The 'equals sign': a novel marker in the diagnosis of fetal isolated cleft palate

Association of prenatal Cleft Lip and Palate ultrasound abnormalities with copy number variants at a single Chinese tertiary center

BACKGROUD

A systematic analysis was conducted to investigate the molecular etiology of fetal cleft lip and/or palate (CL/P) and the association between various types of CL/P and copy number variations (CNVs), as well as their impact on birth outcomes.

METHODS

In this retrospective study conducted between January 2016 and July 2022, a cohort of pregnancies diagnosed with fetal CL/P was enrolled and comprehensive clinical data for all cases were extracted from our medical record database, including demographic data about the pregnancies, ultrasound findings, results of Chromosomal microarray (CMA), as well as relevant pregnant and perinatal outcomes.

RESULTS

Among the 358 cases, 32 clinically significant variants in 29 (8.1%) fetuses with CL/P were detected by CMA. In 338 singleton pregnancies, the diagnostic yield of CMA in the context of CL/P fetuses was determined to be 7.7% (26/338). CP cases exhibited a relatively higher prevalence of pathogenic/likely pathogenic CNVs at a rate of 25% (3/12), followed by CLP cases at 8.0% (23/288). Notably, the CL group did not demonstrate any pathogenic/likely pathogenic CNV findings among the examined cases (0/38). The diagnostic rate of clinically significant variants was notably higher in the non-isolated CL/P group than in the isolated CL/P group (11/33, 33.3% vs. 15/305, 4.9%, p < 0.001). Within the remaining 20 twin pregnancies, three clinically significant variants (15%) were observed.

CONCLUSIONS

This study provides powerful evidence supporting the efficacy of CMA as a valuable tool for facilitating the prenatal genetic diagnosis of fetal CL/P. The presence of CP and CLP in fetal cases demonstrated a relatively higher incidence of pathogenic/likely pathogenic CNVs. Moreover, when these cases were accompanied by additional ultrasound abnormalities, the likelihood of identifying diagnostic CNVs significantly increased. Conversely, cases of CL alone might not be associated with positive CNVs. The present data may significantly enhance prenatal diagnosis accuracy and facilitate informed genetic counseling for cases of fetal CL/P.

An effective ultrasound fetal palate screening software based on the "sequential sector scan through the oral fissure" and three-dimensional ultrasound

BACKGROUND

Orofacial clefts are one of the most common congenital malformations of the fetal face and ultrasound is mainly responsible for its diagnosis. It is difficult to view the fetal palate, so there is currently no unified standard for fetal palate screening, and the diagnosis of cleft palate is not included in the relevant prenatal ultrasound screening guidelines. Many prenatal diagnoses for cleft palate are missed due to the lack of effective screening methods. Therefore, it is imperative to increase the display rate of the fetal palate, which would improve the detection rate and diagnostic accuracy for cleft palate. We aim to introduce a fetal palate screening software based on the "sequential sector scan though the oral fissure", an effective method for fetal palate screening which was verified by our follow up results and three-dimensional ultrasound and to evaluate its feasibility and clinical practicability.

METHODS

A software was designed and programmed based on "sequential sector scan through the oral fissure" and three-dimensional ultrasound. The three-dimensional ultrasound volume data of the fetal face were imported into the software. Then, the median sagittal plane was taken as the reference interface, the anterior upper margin of the mandibular alveolar bone was selected as the fulcrum, the interval angles, and the number of layers of the sector scan were set, after which the automatic scan was performed. Thus, the sector scan sequential planes of the mandibular alveolar bone, pharynx, soft palate, hard palate, and maxillary alveolar bone were obtained in sequence to display and evaluate the palate. In addition, the feasibility and accuracy of the software in fetal palate displaying and screening was evaluated by actual clinical cases.

RESULTS

Full views of the normal fetal palates and the defective parts of the cleft palates were displayed, and relatively clear sequential tomographic images and continuous dynamic videos were formed after the three-dimensional volume data of 10 normal fetal palates and 10 cleft palates were imported into the software.

CONCLUSIONS

The software can display fetal palates more directly which might allow for a new method of fetal palate screening and cleft palate diagnosis.

From Bedside to Bench and Back: Advancing Our Understanding of the Pathophysiology of Cleft Palate and Implications for the Future

OBJECTIVE

To provide a comprehensive understanding of the pathophysiology of cleft palate (CP) and future perspectives.

DESIGN

Literature review.

SETTING

Setting varied across studies by level of care and geographical locations.

INTERVENTIONS

No interventions were performed.

MAIN OUTCOME MEASURE(S)

Primary outcome measures were to summarize our current understanding of palatogenesis in humans and animal models, the pathophysiology of CP, and potential future treatment modalities.

RESULTS

Animal research has provided considerable insight into the pathophysiology, molecular and cellular mechanisms of CP that have allowed for the development of novel treatment strategies. However, much work has yet to be done to connect our mouse model investigations and discoveries to CP in humans. The success of innovative strategies for tissue regeneration in mice provides promise for an exciting new avenue for improved and more targeted management of cleft care with precision medicine in patients. However, significant barriers to clinical translation remain. Among the most notable challenges include the differences in some aspects of palatogenesis and tissue repair between mice and humans, suggesting that potential therapies that have worked in animal models may not provide similar benefits to humans.

CONCLUSIONS

Increased translation of pathophysiological and tissue regeneration studies to clinical trials will bridge a wide gap in knowledge between animal models and human disease. By enhancing interaction between basic scientists and clinicians, and employing our animal model findings of disease mechanisms in concert with what we glean in the clinic, we can generate a more targeted and improved treatment algorithm for patients with CP.

Accuracy of prenatal detection of facial clefts and relation between facial clefts, additional malformations and chromosomal abnormalities: a large referral-center cohort

PURPOSE

Facial clefts belong to the most common congenital malformations and their prenatal diagnosis is a constant challenge. The aim of this study was to determine the accuracy of prenatal ultrasound in correctly classifying facial clefts. Furthermore, we aimed to specify the distribution of the type of clefts and underlying genetic conditions.

METHODS

All fetuses seen with suspected facial cleft in the Department of Obstetrics, Charité - Universitätsmedizin Berlin during a period of 23 years (1999-2022) were included in this retrospective study. Clefts were classified according to the classification of Nyberg. All additional prenatal findings were assessed and correlated with the outcome. The accuracy of prenatal diagnosis was assessed.

RESULTS

292 patients were included in the study. The most common type of clefts were unilateral cleft lip and palate (CL-P) (53.6%) and bilateral CL-P (30.6%), followed by CL (8.1%), CP (5.1%) and median CL-P (2.6%). The overall pre- and postnatal concordance rate corresponding to a correct prenatal diagnosis was high, 88.9%, ranging from 73.7% (CL) to 93.7% (unilateral CL-P). Most of the median clefts (95.2%) and CP (93.3%) were associated with other sonographic abnormalities, as well as 52.2% of bilateral CL-P. Chromosomal abnormalities, mostly trisomy 13 and trisomy 18, were observed in in the median CL-P (47.6%), bilateral CL-P (31.1%) and CP (26.7%) groups, in contrast to the CL (9.1%) and unilateral CL-P (12.9%) groups. It was exceptional to have a chromosomal abnormality without additional malformations (4.8%). The mortality rate including one late miscarriage, 5 IUFD's, 74 TOPs and 6 palliative cares at birth was 29.8%, particularly high for median clefts (90.5%).

CONCLUSION

Prenatal ultrasound exhibited a high accuracy to assess the type of facial clefts with an average rate of 88.9% (73.7%-93.7%) and a concordance rate of up to 93.7%, depending on the type of cleft. The search for additional malformations as well as clarifying underlying genetic conditions is essential. This allows for a targeted counseling of the parents and to best prepare for postnatal care, including surgery by the maxillofacial team.

The Hard Palate Sweep: a multiplanar 2-dimensional sonographic method for the prenatal detection of cleft palate

BACKGROUND

Prenatal diagnosis of cleft palate is challenging. Numerous 2-dimensional and 3-dimensional methods have been proposed to assess the integrity of the fetal palate, yet detection rates remain relatively low. We propose the "Hard Palate Sweep," a novel 2-dimensional method that enables clear demonstration of the entire fetal palate throughout pregnancy, in a single sweep, avoiding acoustic shadows cast by surrounding bones.

OBJECTIVE

This study aimed to assess the feasibility and performance of the Hard Palate Sweep, performed throughout pregnancy.

STUDY DESIGN

This was a prospective cross-sectional study performed between 2018 and 2022 in pregnant patients referred for a routine or targeted anomaly scan between 13 and 40 weeks of gestation. The presence or absence of a cleft palate was determined using the "Hard Palate Sweep." This was compared with the postnatal palate integrity assessment. Test feasibility and performance indices, including sensitivity, specificity, and positive and negative predictive values were calculated. Offline clips were reviewed by 2 investigators for the assessment of inter- and intraoperator agreement, using Cohen's kappa formula. The study protocol was approved by the institutional ethics committee. All participating patients were informed and provided consent.

RESULTS

A total of 676 fetuses were included in the study. The Hard Palate Sweep was successfully performed in all cases, and 19 cases were determined to have a cleft palate. Of these, 13 cases were excluded because postmortem confirmation was not performed, leaving 663 cases available for analysis. Six cases determined to have a cleft palate were confirmed postnatally. In 655 of 657 cases prenatally determined to have an intact palate, this was confirmed postnatally. In the 2 remaining cases, rare forms of cleft palate were diagnosed postnatally, rendering 75% sensitivity, 100% specificity, 100% positive predictive value, and 99.7% negative predictive value for the Hard Palate Sweep (P<.001). There was complete intra- and interoperator agreement (kappa=1; P<.0001).

CONCLUSION

The Hard Palate Sweep is a feasible and accurate method for prenatally detecting a cleft palate. It was successfully performed in all attempted cases between 13 and 40 weeks of gestation. This method is reproducible, offering high sensitivity and specificity. Implemented routinely, the Hard Palate Sweep is expected to increase the prenatal detection of cleft palate.

Orofacial clefts: Reflections on prenatal diagnosis and family history based on a series of cases of a tertiary children hospital

Prenatal diagnosis of orofacial clefts allows adequate counseling and planning for prenatal care and delivery. In 2001, two-dimensional ultrasound screening became universally used in Portugal by government guidelines, and after 2007 more advanced ultrasound became available. This study aimed to describe the prevalence of family history in patients with orofacial clefts and analyze prenatal diagnosis in patients born before 2001, between 2001 and 2007 and after 2007. Retrospective analysis of a cohort of patients with orofacial clefts followed by the trans-disciplinary team of a tertiary hospital. A total of 672 OFCs were identified: 40.9% isolated cleft palate, 38.1% cleft lip and palate, 19.7% cleft lip and 1.3% atypical cleft; 57.1% were male. The prevalence of family history was 26.0% of which 30.9% had a recognizable syndrome. Of those born before 2001, 13.7% had prenatal diagnosis; of those born between 2001 and 2007, 32.6% orofacial clefts were diagnosed in utero; and in children born after 2007, prenatal diagnosis increased to 47.1%. In our study, about one-fourth of children had a positive family history. Since the implementation of universal ultrasound screening in Portugal, more orofacial clefts were identified in utero (42.5% vs. 13.7%; p < 0.05) and after the availability of advanced ultrasound, prenatal diagnosis increased to 47.1% (vs. 20.4% before 2007; p < 0.05). Of all orofacial clefts diagnosed prenatally, ultrasound revealed more accuracy for the diagnosis of cleft lip and palate (65.4%) and cleft lip (24.8%). Cleft palate is the most difficult to detect in utero (9.3%). Prenatal ultrasound screening in Portugal has technically evolved with consequent better diagnostic accuracy for the identification of orofacial clefts, allowing better parenteral counseling.

Alveolar Cleft Size on Prenatal Two-Dimensional Ultrasonography Predicts Cleft of the Secondary Palate in Unilateral Cleft Lip

SUMMARY

Prenatal diagnosis of cleft palate (CP) is challenging. The current study's objective was to investigate whether prenatal alveolar cleft width is associated with the likelihood of a cleft of the secondary palate in unilateral cleft lip (CL). The authors reviewed two-dimensional ultrasound (US) images in fetuses with unilateral CL from January of 2012 to February of 2016. Images of the fetal face were obtained with a linear and/or curved probe in the axial and coronal planes. Measurements of the alveolar ridge gap were taken by the senior radiologist. Postnatal phenotype findings were compared with prenatal findings. Thirty patients with unilateral CL met inclusion criteria; average gestational age was 26.67 ± 5.11 weeks (range, 20.71 to 36.57 weeks). Ten fetuses were found to have an intact alveolar ridge by prenatal US; postnatal examination confirmed intact secondary palate in all. Small alveolar defects (<4 mm) were noted in three fetuses; postnatal examination documented CP in a single patient. CP was confirmed in 15 of the remaining 17 fetuses who had alveolar cleft width greater than 4 mm. An alveolar defect of greater than or equal to 4 mm on prenatal US was associated with greater likelihood of a cleft of the secondary palate [c 2 (2, n = 30) = 20.23; P < 0.001]. In the setting of unilateral CL, prenatal US documentation of alveolar defects greater than or equal to 4 mm are highly predictive of the presence of a cleft of the secondary palate. Conversely, an intact alveolar ridge is associated with an intact secondary palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Exome sequencing improves genetic diagnosis of congenital orofacial clefts

Objective: This retrospective study aims to evaluate the utility of exome sequencing (ES) in identifying genetic causes of congenital orofacial clefts (OFCs) in fetuses with or without other structural abnormalities, and to further explore congenital OFCs genetic causes. Methods: The study enrolled 107 singleton pregnancies diagnosed with fetal OFCs between January 2016 and May 2022, and categorized them into two groups: isolated cleft lip and/or palate (CL/CP) and syndromic CL/CP. Cases with positive karyotyping and chromosomal microarray analysis results were excluded. Whole-exome sequencing was performed on eligible fetuses and their parents. Monogenic variants identified by ES and perinatal outcomes were recorded and evaluated during postnatal follow-up. Results: Clinically significant variants were identified in 11.2% (12/107) of fetuses, with no significant difference in detection rate between the isolated CL/CP group and the syndromic CL/CP group (8/83, 9.6% vs. 4/24, 16.7%, p = 0.553). Additionally, sixteen (16/107, 15.0%) fetuses had variants of uncertain significance. We identified 12 clinically significant variations that correlated with clinical phenotypes in 11 genes from 12 fetuses, with CHD7 being the most frequently implicated gene (n = 2). Furthermore, we observed a significant difference in termination rates and survival rates between the isolated CL/CP and syndromic CL/CP groups (41.0% vs. 70.8% and 56.6% vs. 20.8%, p < 0.05 for both). Conclusion: Based on our findings, it is clear that ES provides a significant increase in diagnostic yield for the molecular diagnosis of congenital OFCs, thereby substantially improving the existing prenatal diagnostic capabilities. This study also sheds light on seven novel pathogenic variants, broadening our understanding of the genetic underpinnings of OFCs and expanding the disease spectrums of relevant genes.

Understanding the distinction between cleft lip and cleft palate: a critical step for successful prenatal detection

PURPOSE OF REVIEW

Orofacial clefts (OCs) are among the most common congenital anomalies, however, prenatal detection of cleft palate without cleft lip (CP) remains low. CP is associated with a higher risk of associated structural anomalies, recurrence risk and genetic aberrations. There is opportunity to optimize prenatal diagnosis, counseling and diagnostic genetic testing for OCs.

RECENT FINDINGS

Improving prenatal diagnosis of CP requires understanding that embryologically, the secondary palate develops from the 6th to the 10th week and fuses with the primary palate by the 12th week. Multiple first, second and third trimester 2D ultrasonographic markers for OCs have been described including the maxillary gap, frontal space, maxilla-nasion-mandible angle, retronasal triangle, palatino-maxillary diameter, equal sign, nonvisualization or gap in the soft to hard palate interface and loss of the superimposed line. We discuss the technique, evidence and limitations of each.

SUMMARY

Prenatal detection of OC can be optimized by employing 2D sonographic markers. Prenatal detection of CP may be improved by recognizing its high association with retrognathia/micrognathia.

A feasible method to evaluate fetal palate: sequential sector-scan through oral fissure

BACKGROUND

Prenatal diagnosis of cleft palate is still challenging. To describe a practical and efficient method, sequential sector-scan through oral fissure (SSTOF), to evaluate palate.

METHODS

According to the characteristics of the fetal oral anatomy and ultrasonic directivity, we designed a practical method, sequential sector-scan through oral fissure, to evaluate the fetal palate, and the approach was verified efficiently by following up results of those fetuses with orofacial cleft who were induced because of their accompanied lethal malformations. Then, the 7098 fetuses were evaluated using sequential sector-scan through oral fissure. Fetuses were followed up after birth or induction to validate and analyze prenatal diagnosis.

RESULT

According to the scanning design, sequential sector-scan through oral fissure was performed successfully from the soft palate to the upper alveolar ridge in induced labor fetuses, and the structures were displayed clearly. Among 7098 fetuses, satisfactory images were obtained for 6885 fetuses and the remaining 213 fetuses' images were unsatisfactory because of fetuses' positions and pregnant women with high BMI. Among 6885 fetuses, 31cases were diagnosed CLP or CP, which were confirmed after delivery or termination. There were no missing cases.

CONCLUSIONS

SSTOF is a practical and efficient method to diagnose cleft palate, which might be applied to evaluate the fetal palate in prenatal diagnosis.

[Antenatal ear examination: When, how and why?]

Antenatal ear examination is an integral part of the thorough examination of the fetal face. The discovery of an anomaly, whether it is made by chance or during a complementary in-depth examination, leads the practitioner to determine its isolated or associated character, in order to characterise its possible belonging to a syndromic entity. In this context, the realization of genetic analysis more precise and wider allowing a return of the results in a time compatible with an evolutive pregnancy, gives to the geneticist a central role in the management of these couples. The main challenge lies in obtaining a set of concordant clinical and biological clues, enabling the genetic results identified to be interpreted correctly, the optimised functioning of the ultrasound practitioner - geneticist duo is therefore fundamental. This results in a complex information to deliver, in the fact that the clinical translation of an ear anomaly in antenatal can go from an isolated aesthetic anomaly to a genetic syndrome with neurodevelopmental disorder. The objective of this work is to describe, from a methodological analysis of antenatal ears, the accessible malformative entities, isolated or associated, and to discuss the problems in the need or not to propose their screening.

Imaging of Congenital Craniofacial Anomalies and Syndromes

Craniofacial malformation is one of the most commonly encountered birth defects in the prenatal and postnatal periods. Higher-resolution and 3D antenatal ultrasonography and multidetector computed tomographic scan with 3D reformatted images have improved the definition of the soft tissue and bone structures of the craniofacial anatomy and its malformations. Early diagnosis of these conditions is important to make the clinical decisions and more so in understanding the possibility of malformation recurring in the next pregnancy, which is one of the major concerns for the parents and the treating physicians.

Trends in cleft palate incidence in the era of obstetric sonography and early detection

BACKGROUND

The effect of improvement in prenatal identification of cleft lip or palate (CL/P) on termination of pregnancy (TOP) worldwide is scarcely reported. Our aim was to assess changes in the prevalence of cleft palate attributed to the high access and availability of prenatal advanced screening and pregnancy termination in Israel.

METHODS

A retrospective study was conducted on CL/P patients which were treated in our institute and born between January 2000 and December 2018. Clinical and demographic data were extracted from medical records. Data on TOP were collected based on accessible information from the Ministry of Health. Cleft palate severity was evaluated using the Veau Classification.

RESULTS

The study was conducted on 258 patients. Higher incidence of Veau II and III was evident throughout the examined period (2000-2018). However, when evaluating the incidence per year, we found that the incidence of severe cases (Veau III and IV) decreased every year showing a major decline of 60% in the last decade, whereas mild cases (Veau type I and II) demonstrated a marked increase of 90%. Regarding the incidence of abortions in Israel, a decrease of 30% was observed in the last two decades, meanwhile a substantial increase was detected in the rate of abortions related to physical malformations of the fetus. Additionally, the number of late terminations due to physical malformations significantly increased in the last decade.

CONCLUSIONS

Significant decrease was observed in the incidence of severe cleft palate cases in the last decade. Concurrently, we found a substantial increase in percentage of abortions performed due to physical malformations. We suggest that these changes might be attributed to the accessibility of advanced prenatal screening and pregnancy termination in Israel under the social healthcare system.

Fetal markers for the detection of infants with craniofacial malformation

Facial clefts and Robin sequence (RS) share the timing of the diagnosis during the course of pregnancy, their association with genetic diseases and the subsequent management following the initial diagnosis. If a suspicion of a facial cleft or RS is made, a detailed anatomical examination of the fetus should be carried out to identify further anomalies. This may also involve genetic testing including a microarray or an exome analysis. Interdisciplinary counseling, including pre- and postnatal experts with sufficient experience in the management of such neonates, should be involved in this counseling. Parents should be informed about disease-specific therapeutic options and postnatal outcome. Delivery should take place in a center with experience in craniofacial malformations where clinicians are prepared for potentially life-threatening airway obstruction immediately after birth.

The application of three-dimensional ultrasound with reformatting technique in the diagnosis of fetal cleft lip/palate

OBJECTIVE

To evaluate the clinical value of three-dimensional ultrasound (3D-US) with reformatting technique in the diagnosis of fetal cleft lip/palate (CL/P), especially those involving the secondary palate.

METHODS

A total of 113 fetuses suspected with cleft lip (CL) on two-dimensional ultrasound (2D-US) were further evaluated by 2D-US and 3D-US with reformatting technique, in order to clarify the type of oral cleft. Lesions were classified as cleft lip (CL), cleft lip and alveolus (CLA), and cleft lip and palate (CLP) (including primary and secondary palate). All fetuses were followed until birth or termination of pregnancy. The diagnostic accuracies of 2D-US and 3D-US with reformatting technology were compared.

RESULTS

Both 2D-US and 3D-US with reformatting successfully detected CLs in the final 103 participants. Among these, 29, 25, and 49 cases were confirmed to have CL, CLA, and CLP, respectively. CL, CLA, and CLP were diagnosed by 2D-US in 34, 66, and 3 cases, respectively, and by 3D-US with reformatting technology in 31, 27, and 45 cases, respectively. The sensitivities of 2D-US and 3D-US with reformatting technology in the diagnosis of CLA were 80% (20/25) and 92.0% (23/25), respectively, and the difference was not statistically significant. For CLP, however, the sensitivities were 6.1% (3/49) and 91.8% (45/49), respectively (P < .001).

CONCLUSIONS

Both 2D-US and 3D-US with reformatting technique have high diagnostic accuracy for CL and CLA. However, 3D-US has a much higher diagnostic accuracy for CLP.

[Ultrasound scan of a fetus with facial cleft must be done from the lip to the uvula: What's new?]

Facial cleft are the most frequent craniofacial anomalies with an incidence of one for 1000 births, all births combined, and require specialized multidisciplinary care. Since 2005, the systematic realization of two ultrasound views (nose-lip and profile) is recommended for the exploration of the fetal face in the 2nd trimester of pregnancy. Application of these recommendations should allow screening of the majority of cleft lip and palate. However, cleft palates, without labiomaxillary involvement, are currently largely underdiagnosed at prenatal ultrasound, although they can be associated with a syndromic diagnosis in up to 30% of cases. The aim of this work is to describe, from embryology to surgical consultation, the complete ultrasound examination of a fetus with a classic facial cleft.

A new two-dimensional sonographic approach to the assessment of the fetal hard and soft palates

Facial clefts are among the most common congenital defects. Ultrasound (US) imaging of secondary fetal palate, especially the detection of isolated defects, remains challenging. Currently described two-dimensional (2D) and three-dimensional methods are technically demanding and impractical for application during routine fetal anatomy evaluation. As an adjunct method, magnetic resonance imaging can provide additional information but has its limitations. We present a novel 2D US approach using axial and sagittal planes to evaluate the fetal palate and demonstrate the main differences between an intact palate, isolated cleft palate, and a cleft lip with cleft palate.

Absent 'superimposed-line' sign: novel marker in early diagnosis of cleft of fetal secondary palate

OBJECTIVES

To describe a novel sign, the 'superimposed-line' sign, for early diagnosis of cleft of the fetal secondary palate on two-dimensional imaging of the vomeromaxillary junction in the midsagittal view.

METHODS

This was a prospective evaluation of the superimposed-line sign using two-dimensional sonography (midsagittal view) in 9576 singleton fetuses referred for routine screening between 12 and 20 weeks of gestation. In this view, the vomer bone appears as a line superimposed on the distal two-thirds of the maxillary line, as the vomer fuses with the secondary palate in the midline. If there is a midline cleft of the secondary palate, the line formed by the palate is absent and hence only the vomer bone is visualized, creating a single line instead of the normal superimposed double line. Multiplanar three-dimensional (3D) views were assessed in cases in which the superimposed-line sign was absent.

RESULTS

The superimposed line was absent in 17 fetuses with a cleft of the secondary palate that was confirmed by 3D evaluation. Of these, 13 had defects involving the premaxilla and four had an isolated cleft of the secondary palate. Postnatal confirmation was available in all cases. The sign was useful in ruling out cleft of the fetal secondary palate in 32 high-risk cases with a family history of cleft palate. The superimposed-line sign had a sensitivity of 89.5% in detecting cleft of the secondary palate.

CONCLUSIONS

The superimposed-line sign is a new sonographic marker for evaluation of cleft of the fetal secondary palate; documentation of this sign proves the presence of both the palate and vomer in the midline. This marker can be demonstrated clearly in the late first trimester, allowing early diagnosis of secondary palatine cleft. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prenatal Diagnosis of Robin Sequence: Sensitivity, Specificity, and Clinical Relevance of an Index for Micrognathia

OBJECTIVE

Micrognathia in connection with glossoptosis (called Robin sequence) may lead to life-threatening respiratory problems immediately after birth. An objective detection during prenatal routine ultrasound sonography is possible using an index that relates fetal lower jaw length to femur length or gestational age. The aim of this study was to test the method's sensitivity and specificity and to discuss its predictive power concerning neonatal respiratory insufficiency.

DESIGN

Patients with subjectively identified suspicious signs in the sagittal profile view were included in the study: Two-dimensional serial ultrasound scans of their fetal mandible were used to measure the lower jaw lengths and compare them to predicted values according to an index, derived from 313 healthy fetuses. Follow-up data provided additional information on the clinical appearance of the newborns.

RESULTS

The index showed a high sensitivity: 15 of the 16 cases with a micrognathia were correctly diagnosed (sensitivity of 93.75%). Follow-up data showed that newborns with similar index values differed in terms of their upper airway obstruction and treatment need.

CONCLUSION

Fetal mandibular micrognathia can be objectively evaluated with the help of the index. The method allows an early detection of micrognathia, which helps to take the necessary steps for proper treatment of potential life-threatening respiratory impairment. Observations ranging outside the prediction interval could prompt the ultrasonographer to check for other associated malformations.

Prenatal ultrasound diagnosis of cleft palate without cleft lip, the new ultrasound semiology

OBJECTIVES

The aim of this study was to define the prenatal ultrasound semiology of cleft palate without cleft lip using 3D visualization of the fetal palate.

METHODS

A prospective longitudinal study was performed in our University Hospital Center from 2011 to 2018. The fetal secondary palate was studied in 3D, starting with 2D axial transverse ultrasound view. We defined a cleft palate as a disruption of the horizontal plate of the palatine bone of the secondary palate. Prenatal findings were correlated to anatomic postnatal examinations performed by a paediatric plastic surgeon.

RESULTS

Forty-three cases of cleft palate without cleft lip were prenatally diagnosed, of whom 34 were associated with malformations. We defined four types of disruptive appearances: isolated nonvisualization of the posterior nasal spine; partial-disruption or cleft velum; complete disappearance or V-shaped cleft palate; and complete disappearance or U-shaped cleft palate. The adjusted kappa coefficient, between prenatal and postnatal evaluation, was 0.88 (95% CI: 0.79-0.97), corresponding to an excellent agreement.

CONCLUSIONS

Using a strictly axial transverse ultrasound view, visualization of the secondary fetal palate enables to diagnose a cleft palate without cleft lip. This method offers a prenatal anatomic classification of cleft palate with a high level of concordance to postnatal findings.

Coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center: Application to Early Management of Infants With Cleft Lip and Palate

BACKGROUND/PURPOSE

The primary objective of this study is to describe the authors' experience at the Children's National Health System with the coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center. This collaboration highlights the accuracy and completeness of prenatal diagnosis of cleft abnormalities with expedient postnatal management.

METHODS

With Institutional Review Board approval, the authors retrospectively reviewed 74 patients referred for potential orofacial cleft and 44 met the inclusion criteria. Follow-up fetal ultrasonography is typically performed and three-dimensional imaging was performed when feasible. If questionable anomalies or facial findings are present on these studies, the authors proceed with fetal magnetic resonance imaging. A thorough consultation is held with the cleft team, resulting in a comprehensive plan of care. Postnatal examination confirmed the correct prenatal diagnosis in nearly all patients.

RESULTS

Sensitivity and specificity for isolated unilateral cleft lip were 89% and 100%, respectively; for unilateral cleft lip and palate, sensitivity and specificity were 82% and 90%, respectively; for bilateral cleft lip and palate, sensitivity and specificity were 97% and 90%, respectively. Initial postnatal evaluation by the cleft surgeon occurred at an average age of 21 days after birth. All patients who were candidates for presurgical orthodontia were treated at an appropriate young age (mean: 66.5 days).

CONCLUSIONS

Coordinated prenatal evaluation of patients with cleft lip/palate by multidisciplinary centers plays an important role in the care of these complex patients. The results of the authors' study demonstrated high sensitivity and specificity for the prenatal diagnosis of cleft lip/palate, leading to timely postnatal evaluation and treatment.

Ultrasound imaging of the fetal secondary palate: Methodological description of a two-dimensional approach and a case series

OBJECTIVE

The study aims to describe our two-dimensional (2D) ultrasound approach to visualize the fetal secondary palate and plot its growth curve and to describe and demonstrate its clinical implementation.

METHODS

This is a two parts retrospective study. First, we measured the antero-posterior length of the bony secondary palate, from the soft to hard palate interface (SHPI) line to the alveolar ridge, blindly by two operators during routine scans of low-risk fetuses, and plot a longitudinal growth curve. In the second part, we describe four cases of prenatal diagnosis of secondary palate cleft.

RESULTS

Sixty-eight fetuses were included: 14 to 15 weeks (n = 20), 21 to 24 weeks (n = 32), and 29 to 35 weeks (n = 16). The bony secondary palate elongates along gestation from a mean of 5.3 mm (+/-0.46 mm) at 14 to 15 weeks to 15.9 mm (+/-1.7 mm) at 29 to 35 weeks. We found high intraobserver and interobserver correlation between measurements. All four cases diagnosed by this approach were confirmed postnatally.

CONCLUSIONS

The SHPI, representing the normally developed secondary bony palate, can be imaged in the fetus by direct 2D ultrasound as early as 14 weeks. A gap within or nonvisualization of the SHPI is highly suggestive for a secondary palate cleft.

Accurate diagnosis of fetal cleft lip/palate by typical signs of magnetic resonance imaging

OBJECTIVE

This study aims to evaluate the accuracy of magnetic resonance imaging (MRI) in diagnosing orofacial clefts and proposes specific signs for determining the type of cleft.

METHODS

Pregnant women in whom fetal facial malformations are suspected by ultrasonography (US) underwent 1.5 T MRI. The accuracy of the prenatal US and MRI diagnosis was compared with the postnatal findings.

RESULTS

A total of 71 fetuses were included in the final analysis, which comprised of 35 cases of isolated cleft lip, six cases of cleft lip and alveolus, 21 cases of cleft lip and palate, four cases of isolated cleft palate, and five normal fetuses. MRI was more sensitive than US (MRI 100%, US 77.5%; Fisher's exact test: MRI vs US P=0.000). The accuracy of MRI for all types was 100%. Specific signs (Inverted T, L/anti-L, U, and "Notch" signs) were proposed, indicating the normal hard, unilateral cleft, bilateral cleft, and cleft soft palates, respectively, which can facilitate the identification of different types of cleft palates.

CONCLUSION

MRI can accurately diagnose the type of cleft based on typical signs, which can serve as a definite diagnostic modality and an effective supplement of US.

[Cleft lip and palate]

BACKGROUND

Cleft lip and palate (CLP) represents a group of malformations of unknown etiology but similar phenotypes. This implies consequences for the diagnostics, therapy, prevention, prognosis and risk estimation.

OBJECTIVE

Definition of CLP subtypes and the embryonic development, clarification of correlations and differences between entities using epidemiological data, overview of the present state of genetic analyses, correlation to syndromes, sequences and associations and resulting consequences for clinical practice.

MATERIAL AND METHODS

Update on embryological development of the face, summary of epidemiological and genetic studies and considerations on pedopathological and forensic aspects.

RESULTS

Syndromic and non-syndromic CLP exhibit different and highly variable etiologies, therapeutic needs and prognosis. A thorough understanding is mandatory to distinguish between the different subgroups. In addition to specific aspects of CLP for the pediatric (forensic) pathologist this article provides an overall view of the topic which aims to help understand these malformations.

A score-based method for quality control of fetal hard palate assessment during routine second-trimester ultrasound examination

INTRODUCTION

When an orofacial cleft lip is discovered, precise characterization of this malformation is necessary, especially the extension of this cleft to the secondary palate. We aimed to develop and evaluate the feasibility/reproducibility of a score-based quality control for the visualization of the fetal hard palate during the second-trimester scan.

MATERIAL AND METHODS

All ultrasound images of fetal hard palate assessed routinely during second-trimester scan were retrospectively retrieved for a 6-month period. One hundred of these images were randomly selected and analyzed by two blinded reviewers, according to a scoring system (0-6 points). Criteria retained in the score were complete palate bone horizontal plate, presence of two pterygoid processes, visible alveolar ridge, and horizontal axis of insonation. A score ≥4 defined images of good quality. Inter- and intra-reviewer reproducibility was assessed.

RESULTS

Inter-reviewer reproducibility was excellent with significant correlation (Pearson coefficient 0.953; P < .0001), global adjusted κ coefficient (0.86, 95% CI 0.79-0.94) and individual criteria adjusted κ coefficient always > 0.8. Rates of images of good quality (score ≥ 4) were 75%-77%, also with excellent agreement (κ coefficient 0.89, 95% CI 0.79-0.99). Intra-reviewer reproducibility retrieved the same results (excellent agreement) except for the axis of insonation (satisfactory agreement).

CONCLUSIONS

This simple image scoring system for the fetal palate is easy, has excellent inter- and intra-reviewer reproducibility and could also help sonographers to correctly identify the palate structure.

Prenatal ultrasonography of craniofacial abnormalities

Craniofacial abnormalities are common. It is important to examine the fetal face and skull Epub ahead of print during prenatal ultrasound examinations because abnormalities of these structures may indicate the presence of other, more subtle anomalies, syndromes, chromosomal abnormalities, or even rarer conditions, such as infections or metabolic disorders. The prenatal diagnosis of craniofacial abnormalities remains difficult, especially in the first trimester. A systematic approach to the fetal skull and face can increase the detection rate. When an abnormality is found, it is important to perform a detailed scan to determine its severity and search for additional abnormalities. The use of 3-/4-dimensional ultrasound may be useful in the assessment of cleft palate and craniosynostosis. Fetal magnetic resonance imaging can facilitate the evaluation of the palate, micrognathia, cranial sutures, brain, and other fetal structures. Invasive prenatal diagnostic techniques are indicated to exclude chromosomal abnormalities. Molecular analysis for some syndromes is feasible if the family history is suggestive.

MR Imaging of the Fetal Face: Comprehensive Review

The human face is a complex anatomic structure with an equally complex embryologic development. Derangement of the developmental process can result in various structural anomalies, which range from a mainly cosmetic deformity, such as cleft lip, to potentially life-threatening conditions such as arhinia. These anomalies (a) can occur as isolated anomalies; (b) can be associated with intracranial, spinal, or dental anomalies; or (c) can be a part of various syndromes, thus serving as diagnostic clues in such cases. Proper evaluation of fetal facial deformities can help in prognostication, family counseling, and prenatal or early postnatal intervention. Ultrasonography (US) is the first line of investigation in these cases. However, when US does not allow complete evaluation of these anomalies owing to its inherent limitations, magnetic resonance (MR) imaging allows comprehensive evaluation of the anomaly itself and also evaluation of various associations and the treatment approach. The embryology of the fetal facial structures is considered with regard to the MR imaging technique and the MR imaging anatomy. The MR imaging features of various structural anomalies are described and classified into six groups, namely, orofacial clefts, orbital anomalies, nasal anomalies, facial masses, external ear anomalies, and abnormal face shape or profile. Also, the key associations and relevant treatment implications are reviewed. The article provides a "one-stop shop" review of these unique disorders-from basic understanding of the embryology to applying the knowledge in clinical practice, helping the interprofessional team and the patients alike. ^©RSNA, 2018.

Syndromale und nichtsyndromale orofaziale Spalten

Orofaziale Spalten sind die zweithäufigste angeborene Fehlbildung. Die beiden häufigen Untergruppen sind die Formen der Lippen-Kiefer-Gaumen-Spalte (LKGS) und der reinen Gaumenspalte (GS). Beide können im Zuge zahlreicher Syndrome auftreten, LKGS sind häufiger nichtsyndromal (ca. 70 %) als GS (ca. 50 %). Nichtsyndromale Spalten sind multifaktoriell und bergen relativ geringe Wiederholungsrisiken für Angehörige. Manche syndromalen Spaltformen beruhen auf Chromosomenaberrationen, die meisten sind jedoch monogen. Das autosomal-dominante Van-der-Woude-Syndrom ist eine wichtige Differenzialdiagnose zu nichtsyndromalen Spaltformen, die sich nur durch Unterlippengrübchen von diesen unterscheidet, aber höhere Risiken für eine Spaltbildung bei Nachkommen birgt. Die Pränataldiagnostik orofazialer Spalten erfolgt sonographisch. Erfahrene Untersucher können LKGS in der 20. Schwangerschaftswoche diagnostizieren; die Detektion von GS ist schwieriger.

Isolated Cleft Lip and Palate: Maxillary Gap Sign and Palatino-Maxillary Diameter at 11-13 Weeks

OBJECTIVE

To evaluate the maxillary gap sign and describe markers for the first-trimester diagnosis of isolated cleft lip and palate (CLP) at 11-13 weeks.

METHODS

Firstly, this was a prospective assessment of 1,087 fetuses including 5 cases of isolated CLP in 2 centers which were referred for the 11-13 weeks scan. Secondly, intra- and interobserver variability of the maxillary gap sign was evaluated for observers R.L. and A.B. in 2 sessions (affected cases vs. 50 normal fetuses in each session) to reduce the bias of different ultrasound manufacturer visualizations (Philips, GE). Thirdly, the palatino-maxillary diameter (PMD) was examined in stored images, DICOM loops and volumes of the midsagittal and parasagittal view of the fetal head and brain at 11+0-13+6 weeks of gestation from 5 fetuses with isolated CLP and 302 consecutively assessed normal controls. The PMD values in fetuses with isolated CLP and normal controls were compared.

RESULTS

Firstly, 5 out of 6 referred pregnancies with isolated CLP were detected prospectively using the midsagittal view for measurement of nuchal translucency due to an abnormal appearance. One out of 6 patients with isolated CLP declined the 11-13 weeks scan. Secondly, intra- and interobserver variability showed no false positive cases; all cases with isolated CLP were identified by both sonographers; however, in 2 cases the maxillary gap sign was doubtful. Therefore, thirdly, we developed the PMD measurement which increased significantly with crown-rump length (CRL) from respective mean values at CRL of 45 mm to 4.66 mm and to 8.95 mm at CRL of 84 mm. In the CLP group, the PMD was below the 5th percentile of the control group in 4 out of 5 (80%) cases.

CONCLUSIONS

The midsagittal view for measurement of nuchal translucency shows a high reproducibility regarding abnormal views for maxillary gap sign. In the midsagittal view of the fetal head, face, and brain at 11-13 weeks, the majority of fetuses with isolated CLP have a measurable abnormality in addition, the PMD.

Accurate diagnosis of prenatal cleft lip/palate by understanding the embryology

Cleft lip with or without cleft palate (CP) is one of the most common congenital malformations. Ultrasonographers involved in the routine 20-wk ultrasound screening could encounter these malformations. The face and palate develop in a very characteristic way. For ultrasonographers involved in screening these patients it is crucial to have a thorough understanding of the embryology of the face. This could help them to make a more accurate diagnosis and save time during the ultrasound. Subsequently, the current postnatal classification will be discussed to facilitate the communication with the CP teams.

First-Trimester Sonographic Evaluation of Palatine Clefts: A Novel Diagnostic Approach

OBJECTIVES

Sonographic evaluation of the palate is a difficult task, and most palatine clefts are diagnosed in the neonatal period because of the limitations of 2-dimensional (2D) sonography. The objective is to describe a sonographic technique based on 2D markers for screening of palatine clefts during the nuchal translucency scan and to assess the ability of 3-dimensional (3D) sonography in imaging the normal and abnormal palate.

METHODS

A total of 2014 women who enrolled for first-trimester screening were included in this prospective study. Screening for palatine clefts was done by 2D evaluation of bony landmarks of the palate, which were the appearance of the palatal line in the sagittal view, retronasal triangle in the coronal view, and alveolar ridge of the maxilla in the axial view followed, by 3D evaluation in suspicious cases. All cases included in the study were followed by second-trimester anomaly scans and evaluated postnatally. Additionally, in 100 consecutive normal cases, 3D evaluation of the palate was done.

RESULTS

Visualization of 2D landmarks could be done in all, and 3D assessment was feasible in 94% of cases. Fourteen cases, of which 5 were unilateral, 4 bilateral, and 2 median cleft lip and palate, 2 median cleft palate, and 1 atypical palatine cleft were identified. There were no false-positives results reported, and 1 case of a bifid uvula was missed.

CONCLUSIONS

The study demonstrates that evaluation of the palate can be done at the 11 to 14 week scan based on 2D markers and can also be assessed with 3D sonography. The inclusion of 2D markers in all 3 planes increases the sensitivity for detection of palatine clefts.

The Importance of Multidisciplinary Management during Prenatal Care for Cleft Lip and Palate

Background

The prenatal ultrasound detection of cleft lip with or without cleft palate (CL/P) and its continuous management in the prenatal, perinatal, and postnatal periods using a multidisciplinary team approach can be beneficial for parents and their infants. In this report, we share our experiences with the prenatal detection of CL/P and the multidisciplinary management of this malformation in our institution's Congenital Disease Center.

Methods

The multidisciplinary team of the Congenital Disease Center for mothers of children with CL/P is composed of obstetricians, plastic and reconstructive surgeons, pediatricians, and psychiatrists. A total of 11 fetuses were diagnosed with CL/P from March 2009 to December 2013, and their mothers were referred to the Congenital Disease Center of our hospital. When CL/P is suspected in the prenatal ultrasound screening examination, the pregnant woman is referred to our center for further evaluation.

Results

The abortion rate was 28% (3/11). The concordance rate of the sonographic and final diagnoses was 100%. Ten women (91%) reported that they were satisfied with the multidisciplinary management in our center.

Conclusions

Although a child with a birth defect is unlikely to be received well, the women whose fetuses were diagnosed with CL/P on prenatal ultrasound screening and who underwent multidisciplinary team management were more likely to decide to continue their pregnancy.

Maxillary gap at 11-13 weeks' gestation: marker of cleft lip and palate

OBJECTIVE

To describe a new sign of cleft lip and palate (CLP), the maxillary gap, which is visible in the mid-sagittal plane of the fetal face used routinely for measurement of nuchal translucency thickness.

METHODS

This was a retrospective study of stored images of the mid-sagittal view of the fetal face at 11-13 weeks' gestation in 86 cases of CLP and 86 normal controls. The images were examined to determine if a maxillary gap was present, in which case its size was measured.

RESULTS

In 37 (43.0%) cases of CLP the defect was isolated and in 49 (57.0%) there were additional fetal defects. In the isolated CLP group, the diagnosis of facial cleft was made in the first trimester in nine (24.3%) cases and in the second trimester in 28 (75.7%). In the group with additional defects, the diagnosis of facial cleft was made in the first trimester in 46 (93.9%) cases and in the second trimester in three (6.1%). A maxillary gap was observed in 96% of cases of CLP with additional defects, in 65% of those with isolated CLP and in 7% of normal fetuses. There was a large gap (>1.5 mm) or complete absence of signals from the maxilla in the midline in 69% of cases of CLP with additional defects, in 35% of those with isolated CLP and in none of the normal controls.

CONCLUSIONS

The maxillary gap is a new simple marker of possible CLP, which could increase the detection rate of CLP, especially in isolated cases.

Hysteroscopic fetoscopy: A role as virtuopsy for parents who refuse full autopsy? A case of facial clefting, proboscis, and limb deformities

OBJECTIVE

To describe the value of hysteroscopic fetoscopy (virtuopsy) at the time of uterine suction in a case of early diagnosis of congenital anomalies in parents refusing conventional full autopsy examination.

CASE REPORT

First trimester ultrasound diagnosis of proboscis, median cleft lip and palate and limb deformities. Chorionic villus sampling demonstrated normal karyotype. Parents refused medical induction of termination of pregnancy with subsequent conventional autopsy. At this stage, hysteroscopic fetoscopy was consented and carried out under local anesthesia prior to uterine evacuation.

CONCLUSION

Hysteroscopic fetoscopy (virtuopsy) proved to be a valuable complementary diagnostic investigation and enhanced the parental bonding process concerning the fetal phenotype. Notwithstanding, the woman declared an acceptable compliance during the procedure. In selected cases, virtuopsy may be a valid option in confirming early prenatal ultrasound diagnosis in parents refusing conventional autopsy or when full postmortem examination may not be clinically indicated or warranted.

Antenatal Ultrasound Detection of Cleft in Western Australia from 2003 to 2012: A Follow-Up Study

AIM

To investigate trends in the rate of antenatal detection of cleft lip and palate (CLP) patients referred to the CLP Unit at Princess Margaret Hospital for Children in Perth, Western Australia during the period 2003-2012 and compare data with a previously published report covering the years 1996-2003.

METHODS

This is a single-center, retrospective survey of antenatal transabdominal ultrasound screenings of mothers of infants born between July 1, 2003 and June 30, 2012 that were referred to the CLP Unit at Princess Margaret Hospital.

RESULTS

Detection rates of oral clefts increased significantly when compared with outcomes reported in the same population between 1996 and 2003 (P < .05). An overall detection rate of 71.7% (165/230) was achieved for clefts involving lip and palate. Detection of isolated cleft palate (1/99) and microform (0/8) remained elusive. Most detections (76.5%) were achieved at 15 to 20 weeks of gestational age, corresponding with routine anatomical screening. A further 16.8% were detected post-20 weeks of gestation. Scans were performed by specialist obstetricians, and sonography clinics reported a detection rate of 84.6% (55/65), whereas nonspecialist clinics reported a detection rate of only 67.1% (110/164).

CONCLUSION

The antenatal detection rates of oral clefts involving the lip have improved to the extent that the majority of mothers are now being referred to a cleft unit in Western Australia prior to the births of their children. As a result of this improvement, antenatal counseling is now a common facet of cleft management.

Fetal MRI: the sonographer's view

Fetal magnetic resonance imaging (MRI) is used with increasing frequency as a complementary imaging modality to ultrasound (US) in prenatal diagnosis. Fetal MRI displays the fetal, uterine, and extrauterine anatomy in ways that allow confirmation of normal anatomy and the diagnosis of pathological entities that were formerly very difficult to detect prenatally. Comparison of US views with standard orthogonal plane MR images reinforces the understanding of fetal anatomy as visualized with US. Technological advances in US equipment have allowed the recent description of subtle fetal anatomical structures. Similarly, knowledge of the MRI appearances of pathological conditions has opened opportunities for the sonographic diagnosis of entities such as brainstem malformations and alterations in the normal transient laminar pattern that occur during development of the fetal cerebrum. Fetal MRI can confirm suspicious US findings and thus add confidence in a particular prenatal diagnosis before performing invasive and interventional procedures. Specific MRI sequences can be used to add information about the chemical composition of fetal structures, such as fat, blood, and meconium. Dynamic MRI sequences have increased understanding of gestational age-dependent behavior, and assist the sonographer in assessment of fetal structural anomalies that cause abnormal movement and behavior. The technological ability of US to demonstrate very small structures complements the lower resolution of fetal MR images, whereas the ability of MR to visualize the whole fetus improves the limited views necessitated by US. Therefore, both US and fetal MRI have complementary strengths and weaknesses that can be used to full advantage in prenatal diagnosis.

Arthrogryposis multiplex congenita-like syndrome associated with median cleft lip and palates: first prenatally detected case

An early second-trimester prenatal ultrasound diagnosis of an arthrogryposis multiplex congenita-like syndrome associated with median clefts is reported. A molecular biological work-up was performed to search for a potentially overlapping syndrome and dysostosis. Autopsy and postmortem radiogram were performed to confirm the ultrasound diagnosis. Prenatal diagnosis enabled early detection of multiple fetal malformations, thus allowing early termination of pregnancy. Moreover, three-dimensional ultrasound with volume rendering in the maximum surface mode demonstrated its value in diagnosing oro-facial clefts, even at an early stage of fetal development.