dandy-Walker malformation, Blake's pouch cyst, and control subjects (P<.0001). The brainstem-occipital bone z-scores of fetuses with Dandy-Walker malformation and Blake's pouch cyst were always +3 or more and +1.7 or more, respectively. The brainstem-tentorium angle z-scores were always -5 or less and -0.1 or less, respectively. CONCLUSION Our study confirms that sonography of the posterior brain at 11-14 weeks gestation allows the identification of cystic posterior fossa anomalies. A large brainstem-occipital bone predicts Dandy-Walker malformation or Blake's pouch cyst. The presence of 2 brain spaces and a small brainstem-tentorium angle are correlated significantly with the presence of Dandy-Walker malformation.
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Affiliation(s)
- Paolo Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL BA, Bari, Italy.
| | - Nicola Persico
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Tiziana Fanelli
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL BA, Bari, Italy
| | | | | | - Simona Boito
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Gianluigi Pilu
- Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
| | - Carmela Votino
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL BA, Bari, Italy
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Garcia-Rodriguez R, Garcia-Delgado R, Romero-Requejo A, Medina-Castellano M, Garcia-Hernandez JA, Gonzalez-Martin JM, Sepulveda W. First-trimester cystic posterior fossa: reference ranges, associated findings, and pregnancy outcomes. J Matern Fetal Neonatal Med 2019; 34:933-942. [PMID: 31113257 DOI: 10.1080/14767058.2019.1622673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To report reference ranges for fetal cerebral posterior fossa measurements and to describe the sonographic findings, karyotype results, and pregnancy outcomes in fetuses presenting with cystic posterior fossa (CPF) in the first trimester of pregnancy. METHODS Two groups of patients undergoing first-trimester sonographic screening at 11-13 weeks' gestation were studied. The first (control group) consisted of 253 consecutive fetuses with normal posterior fossa, in which the brainstem (BS), fourth ventricle, cisterna magna, and BS-occipital bone (BS-OB) diameter were prospectively measured and the BS/BS-OB diameter ratio was calculated. The second (study group) consisted of 14 fetuses in which a CPF was detected. Information on sonographic findings, prenatal karyotype results, and pregnancy outcomes was obtained by reviewing ultrasound reports and medical records. The results from the two groups were then compared. RESULTS In the control group, the size of all posterior fossa structures increased and the BS/BS-OB diameter ratio slightly decreased as the pregnancy progressed. In the study group, the BS diameter did not differ significantly from the measurements obtained in the control group. However, the BS-OB diameter and the fourth ventricle were significantly larger (p < .05 and p < .001, respectively) in the study group than in the control group. Additionally, the cisterna magna was not identified in 13 of the 14 fetuses (93%) in the study group, in comparison to zero out of the 253 fetuses in the control group (p < .001). Finally, the BS/BS-OB diameter ratio was significantly smaller in the study group when compared with the control group (p < .05). Regarding pregnancy outcomes, 12 of the 14 (86%) affected pregnancies underwent elective termination (n = 11) or ended in an early intrauterine demise (n = 1) due to the associated chromosomal abnormalities or structural defects. The two fetuses with isolated CPF had a normal second-trimester scan and resulted in the delivery of healthy newborn infants. CONCLUSIONS The detection of a CPF in the first trimester is associated with a high rate of chromosomal and structural defects. By using normative data, early sonographic screening and detection of mildly and moderately abnormal cases is possible. Fetuses with isolated CPF require further study with a detailed second-trimester scan. This is essential in order to differentiate cases with poor and good perinatal outcomes. Finally, our data also demonstrate that the main sonographic tool when screening for CPF in the first trimester is the assessment of the fourth ventricle, which is significantly larger in abnormal cases as the result of the wide communication between the fourth ventricle and the cisterna magna.
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Affiliation(s)
- Raquel Garcia-Rodriguez
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil de Canarias, Las Palmas de Gran Canaria, Spain
| | - Raquel Garcia-Delgado
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil de Canarias, Las Palmas de Gran Canaria, Spain
| | - Azahar Romero-Requejo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil de Canarias, Las Palmas de Gran Canaria, Spain
| | - Margarita Medina-Castellano
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil de Canarias, Las Palmas de Gran Canaria, Spain
| | - Jose Angel Garcia-Hernandez
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil de Canarias, Las Palmas de Gran Canaria, Spain
| | | | - Waldo Sepulveda
- Fetal Imaging Unit, FETALMED - Maternal-Fetal Diagnostic Center, Santiago, Chile
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Paladini D, Donarini G, Parodi S, Chaoui R. Differentiating features of posterior fossa at 12-13 weeks' gestation in fetuses with Dandy-Walker malformation and Blake's pouch cyst. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:850-852. [PMID: 30575134 DOI: 10.1002/uog.20190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 06/09/2023]
Affiliation(s)
- D Paladini
- Fetal Medicine and Surgery Unit, Istituto G.Gaslini, Genoa, Italy
| | - G Donarini
- Fetal Medicine and Surgery Unit, Istituto G.Gaslini, Genoa, Italy
| | - S Parodi
- Biostatistics, Istituto G.Gaslini, Genoa, Italy
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Wang L, Nie H, Wang Q, Zhang G, Li G, Bai L, Hua T, Wei S. Use of magnetic resonance imaging combined with gene analysis for the diagnosis of fetal congenital heart disease. BMC Med Imaging 2019; 19:12. [PMID: 30683072 PMCID: PMC6347844 DOI: 10.1186/s12880-019-0314-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 01/16/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Fetal deformity is a disease caused by abnormal chromosome structure, which may be influenced by genetic factors as well as the maternal and external environment. Magnetic resonance imaging (MRI) may be used to effectively diagnose fetus deformities. However it has been reported that gene analysis is a more accurate diagnostic method. The aim of the present study was to investigate the effectiveness of MRI in combination with gene analysis for the diagnosis of fetal congenital heart disease, a form of fetus deformity. METHODS MRI, array comparative genome hybridization analysis and fluorescence in situ hybridization were used to analyze the effectiveness of the two methods in a total of 78 pregnant women with suspected fetal congenital heart disease. RESULTS Our findings demonstrated that the combination of MRI and gene analysis resulted in significantly improved diagnostic accuracy, sensitivity and specificity for fetal congenital heart disease compared with either method alone. MRI combined with gene analysis confirmed 42 fetuses with pulmonary stenosis, 24 with aortic stenosis and 12 healthy fetuses, which was significantly improved compared with MRI or gene analysis alone. It was also observed that gene analysis was a more efficient method of diagnosis compared with MRI; however, the combination of the two methods was the most effective. CONCLUSION In conclusion, the results of the present study suggest that MRI combined with gene analysis may be a more effective diagnostic method for fetal congenital heart disease compared with the current protocol.
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Affiliation(s)
- Lishun Wang
- Department of Radiology, Maternity and Child Care Center of Qinhuangdao, Qinhuangdao Maternal and Child Health Hospital, Qinhuangdao, Hebei, 066000, People's Republic of China.
| | - Hongyan Nie
- Department of Ultrasound, Maternity and Child Care Center of Qinhuangdao, Qinhuangdao Maternal and Child Health Hospital, Qinhuangdao, Hebei, 066000, People's Republic of China
| | - Qichen Wang
- Department of Radiology, Maternity and Child Care Center of Qinhuangdao, Qinhuangdao Maternal and Child Health Hospital, Qinhuangdao, Hebei, 066000, People's Republic of China
| | - Guoliang Zhang
- Department of Radiology, Maternity and Child Care Center of Qinhuangdao, Qinhuangdao Maternal and Child Health Hospital, Qinhuangdao, Hebei, 066000, People's Republic of China
| | - Gang Li
- Department of Anesthesiology, Maternity and Child Care Center of Qinhuangdao, Qinhuangdao Maternal and Child Health Hospital, qinhuangdao, Hebei, 066000, People's Republic of China
| | - Liwei Bai
- Prenatal Diagnosis Center, Maternity and Child Care Center of Qinhuangdao, Qinhuangdao Maternal and Child Health Hospital, Qinhuangdao, Hebei, 066000, People's Republic of China
| | - Tianshu Hua
- Department of Epigenetics, Maternity and Child Care Center of Qinhuangdao, Qinhuangdao Maternal and Child Health Hospital, Qinhuangdao, Hebei, 066000, People's Republic of China
| | - Shuzhang Wei
- Department of Radiology, Maternity and Child Care Center of Liuzhou, Liuzhou, Guangxi Zhuang Autonomous Region, 545000, People's Republic of China
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Altmann R, Specht C, Scharnreitner I, Schertler C, Mayer R, Arzt W, Scheier M. Reference Ranges for Transvaginal Examined Fossa Posterior Structures in Fetuses from 45 to 84 mm Crown-Rump Length. Gynecol Obstet Invest 2018; 83:375-380. [PMID: 29870989 DOI: 10.1159/000486334] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 12/14/2017] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Reinhard Altmann
- Department of Prenatal Medicine, Kepler University Hospital, Linz, Austria
| | | | - Iris Scharnreitner
- Department of Prenatal Medicine, Kepler University Hospital, Linz, Austria
| | | | - Richard Mayer
- Department of Prenatal Medicine, Kepler University Hospital, Linz, Austria
| | - Wolfgang Arzt
- Department of Prenatal Medicine, Kepler University Hospital, Linz, Austria
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Kumar Vikraman S. An Inclusive Prototype for an Obstetric Imaging Checklist. JOURNAL OF FETAL MEDICINE 2018. [DOI: 10.1007/s40556-017-0148-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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28
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Martinez-Ten P, Illescas T, Adiego B, Estevez M, Bermejo C, Wong AE, Sepulveda W. Non-visualization of choroid plexus of fourth ventricle as first-trimester predictor of posterior fossa anomalies and chromosomal defects. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:199-207. [PMID: 28236314 DOI: 10.1002/uog.17445] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 02/05/2017] [Accepted: 02/15/2017] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To assess non-visualization of the choroid plexus of the fourth ventricle (CP-4V) as a simple, qualitative and reproducible first-trimester ultrasound feature of the posterior fossa for the prediction of central nervous system (CNS) anomalies and chromosomal defects. METHODS First-trimester three-dimensional ultrasound datasets of the fetal brain were obtained prospectively from 65 consecutive normal singletons and retrospectively from 27 fetuses identified as having an abnormal posterior fossa on first-trimester ultrasound examination, and randomly combined to form the final study group. The stored ultrasound volumes were analyzed offline by two accredited sonologists, who were not aware of the final diagnoses. The CP-4V was assessed by multiplanar navigation and classified as visible or non-visible in its normal position depending on whether or not the echogenic structure that separates the fourth ventricle from the cisterna magna was identified in both midsagittal and axial planes. Correlation with subsequent second-trimester ultrasound, fetal magnetic resonance imaging, or postmortem or postnatal findings was performed to determine the predictive value of the first-trimester findings. RESULTS Among the 92 ultrasound datasets analyzed, 73 (79%) were acquired transabdominally and 19 (21%) transvaginally. The CP-4V was classified as visible in 64 cases and non-visible in 28 cases, with agreement between the two observers in both sagittal and axial planes in all but one case. Twelve of the 28 (43%) fetuses with non-visible CP-4V were subsequently diagnosed as having a CNS malformation (open spina bifida (n = 6), Dandy-Walker malformation (n = 2), Blake's pouch cyst (n = 2), cephalocele (n = 1) and megacisterna magna (n = 1)). In addition, 20 of these 28 (71%) fetuses had aneuploidy (trisomy 18 (n = 10), triploidy (n = 5), trisomy 13 (n = 3), Turner syndrome (n = 1) or trisomy 21 (n = 1)). There was only one false-positive case, in which the CP-4V was classified as absent in a normal fetus. CONCLUSIONS Non-visualization of the CP-4V in the first trimester appears to be a strong marker of posterior fossa anomalies and chromosomal defects. Qualitative evaluation of this anatomic structure is simple, feasible and reproducible, and its routine assessment during the first-trimester scan may facilitate the early detection of CNS anomalies and associated fetal aneuploidy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- P Martinez-Ten
- DELTA-Ultrasound Diagnosis Center in Obstetrics and Gynecology, Madrid, Spain
| | - T Illescas
- DELTA-Ultrasound Diagnosis Center in Obstetrics and Gynecology, Madrid, Spain
| | - B Adiego
- DELTA-Ultrasound Diagnosis Center in Obstetrics and Gynecology, Madrid, Spain
| | - M Estevez
- DELTA-Ultrasound Diagnosis Center in Obstetrics and Gynecology, Madrid, Spain
| | - C Bermejo
- DELTA-Ultrasound Diagnosis Center in Obstetrics and Gynecology, Madrid, Spain
| | - A E Wong
- FETALMED-Maternal-Fetal Diagnostic Center, Fetal Imaging Unit, Santiago, Chile
| | - W Sepulveda
- FETALMED-Maternal-Fetal Diagnostic Center, Fetal Imaging Unit, Santiago, Chile
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Kose S, Altunyurt S, Keskinoglu P. A prospective study on fetal posterior cranial fossa assessment for early detection of open spina bifida at 11-13 weeks. Congenit Anom (Kyoto) 2018; 58:4-9. [PMID: 28378426 DOI: 10.1111/cga.12223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/22/2017] [Accepted: 03/24/2017] [Indexed: 11/27/2022]
Abstract
The objective of this study was to test three measurements: brain stem (BS), intracranial translucency (IT) and brain stem to occipital bone distance (BSOB), as well as one landmark: cisterna magna (CM) visibility, for early diagnosis of open spina bifida (OSB) in a low risk population. A prospective observational study was undertaken in a university hospital. A sample of 1479 women consented to participate between 20 September 2013 and 30 June 2015. Measurements were performed from the mid-sagittal view, as is routinely used for nuchal thickness assessment. CM visibility was assessed qualitatively as the third anechoic band in the posterior cranial fossa (PCF). All pregnancies were screened with a combination of maternal serum alpha-fetoprotein and second trimester anomaly scan and followed until delivery. Predictive values were calculated for each marker. We were able to diagnose two OSB cases and highly suspect one Dandy-Walker malformation case at the first trimester scan by the observation of PCF. PCF characteristics of OSB cases were increased BS diameter, increased BS-BSOB ratio and non-visualization of the CM. All the markers demonstrated high sensitivity and specificity but CM visibility reached the highest positive predictive value. Due to relatively high false positive rates, PCF measurements could not reach a satisfactory performance to validate their clinical use as a single marker. CM visibility has the advantage of being a qualitative marker and reduces the need for sophisticated and time-consuming measurements. Intracranial translucency and BS-BSOB ratio measurements should be used when the CM visibility is absent or in doubt.
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Affiliation(s)
- Semir Kose
- Division of Perinatology, Department of Obstetrics and Gynecology, Dokuz Eylul University School of Medicine, Balcova, Izmir, Turkey
| | - Sabahattin Altunyurt
- Division of Perinatology, Department of Obstetrics and Gynecology, Dokuz Eylul University School of Medicine, Balcova, Izmir, Turkey
| | - Pembe Keskinoglu
- Department of Biostatistics, Dokuz Eylul University School of Medicine, Balcova, Izmir, Turkey
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30
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Malinger G, Paladini D, Pilu G, Timor-Tritsch IE. Fetal cerebral magnetic resonance imaging, neurosonography and the brave new world of fetal medicine. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:679-680. [PMID: 28568972 DOI: 10.1002/uog.17538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/18/2017] [Accepted: 05/25/2017] [Indexed: 06/07/2023]
Affiliation(s)
- G Malinger
- Division of Ultrasound in Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Paladini
- Fetal Medicine & Surgery Unit, G. Gaslini Children's Hospital, Genoa, Italy
| | - G Pilu
- Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
| | - I E Timor-Tritsch
- Division of Obstetrical & Gynecological Ultrasound, Department of Obstetrics and Gynecology, NYU School of Medicine, New York, NY, USA
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Li X, Liu Y, Yue S, Wang L, Zhang T, Guo C, Hu W, Kagan KO, Wu Q. Uniparental disomy and prenatal phenotype: Two case reports and review. Medicine (Baltimore) 2017; 96:e8474. [PMID: 29137034 PMCID: PMC5690727 DOI: 10.1097/md.0000000000008474] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
RATIONALE Uniparental disomy (UPD) gives a description of the inheritance of both homologues of a chromosome pair from the same parent. The consequences of UPD depend on the specific chromosome/segment involved and its parental origin. PATIENT CONCERNS We report prenatal phenotypes of 2 rare cases of UPD. DIAGNOSES The prenatal phenotype of case 1 included sonographic markers such as enlarged nuchal translucency (NT), absent nasal bone, short femur and humerus length, and several structural malformations involving Dandy-Walker malformation and congenital heart defects. The prenatal phenotype of Case 2 are sonographic markers, including enlarged NT, thickened nuchal fold, ascites, and polyhydramnios without apparent structural malformations. INTERVENTIONS Conventional G-band karyotype appears normal in case 1, while it shows normal chromosomes with a small supernumerary marker chromosome (sSMC) in case 2. Genetic etiology was left unknown until single-nucleotide polymorphism-based array (SNP-array) was performed, and segmental paternal UPD 22 was identified in case 1 and segmental paternal UPD 14 was found in case 2. OUTCOMES The parents of case 1 chose termination of pregnancy. The neonate of case 2 was born prematurely with a bellshaped small thorax and died within a day. LESSONS UPD cases are rare and the phenotypes are different, which depend on the origin and affected chromosomal part. If a fetus shows multiple anomalies that cannot be attributed to a common aneuploidy or a genetic syndrome, or manifests some features possibly related to an UPD syndrome, such as detection of sSMC, SNP-array should be considered.
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Affiliation(s)
| | - Yan Liu
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | | | | | | | | | | | - Karl-Oliver Kagan
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
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Principles of first trimester screening in the age of non-invasive prenatal diagnosis: screening for other major defects and pregnancy complications. Arch Gynecol Obstet 2017; 296:635-643. [DOI: 10.1007/s00404-017-4460-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 07/05/2017] [Indexed: 01/19/2023]
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Wüest A, Surbek D, Wiest R, Weisstanner C, Bonel H, Steinlin M, Raio L, Tutschek B. Enlarged posterior fossa on prenatal imaging: differential diagnosis, associated anomalies and postnatal outcome. Acta Obstet Gynecol Scand 2017; 96:837-843. [DOI: 10.1111/aogs.13131] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 03/07/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Anja Wüest
- Department of Obstetrics and Gynecology; Inselspital; University of Bern; Bern Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynecology; Inselspital; University of Bern; Bern Switzerland
| | - Roland Wiest
- Institute of Diagnostic and Interventional Neuroradiology; Inselspital; University of Bern; Bern Switzerland
| | - Christian Weisstanner
- Institute of Diagnostic and Interventional Neuroradiology; Inselspital; University of Bern; Bern Switzerland
| | - Harald Bonel
- Institute of Diagnostic and Interventional Neuroradiology; Inselspital; University of Bern; Bern Switzerland
| | - Maja Steinlin
- Division of Pediatric Neurology; Inselspital; University of Bern; Bern Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynecology; Inselspital; University of Bern; Bern Switzerland
| | - Boris Tutschek
- Prenatal Zürich; Zürich Switzerland
- Medical Faculty; Heinrich Heine University; Düsseldorf Germany
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Beyond Open Neural Tube Defects: Sagittal Landmarks at 11–14 Weeks in the Prediction of Second Trimester Posterior Fossa Abnormalities. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0113-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Katorza E, Gat I, Duvdevani N, Meller N, Pardo N, Barzilay E, Achiron R. Fetal brain anomalies detection during the first trimester: expanding the scope of antenatal sonography. J Matern Fetal Neonatal Med 2017; 31:506-512. [PMID: 28282781 DOI: 10.1080/14767058.2017.1289165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to describe fetal brain anomalies identified during nuchal translucency (NT) examination and their clinical management. MATERIALS AND METHODS In this retrospective study, we evaluated charts of pregnant women performed the first trimester scan (FTS) between 1.1.2011 and 31.12.14 in a tertiary referral center. Study population consisted of 952 patients scheduled for routine NT scan for aneuploidy screening between 11.0 and 13.6 gestational weeks, and 32 referred patients due to suspicious CNS finding during previous NT scan. Targeted brain assessment was performed according to clinical judgment during routine scans and in all referred cases. Patients with suspicious CNS findings were referred to pregnancy termination or further evaluation including genetic consultation and second trimester anatomical scan. RESULTS Thirty-one fetuses were diagnosed with variable brain anomalies. Acrania/anencephaly was the most common defect (nine cases) while the rarest findings were inter-hemispheric cyst, microcephaly, and Walker-Warburg Syndrome (one case each). Genetic testing revealed variable results. Twenty-six (83.9%) couples decided to terminate their pregnancies. CONCLUSIONS The current report highlights the evolving ability to detect CNS malformation during NT scan. FTS novel findings expand our embryological understanding of early fetal development. While severe anomalies can be managed by early termination, other defects necessitate comprehensive evaluation and repetitive imaging.
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Affiliation(s)
- Eldad Katorza
- a Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel.,b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Itai Gat
- a Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel.,b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel.,c Pinchas Borenstein Talpiot Medical Leadership Program , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel
| | - Nir Duvdevani
- a Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel.,b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Nir Meller
- a Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel.,b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Noam Pardo
- a Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel.,b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Eran Barzilay
- a Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel.,b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Reuven Achiron
- a Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology , Sheba Medical Center , Tel HaShomer , Ramat Gan , Israel.,b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
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Abstract
First-trimester pregnancy evaluation using fetal and maternal parameters not only allows for diagnoses to be made early in gestation but can also assess the risk of complications that become clinically evident later in pregnancy. This evaluation makes it possible for pregnancy care to be individualized. In select cases, treatment that reduces the risk of complications can be started early in pregnancy. Even though cell free DNA is a significant advance in diagnosing fetal aneuploidy, the combination of first-trimester ultrasound and maternal serum biochemistries casts a much wider diagnostic net; therefore, the 2 technologies are best used in combination.
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Affiliation(s)
- Jiri D Sonek
- Center for Maternal-Fetal Medicine, Ultrasound, and Genetics, Fetal Medicine Foundation of USA, Wright State University, Berry Pavilion, 1 Wyoming Street, Dayton, OH 45409, USA.
| | - Karl Oliver Kagan
- Department of Gynecology and Obstetrics, Universitäts-Frauenklinik, Calwerstrasse, Tübingen 772076, Germany
| | - Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, 16-20 Windsor Walk, London SE5 8BB, UK
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