Ultrasound screening and perinatal mortality: controlled trial of systematic one-stage screening in pregnancy. The Helsinki Ultrasound Trial

Trends over 50 years with liberal abortion laws in the Nordic countries

BACKGROUND

During the 1970s the Nordic countries liberalized their abortion laws.

OBJECTIVE

We assessed epidemiological trends for induced abortion on all Nordic countries, considered legal similarities and diversities, effects of new medical innovations and changes in practical and legal provisions during the subsequent years.

METHODS

New legislation strengthened surveillance of induced abortion in all countries and mandated hospitals that performed abortions to report to national abortion registers. Published data from the Nordic abortion registers were considered and new comparative analyses done. The data cover complete national populations.

RESULTS AND CONCLUSIONS

After an increase in abortion rates during the first years following liberalization, the general abortion rates stabilized and even decreased in all Nordic countries, especially for women under 25 years. From the mid-1980s higher awareness about pregnancy termination led women to present at an earlier gestational age, which was accelerated by the introduction of medical abortion some years later. Most terminations (80-86%) are now done before the 9th gestational week in all countries, primarily by medical rather than surgical means. Introduction of routine ultrasound screening in pregnancy during the late 1980s, increased the number of 2nd trimester abortions on fetal anomaly indications without an overall increase in the proportion of 2nd relative to 1st trimester abortions. Further refinement of ultrasound screening and non-invasive prenatal diagnostic methods led to a slight increase in the proportion of early 2nd trimester abortions after the year 2000. Country-specific differences in abortion rates have remained stable over the 50 years of liberalized abortion laws.

How safe is it to use ultrasound in prenatal medicine? Facts and contradictions - Part 2 - Laboratory experiments regarding non-thermal effects and epidemiological studies

The first part of this CME article (issue 5/20) provided a detailed examination of the biophysical effects of ultrasound waves, the exposure values, and in particular the thermal effect. In vivo and in vitro measurements have shown that the temperature increase in tissue associated with B-mode ultrasound is far too low to pose a potential risk. Even experiments with exposure values in the range of pulsed Doppler have shown that temperature increases of over 1.5 °C can only occur in areas in direct contact with the probe, thus making a limited exposure time particularly in the case of transvaginal application advisable. The second part of this CME article describes various laboratory and animal experiments for evaluating non-thermal effects and also presents the most important epidemiological studies in the last 30 years in the form of an overview and review. In addition to direct insonation of isolated cells to examine possible mutagenic effects, the blood of patients exposed in vivo to ultrasound was also analyzed in multiple experiments. Reproducible chromosome aberrations could not be found in any of the studies. In contrast, many experiments on pregnant rodents showed some significant complications, such as abortion, deformities, and behavioral disorders. As in the case of thermal effects, the results of these experiments indicate the presence of an intensity- or pressure-dependent effect threshold. Numerous epidemiological studies examining possible short-term and long-term consequences after intrauterine ultrasound exposure are available with the most important studies being discussed in the following. In contrast to information presented incorrectly in the secondary literature and in the lay press, health problems could not be seen in the children observed in the postpartum period in any of these studies.

Routine ultrasound for fetal assessment before 24 weeks' gestation

BACKGROUND

Ultrasound examination of pregnancy before 24 weeks gestation may lead to more accurate dating and earlier diagnosis of pathology, but may also give false reassurance. It can be used to monitor development or diagnose conditions of an unborn baby. This review compares the effect of routine or universal, ultrasound examination, performed before 24 completed weeks' gestation, with selective or no ultrasound examination.  OBJECTIVES: To assess the effect of routine pregnancy ultrasound before 24 weeks as part of a screening programme, compared to selective ultrasound or no ultrasound, on the early diagnosis of abnormal pregnancy location, termination for fetal congenital abnormality, multiple pregnancy, maternal outcomes and later fetal compromise. To assess the effect of first trimester (before 14 weeks) and second trimester (14 to 24 weeks) ultrasound, separately.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform (ICTRP) on 11 August 2020. We also examined the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and RCTs published in abstract form. We included all trials with pregnant women who had routine or revealed ultrasound versus selective ultrasound, no ultrasound, or concealed ultrasound, before 24 weeks' gestation. All eligible studies were screened for scientific integrity and trustworthiness.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and risk of bias, extracted data and checked extracted data for accuracy. Two review authors independently used the GRADE approach to assess the certainty of evidence for each outcome MAIN RESULTS: Our review included data from 13 RCTs including 85,265 women. The review included four comparisons. Four trials were assessed to be at low risk of bias for both sequence generation and allocation concealment and two as high risk. The nature of the intervention made it impossible to blind women and staff providing care to treatment allocation.  Sample attrition was low in the majority of trials and outcome data were available for most women. Many trials were conducted before it was customary for trials to be registered and protocols published. First trimester routine versus selective ultrasound: four studies, 1791 women, from Australia, Canada, the United Kingdom (UK) and the United States (US). First trimester scans probably reduce short-term maternal anxiety about pregnancy (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.65 to 0.99; moderate-certainty evidence). We do not have information on whether the reduction was sustained.  The evidence is very uncertain about the effect of first trimester scans on perinatal loss (RR 0.97, 95% CI 0.55 to 1.73; 648 participants; one study; low-certainty evidence) or induction of labour for post-maturity (RR 0.83, 95% CI 0.50 to 1.37; 1474 participants; three studies; low-certainty evidence). The effect of routine first trimester ultrasound on birth before 34 weeks or termination of pregnancy for fetal abnormality was not reported. Second trimester routine versus selective ultrasound: seven studies, 36,053 women, from Finland, Norway, South Africa, Sweden and the US. Second trimester scans probably make little difference to perinatal loss (RR 0.98, 95% CI 0.81 to 1.20; 17,918 participants, three studies; moderate-certainty evidence) or intrauterine fetal death (RR 0.97, 95% CI 0.66 to 1.42; 29,584 participants, three studies; low-certainty evidence). Second trimester scans may reduce induction of labour for post-maturity (RR 0.48, 95% CI 0.31 to 0.73; 24,174 participants, six studies; low-certainty evidence), presumably by more accurate dating. Routine second trimester ultrasound may improve detection of multiple pregnancy (RR 0.05, 95% CI 0.02 to 0.16; 274 participants, five studies; low-certainty evidence). Routine second trimester ultrasound may increase detection of major fetal abnormality before 24 weeks (RR 3.45, 95% CI 1.67 to 7.12; 387 participants, two studies; low-certainty evidence) and probably increases the number of women terminating pregnancy for major anomaly (RR 2.36, 95% CI 1.13 to 4.93; 26,893 participants, four studies; moderate-certainty evidence). Long-term follow-up of children exposed to scans before birth did not indicate harm to children's physical or intellectual development (RR 0.77, 95% CI 0.44 to 1.34; 603 participants, one study; low-certainty evidence). The effect of routine second trimester ultrasound on birth before 34 weeks or maternal anxiety was not reported. Standard care plus two ultrasounds and referral for complications versus standard care: one cluster-RCT, 47,431 women, from Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia. This trial included a co-intervention, training of healthcare workers and referral for complications and was, therefore, assessed separately. Standard pregnancy care plus two scans, and training and referral for complications, versus standard care probably makes little difference to whether women with complications give birth in a risk appropriate setting with facilities for caesarean section (RR 1.03, 95% CI 0.89 to 1.19; 11,680 participants; moderate-certainty evidence).  The intervention also probably makes little to no difference to low birthweight (< 2500 g) (RR 1.01, 95% CI 0.90 to 1.13; 47,312 participants; moderate-certainty evidence). The evidence is very uncertain about whether the community intervention (including ultrasound) makes any difference to maternal mortality (RR 0.92, 95% CI 0.55 to 1.55; 46,768 participants; low-certainty evidence). Revealed ultrasound results (communicated to both patient and doctor) versus concealed ultrasound results (blinded to both patient and doctor at any time before 24 weeks): one study, 1095 women, from the UK. The evidence was very uncertain for all results relating to revealed versus concealed ultrasound scan (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Early scans probably reduce short term maternal anxiety.  Later scans may reduce labour induction for post-maturity. They may improve detection of major fetal abnormalities and increase the number of women who choose termination of pregnancy for this reason. They may also reduce the number of undetected twin pregnancies. All these findings accord with observational data.  Neither type of scan appears to alter other important maternal or fetal outcomes, but our review may underestimate the effect in modern practice because trials were mostly  from relatively early in the development of the technology, and many control participants also had scans. The trials were also underpowered to show an effect on other important maternal or fetal outcomes.

A survey of current use, dilemma and outlook of antenatal ultrasonography in Taiwan

OBJECTIVE

According to World Health Organization's Jungner and Wilson criteria for competent screening programs, routine antenatal ultrasound screening is legit and effective to improve both maternal and perinatal outcomes. Health Promotion Administration, Ministry of Health and Welfare in Taiwan followed expert recommendations and started reimbursing one antenatal ultrasonography around mid-second trimester since 1995. However, medical disputes pertaining to examination results grew, while confusions challenged doctors and patients alike. The aim of this study is to assess current use of antenatal ultrasonography for low-risk pregnancies in Taiwan. Specifically, the indications, test frequencies, test items, methods of payment, obstetricians' opinions on important scan timing and areas to be improved are surveyed and analyzed. An overview of international antenatal ultrasound practice guidelines are examined and compared to enhance the quality of antenatal ultrasound screening in Taiwan.

MATERIALS AND METHODS

From December 2015 to December 2016, 925 questionnaires were distributed to all licensed obstetricians registered to Taiwan Association of Obstetrics and Gynecology as well as Taiwan Society of Perinatology. A 10-min self-reporting questionnaire was sent by mail, with stamped return envelopes included. Respondents remained entirely anonymous and disclosed no personal information. Data was collected and analyzed for statistical analysis.

RESULTS

Most hospitals are well equipped with ultrasound machines of 3 or more functions. Eighty-eight percent of the obstetricians in Taiwan perform prenatal ultrasonography in every office visit for their patients, mostly free of charge. Scans at gestational age 15-22 weeks, <10 weeks, 11-14 weeks and 28-32 weeks are polled as the most importance in the order of significance. In general, they perceive the one-time antenatal scan offered by the Health Promotion Administration as for general obstetrics scan but not higher-leveled studies. Patient education and doctor-patient communications are opined as the 2 most important aspects to enhance antenatal ultrasound quality.

CONCLUSION

This report is the first of its kind in Taiwan. It could potentially serve as guidance for national health policy innovations in maternal and fetal care, such as increasing frequency of scans, specifications of scan timing, indications and consequences as well as patient education about this screening modality.

Fetal structural anomalies diagnosed during the first, second and third trimesters of pregnancy using ultrasonography: a retrospective cohort study

BACKGROUND

The prevalence of congenital abnormalities in general populations is approximately 3-5%. One of the most important applications of obstetric ultrasound is in detection of fetal structural defects.

OBJECTIVE

To assess fetal structural anomalies diagnosed using ultrasound in the three trimesters of pregnancy.

DESIGN AND SETTING

Retrospective cohort study at the Mário Palmério University Hospital of the University of Uberaba (Universidade de Uberaba, UNIUBE), from March 2014 to December 2016.

METHODS

Ultrasound data at gestational weeks 11-13 + 6, 20-24 and 32-36 were recorded to identify fetal anomalies in each trimester and in the postnatal period. The primary outcome measurements were sensitivity, specificity, positive predictive value and negative predictive value for detection of fetal anomalies and their prevalence.

RESULTS

The prevalence of anomalies detected using ultrasound was 2.95% in the prenatal period and 7.24% in the postnatal period. The fetal anomalies most frequently diagnosed using ultrasound in the three trimesters were genitourinary tract anomalies, with a prevalence of 27.8%. Cardiac anomalies were diagnosed more often in the postnatal period, accounting for 51.0% of all cases. High specificity, negative predictive value and accuracy of ultrasound were observed in all three trimesters of pregnancy.

CONCLUSION

Ultrasound is safe and has utility for detecting fetal anomalies that are associated with high rates of morbidity and mortality. However, the low sensitivity of ultrasound for detecting fetal anomalies in unselected populations limits its utility for providing reassurance to examiners and to pregnant women with normal results.

No. 214-Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks

OBJECTIVE

To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks.

OUTCOMES

Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy.

EVIDENCE

The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

RECOMMENDATIONS

Does the Use of Diagnostic Technology Reduce Fetal Mortality?

OBJECTIVE

To examine the effect that the introduction of new diagnostic technology in obstetric care has had on fetal death.

DATA SOURCE

The Medical Birth Registry of Norway provided detailed medical information for approximately 1.2 million deliveries from 1967 to 1995. Information about diagnostic technology was collected directly from the maternity units, using a questionnaire.

STUDY DESIGN

The data were analyzed using a hospital fixed-effects regression with fetal mortality as the outcome measure. The key independent variables were the introduction of ultrasound and electronic fetal monitoring at each maternity ward. Hospital-specific trends and risk factors of the mother were included as control variables. The richness of the data allowed us to perform several robustness tests.

PRINCIPAL FINDING

The introduction of ultrasound caused a significant drop in fetal mortality rate, while the introduction of electronic fetal monitoring had no effect on the rate. In the population as a whole, ultrasound contributed to a reduction in fetal deaths of nearly 20 percent. For post-term deliveries, the reduction was well over 50 percent.

CONCLUSION

The introduction of ultrasound made a major contribution to the decline in fetal mortality at the end of the last century.

Isolated low grade prenatally detected unilateral hydronephrosis: do we need long term follow-up?

Purpose:

To assess the need for postnatal evaluation and the medium term outcome in patients with isolated unilateral low grade prenatally detected hydronephrosis.

Materials and Methods:

We prospectively selected 424 patients (690 kidney units) with a prenatal diagnosis of urinary tract dilatation between 2010 and 2013. We included only those patients with isolated unilateral low-grade hydronephrosis who underwent at least 2 postnatal ultrasound examinations. The Society for Fetal Urology (SFU) grading system was utilized for assessment of the hydronephrosis. We excluded patients with bilateral dilation or other urological abnormalities. The fate of hydronephrosis including resolution, stability or worsening was documented.

Results:

A total of 66 infants (44 boys and 22 girls) with antenatally diagnosed unilateral urinary tract dilation (23 right and 43 left) were identified. Ultrasounds showed SFU grade 1 hydronephrosis in 32 patients (48%) and SFU grade 2 hydronephrosis in 34 (52%). After a mean follow-up period of 32 months (range 12 to 60), 37 patients (56%) had complete resolution of hydronephrosis while the remaining 29 were stable (44%). None of our patients developed UTIs during follow-up and none required surgical intervention.

Conclusions:

Prenatally detected, isolated unilateral low-grade hydronephrosis usually have a favorable prognosis. All cases in our cohort showed either stability or resolution of hydronephrosis without any harmful consequences. Based on our findings on medium-term in this category of patients, long-term follow-up is not warranted.

Clinical Utility of Fetal Short-Lag Spatial Coherence Imaging

In this study, we evaluate the clinical utility of fetal short-lag spatial coherence (SLSC) imaging. Previous work has documented significant improvements in image quality with fetal SLSC imaging as quantified by measurements of contrast and contrast-to-noise ratio (CNR). The objective of this study was to examine whether this improved technical efficacy is indicative of the clinical utility of SLSC imaging. Eighteen healthy volunteers in their first and second trimesters of pregnancy were scanned using a modified Siemens SC2000 clinical scanner. Raw channel data were acquired for routinely examined fetal organs and used to generate fully matched raw and post-processed harmonic B-mode and SLSC image sequences, which were subsequently optimized for dynamic range and other imaging parameters by a blinded sonographer. Optimized videos were reviewed in matched B-mode and SLSC pairs by three blinded clinicians who scored each video based on overall quality, target conspicuity and border definition. SLSC imaging was highly favored over conventional imaging with SLSC scoring equal to (28.2 ± 10.5%) or higher than (63.9 ± 12.9%) B-mode for video pairs across all examined structures and processing conditions. Multivariate modeling revealed that SLSC imaging is a significant predictor of improved image quality with p ≤ 0.002. Expert-user scores for image quality support the application of SLSC in fetal ultrasound imaging.

[Ultrasound screening for birth defects: A medico-economic review]

OBJECTIVES

The systematic use of ultrasound during pregnancy aims at birth defect detection. Our objective was to assess the economic efficiency of prenatal ultrasound screening for fetal malformations.

METHODS

We carried out a literature review on Medline via PubMed between 1985 and 2015, from the economic perspective of the prenatal ultrasound screening for fetal malformations.

RESULTS

The literature on this subject was sparse and we selected only twelve articles presenting relevant economic data, of which only eight were proper medico-economic studies. We found arguments for the economic effectiveness of ultrasound screening for fetal malformation detection, which is largely linked to the terminations of pregnancies and to the cost of the handicaps "avoided". However, none of the reviewed articles could reach medico-economic conclusions. Additionally, we highlighted various elements making economic analyses more complex in this field: the choice of the method, the uncertainty around two essential parameters (the efficiency of ultrasound and the costs of procedures) and the difficulties to compare or to generalize results. We also noticed important methodological heterogeneity among the studies and the absence of French study.

CONCLUSIONS

Previously published data are insufficient to assess the economic efficiency of prenatal ultrasound screening for fetal malformations.

Evaluation of the thermal effects of prenatal ultrasound on hematological analysis of young Oryctolagus Cuniculus

Elevated temperatures can induce changes in red blood cell (RBC), white blood cell (WBC) and platelet (PLT) counts. Ultrasound heating during obstetric scans has the potential to increase body temperature owing to the phenomenon of absorption. We conducted a study to determine the thermal effects of prenatal ultrasound on RBCs, hemoglobin concentration (Hb), WBCs and PLTs in young rabbits. We selected 69 rabbits that were 1 month of age and 73 that were 5 months of age, and allocated them to four groups. The control group consisted of four pregnant does that were allowed to have a full term delivery without any ultrasound exposure. The experimental groups were subjected to one-time ultrasound exposure for 30, 60 and 90 min in the middle of each gestational stage accordingly. RBCs and Hb showed significant reductions in the experimental groups of 1- and 5-month-old rabbits (P<0.05). In addition, WBCs and PLTs yielded significant differences in the 1-month group that were not observed in the 5-month group (P>0.05). The highest values recorded were those of the WBCs of 1-month-old subjects that received 90 min of exposure at the second stage of gestation. The PLTs were the lowest values recorded in 1-month-old subjects following 90 min of ultrasound exposure at the third stage of gestation. These findings suggest that hematological fluctuations during the early stages of postnatal life persisted until 1 month of age and recovered thereafter, as the subjects progressed into adulthood. Therefore, ultrasound heating can cause significant, yet reversible effects on the hematological parameters of rabbits.

Routine prenatal ultrasound anomaly screening program in a Nigerian university hospital: Redefining obstetrics practice in a developing African country

BACKGROUND

Congenital anomalies are among the leading causes of fetal and infant morbidity and mortality worldwide. Prenatal ultrasound (US) screening has become an essential part of antenatal care in the developed world. Such practice is just evolving in the developing countries such as Nigeria. The aim of this article is to present our initial experience and demonstrate the effectiveness of a prenatal US screening program in detecting congenital malformation in a developing country.

MATERIALS AND METHODS

This was a prospective evaluation of the prenatal US screenings conducted at a major referral hospital in Southwestern Nigeria. All pregnant women referred to the antenatal clinic for mid-trimester screening during the period of study were assessed.

RESULTS

Two hundred and eighty-seven pregnant women (5 with twin gestations) were presented for fetal anomaly scan during the study period. Twenty-nine anomalies (9.9%) were detected among the scanned population. Sixteen of the anomalies were followed to delivery/termination with a specificity of 93.5%. The commonest malformations were demonstrated in the genitourinary tract (34.5%) followed by malformations within the central nervous system (27.6%). Six (20.6%) of the anomalies were lethal. Five of the anomalies were surgically correctable.

CONCLUSION

Institutions and hospitals across Nigeria and other low- and middle-income countries need to develop policies and programs that would incorporate a standardized routine screening prenatal US in order to improve feto-maternal well-being and reduce the high perinatal mortality and morbidity in developing nations.

Changes in detection of birth defects and perinatal mortality after introduction of prenatal ultrasound screening in the Kola Peninsula (North-West Russia): combination of two birth registries

BACKGROUND

Prenatal diagnostics ultrasound was established in Russia in 2000 as a routine method of screening for birth defects. The aims of the current study were twofold: to assess changes in birth defects prevalence at birth and perinatal mortality after ultrasound screening was implemented and to estimate prenatal detection rates for congenital malformations in the city of Monchegorsk (Murmansk County, North-West Russia).

METHODS

The Murmansk County Birth Registry and the Kola Birth Registry were the primary sources of information, and include 30 448 pregnancy outcomes in Monchegorsk for the period 1973-2011. Data from these registries were supplemented with information derived from hospital records about pregnancy terminations for 2000-2007.

RESULTS

The total number of newborns with any kind of birth defects in Monchegorsk during 1973-2011 was 1099, of whom 816 were born in the 1973-2000 period. The prevalence of defects at birth increased from 34.2/1000 (95% CI = 31.9-36.5) to 42.8/1000 newborns (95% CI = 38.0-47.7) after prenatal ultrasound screening was formally implemented. We observed significant decreases (p < 0.05) in the birth prevalence of congenital malformations of the circulatory system, the musculoskeletal system (including deformations), and other (excluding multiple); those of the urinary system increased from 0.9/1000 to 17.1/1000 (p < 0.0001). The perinatal mortality among newborns with any kind of malformation decreased from 106.6 per 1000 newborns with birth defects (95% CI = 84.3-129.1) to 21.2 (95 % CI = 4.3-38.1). Mothers who had undergone at least one ultrasound examination during pregnancy (n = 9883) had a decreased risk of having a newborn die during the perinatal period [adjusted OR = 0.49 (95% CI = 0.27-0.89)]. The overall prenatal detection rate was 34.9% with the highest for malformations of the nervous system.

CONCLUSION

Improved detection of severe malformations with subsequent pregnancy termination was likely the main contributor to the observed decrease in perinatal mortality in Murmansk County, Russia.

Higher Prevalence of Left-Handedness in Twins? Not After Controlling Birth Time Confounders

Pregnancy- and birth-related factors may have an effect on handedness. Compared with singletons, twins have a lower birth weight, shorter gestational age, and are at higher risk for birth complications. We tested whether the prevalence of left-handedness is higher among twins than singletons, and if so, whether that difference is fully explained by pregnancy and birth-related differences between twins and singletons. We analyzed Finnish population-based datasets; included were 8,786 twins and 5,892 singletons with information on birth weight (n = 12,381), Apgar scores (n = 11,129), and gestational age (n = 11,811). Two twin cohorts were involved: FinnTwin12 included twins born during 1983–1987, and FinnTwin16 included twins born during 1974–1979. We had two comparison groups of singletons: 4,101 individuals born during 1986–1988 and enrolled in the Helsinki Ultrasound Trial, and 1,791 individuals who were partners of FinnTwin16 twins. We used logistic regression models with writing hand as the outcome for comparison and evaluating effects of covariates. Left-handedness was more common in twins (9.67%) than in singletons (8.27%; p = .004). However, Apgar scores were associated with handedness, and after controlling for covariates, we found no difference in the prevalence of left-handedness between twins and singletons. Increased left-handedness among twins, often reported by others, was evident in our data, but only among our older twin cohorts, and that association disappeared after removing effects of perinatal covariates.

Ultrasound for fetal assessment in early pregnancy

BACKGROUND

Diagnostic ultrasound is a sophisticated electronic technology, which utilises pulses of high-frequency sound to produce an image. Diagnostic ultrasound examination may be employed in a variety of specific circumstances during pregnancy such as after clinical complications, or where there are concerns about fetal growth. Because adverse outcomes may also occur in pregnancies without clear risk factors, assumptions have been made that routine ultrasound in all pregnancies will prove beneficial by enabling earlier detection and improved management of pregnancy complications. Routine screening may be planned for early pregnancy, late gestation, or both. The focus of this review is routine early pregnancy ultrasound.

OBJECTIVES

To assess whether routine early pregnancy ultrasound for fetal assessment (i.e. its use as a screening technique) influences the diagnosis of fetal malformations, multiple pregnancies, the rate of clinical interventions, and the incidence of adverse fetal outcome when compared with the selective use of early pregnancy ultrasound (for specific indications).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Published, unpublished, and ongoing randomised controlled trials that compared outcomes in women who experienced routine versus selective early pregnancy ultrasound (i.e. less than 24 weeks' gestation). We have included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the Review Manager software to enter and analyse data.

MAIN RESULTS

Routine/revealed ultrasound versus selective ultrasound/concealed: 11 trials including 37,505 women. Ultrasound for fetal assessment in early pregnancy reduces the failure to detect multiple pregnancy by 24 weeks' gestation (risk ratio (RR) 0.07, 95% confidence interval (CI) 0.03 to 0.17; participants = 295; studies = 7), moderate quality of evidence). Routine scans improve the detection of major fetal abnormality before 24 weeks' gestation (RR 3.46, 95% CI 1.67 to 7.14; participants = 387; studies = 2,moderate quality of evidence). Routine scan is associated with a reduction in inductions of labour for 'post term' pregnancy (RR 0.59, 95% CI 0.42 to 0.83; participants = 25,516; studies = 8), but the evidence related to this outcome is of low quality, because most of the pooled effect was provided by studies with design limitation with presence of heterogeneity (I² = 68%). Ultrasound for fetal assessment in early pregnancy does not impact on perinatal death (defined as stillbirth after trial entry, or death of a liveborn infant up to 28 days of age) (RR 0.89, 95% CI 0.70 to 1.12; participants = 35,735; studies = 10, low quality evidence). Routine scans do not seem to be associated with reductions in adverse outcomes for babies or in health service use by mothers and babies. Long-term follow-up of children exposed to scan in utero does not indicate that scans have a detrimental effect on children's physical or cognitive development.The review includes several large, well-designed trials but lack of blinding was a problem common to all studies and this may have an effect on some outcomes. The quality of evidence was assessed for all review primary outcomes and was judged as moderate or low. Downgrading of evidence was based on including studies with design limitations, imprecision of results and presence of heterogeneity.

AUTHORS' CONCLUSIONS

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity. Caution needs to be exercised in interpreting the results of aspects of this review in view of the fact that there is considerable variability in both the timing and the number of scans women received.

Safety of Exposure From Extremely Low Frequency Magnetic Fields During Prenatal Ultrasound Examinations in Clinicians and Pregnant Women

Investigations into the safety of ultrasonography in pregnancy have focused on the potential harm of ultrasound itself. However, no data have been published regarding the electromagnetic fields that ultrasound devices might produce. This study is the first to measure extremely low-frequency magnetic field (ELF-MF) exposure of clinicians and pregnant women during prenatal ultrasound examinations in the examination room from 2 different ultrasound devices and compare them with ELF-MFs during patient consultation in the consulting room.The ELF-MF intensities that clinicians and pregnant women were exposed to were measured every 10 seconds for 40 prenatal ultrasound examinations using Philips iU22 or Accuvix V20 Prestige machines and 20 patient consultations in a consulting room using portable ELF-MF measurement devices. The mean ELF-MF exposure of both clinicians and pregnant women was 0.18 ± 0.06 mG during prenatal ultrasound examination. During patient consultation, the mean ELF-MF exposures of clinicians and pregnant women were 0.10 ± 0.01 and 0.11 ± 0.01 mG, respectively. Mean ELF-MF exposures during prenatal ultrasound examination were significantly higher than those during patient consultations (P < 0.001 by Mann-Whitney U test).Our results provide basic reference data on the ELF-MF exposure of both clinicians and pregnant women during prenatal ultrasound monitoring from 2 different ultrasound devices and patient consultation, all of which were below 2 mG, the most stringent level considered safe in many studies, thus relieving any anxiety of clinicians and pregnant women regarding potential risks of ELF-MFs.

The utility of prenatal ultrasound as a screening tool for upper extremity congenital anomalies

PURPOSE

To quantify the detection rate and accuracy of prenatal ultrasound in patients with congenital upper extremity anomalies.

METHODS

A total of 100 patients with congenital upper extremity reduction or duplication anomalies were enrolled prospectively in this investigation at the initial visit to our congenital hand clinic. Demographic and pregnancy-related data were collected along with prenatal diagnoses. We recorded all ultrasound-identified upper extremity anomalies as reported by the parents. Finally, we compared the prenatal diagnosis with the final congenital hand clinic diagnosis.

RESULTS

The first ultrasound was performed at a mean 11 weeks' gestation, and patients underwent an average of 8 prenatal ultrasounds (range, 1-40 prenatal ultrasounds). Sixty patients underwent standard ultrasound and 40 had a 3-dimensional ultrasound as well. Of the 100 patients, 31 had an upper extremity anomaly by ultrasound. Of the 31 prenatal ultrasound diagnoses, 18 were confirmed as accurate during evaluation in the congenital hand clinic. Three-dimensional ultrasound was more sensitive for the detection of upper extremity anomalies.

CONCLUSIONS

The overall detection rate and accuracy of ultrasonography for upper extremity anomalies were low despite advancements in imaging technology.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Does the type of provider and the place of residence matter in the utilization of prenatal ultrasonography? Evidence from Canada

BACKGROUND

There has been a proliferation of repeat prenatal ultrasound examinations per pregnancy in many developed countries over the past 20 years, yet few studies have examined the main determinants of the utilization of prenatal ultrasonography.

OBJECTIVE

The objective of this study was to examine the influence of the type of provider, place of residence and a wide range of socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles.

METHODS

The study utilized the data set of the Maternity Experience Survey (MES) conducted by Statistics Canada in 2006. Using an appropriate count data regression model, the study assessed the influence of a wide range of socioeconomic, demographic, maternal risk factors and types of provider on the number of prenatal ultrasounds. The regression model was further extended by interacting providers with provinces to assess the differential influence of types of provider on the number of ultrasounds both across and within provinces.

RESULTS

The results suggested that, in addition to maternal risk factors, the number of ultrasounds was also influenced by the type of healthcare provider and geographic regions. Obstetricians/gynaecologists were likely to recommend more ultrasounds than family physicians, midwives and nurse practitioners. Similarly, birthing women who received their care in Ontario were likely to have more ultrasounds than women who received their prenatal care in other provinces/territories. Additional analysis involving interactions between providers and provinces suggested that the inter-provincial variations were particularly more pronounced for family physicians/general practitioners than for obstetricians/gynaecologists. Similarly, the results for intra-provincial variations suggested that compared with obstetricians/gynaecologists, family physicians/GPs ordered fewer ultrasound examinations in Prince Edward Island, British Columbia, Nova Scotia, Alberta and Newfoundland.

CONCLUSION

After controlling for a number of socioeconomic and demographic factors, as well as maternal risk factors, it was found that the type of provider and the province of prenatal care were statistically significant determinants of the frequency of use of ultrasounds. Additional analysis involving interactions between providers and provinces indicated wide intra- and inter-provincial variations in the use of prenatal ultrasounds. New policy measures are needed at the provincial and federal government levels to achieve more appropriate use of prenatal ultrasonography.

Prenatal ultrasound and urological anomalies

Prenatal ultrasound is an integral part of caring for pregnant women in the United States. Although surprisingly few data exist to support the clinical benefit of screening ultrasound during pregnancy, its use continues to rise. Urologic anomalies are among the most commonly identified, with overall detection sensitivity approaching 90%. Prenatal hydronephrosis is the most frequently identified finding and predicting postnatal pathology based on its presence can be difficult. As the degree of fetal hydronephrosis increases so does the risk of true urinary tract pathology. Diagnoses that require more urgent care include causes of lower urinary tract obstruction and bladder and cloacal exstrophy.

Genetic screening and counseling: family medicine obstetrics

Genetic screening and counseling have become routinely offered during prenatal care in the United States, involving invasive and noninvasive options for assessing fetal genetics. As DNA testing continues to expand proportionately to the increasing ability to detect genetic variations, ethical and fiscal concerns arise. Societal shifts, such as delayed childbearing and the associated genetic consequences, have made antenatal genetic screening more common. Still, genetic screening may be confounded by inaccurate information, false-positives, socioeconomic barriers to testing, and cultural differences. This article reviews these concerns and provides a framework for training in family medicine obstetrics training.

The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan

OBJECTIVE

To compare 2 routine obstetric ultrasound protocols regarding number of clinically relevant events detected and total ultrasound workload.

METHODS

An interventional before-and-after study comparing 2 groups of 750 consecutive low-risk pregnant women was conducted. The 1st group was routinely offered mid-trimester ultrasound and selective ultrasound examinations for specific indications; the 2nd group was, in addition to this, offered a scan at 1st prenatal visit.

RESULTS

The groups were comparable at baseline, and 78% underwent booking scan. The expanded protocol showed no improvement in detection of most clinically relevant findings but did detect twins slightly earlier (P=0.3) and significantly reduced the number of presumed post-term deliveries (8.4% vs 13.1%; OR 0.61 [95% CI, 0.41-0.90]). Although more women were scanned at any point or <24 weeks (P<0.001), the increase in women receiving a properly timed fetal anomaly scan was small (60.7% vs 52.3%; P=0.003). Total ultrasound workload increased by 74%, mainly because of more follow-up scans (323 vs 122) and more women being scanned for the 1st time >24 weeks (146 vs 51; P<0.001).

CONCLUSION

The results do not support a policy of routine booking scans and revealed no significant benefit apart from a small reduction in presumed post-term pregnancies.

Ultrasound in pregnancy and non-right handedness: meta-analysis of randomized trials

OBJECTIVE

To study the association between exposure to ultrasound in pregnancy and non-right handedness in children with available data from randomized trials.

METHODS

Follow-up data of 8865 children aged 8-14 years from three randomized trials on routine ultrasonography at 15-20 weeks' gestation were available. Handedness was assessed through questionnaires to the parents and classified according to five, 10 or 11 questions. Children not classified as right handed were regarded as non-right handed.

RESULTS

There was a statistically significant increased prevalence of non-right handedness in ultrasonographically screened children compared with controls (odds ratio (OR) 1.15; 95% CI, 1.03-1.29). The results in subgroups according to gender are consistent with the overall results, with no significant differences between boys and girls. Among boys, the association became stronger when an exploratory analysis according to ultrasound exposure before 19-22 weeks' gestation was done (OR 1.30; 95% CI, 1.10-1.53).

CONCLUSION

There is a statistically significant-albeit weak-association between ultrasound screening during pregnancy and being non-right handed later in life.

Handedness in the helsinki ultrasound trial

OBJECTIVES

To determine whether exposure to prenatal ultrasound increases non-right-handedness in boys.

METHODS

The association between exposure to prenatal ultrasound and handedness was tested, using logistic regression analysis, in the Helsinki Ultrasound Trial data. We applied an intention-to-treat approach in this analysis of a subset of 4150 subjects whose parents answered a follow-up questionnaire on handedness when the children were aged 13-15 years.

RESULTS

The odds ratio for non-right-handedness of children who had been exposed to prenatal ultrasound was 1.16 (0.98-1.37) for all subjects, 1.12 (0.89-1.41) for boys and 1.24 (0.97-1.58) for girls.

CONCLUSIONS

We could not confirm the hypothesis that prenatal ultrasound exposure and handedness are associated. Our findings were independent of the particular definition of handedness used, whether it was considered according to the writing hand alone or defined using a laterality quotient.

Ultrasonic imaging: safety considerations

Modern ultrasound imaging for diagnostic purposes has a wide range of applications. It is used in obstetrics to monitor the progress of pregnancy, in oncology to visualize tumours and their response to treatment, and, in cardiology, contrast-enhanced studies are used to investigate heart function and physiology. An increasing use of diagnostic ultrasound is to provide the first photograph for baby's album-in the form of a souvenir or keepsake scan that might be taken as part of a routine investigation, or during a visit to an independent high-street 'boutique'. It is therefore important to ensure that any benefit accrued from these applications outweighs any accompanying risk, and to evaluate the existing ultrasound bio-effect and epidemiology literature with this in mind. This review considers the existing laboratory and epidemiological evidence about the safety of diagnostic ultrasound and puts it in the context of current clinical usage.

Prenatal ultrasonography: implications for pediatric urology

Prenatal ultrasonography has become a critical and integral component of the obstetric care of women worldwide. As a result, a number of congenital anomalies are now routinely being detected prior to birth. Anomalies affecting the genitourinary system are among those most commonly detected, and thus pediatric urologists are increasingly being asked to provide parental counseling in such situations. However, much of the data needed to enhance these discussions and provide informed consent are absent from the literature. In this review, we hope to address the published literature describing the rapidly expanding role of ultrasound in prenatal care. More importantly, however, we hope to provide some insight into the manner in which prenatal ultrasound and subsequent urologic anomaly diagnosis has affected the practice of pediatric urology.

Management of pregnancy in patients with congenital heart disease

Congenital heart diseases are the most common birth defects in humans, affecting approximately 0.8% of all live births. In the past, many of the more severe defects resulted in profound disability and death during childhood, and adult survival was exceptional. The past 4 decades have seen dramatic improvements in the survival and quality of life of patients with the more severe defects. As a result of these improvements, the challenges of caring for adults with congenital heart disease are only now being realized. Most women with congenital heart disease are now expected to reach childbearing age and maternal cardiac disease is the major cause of maternal morbidity and mortality. As such, appropriate pre-pregnancy counseling and management during pregnancy are fundamental components of the care of these patients. This article describes the circulatory changes that occur during normal pregnancy and delivery, addresses the risks posed during pregnancy by specific congenital lesions, and reviews the current data on pregnancy outcomes in patients with individual congenital defects.

Three-dimensional ultrasound in evaluating the fetus

In recent years three-dimensional (3D) ultrasound has made a place in clinical practice and has become a major field of research in obstetrics. In this article we will review the diagnostic performance of the most widely used 3D ultrasound applications in the assessment of fetal anomalies, explain the technique to gain correct 3D images and offer some practical advice for their efficient use. Examples are given to demonstrate the applicability and vividness of 3D in daily routine.

Ultrasound findings in aneuploidy fetusus: Evaluation of 332 cases

OBJECTIVE

To evaluate the ultrasound findings found on ultrasound examination among cases that had aneuploidy at amniocentesis.

MATERIAL AND METHODS

This prospective study was performed at Dicle University, School of Medicine, Department of Obstetrics and Gynecology. 332 cases applied to our department for prenatal diagnosis and amniocentesis (AC) was performed. Of these cases, twenty were found to have aneuploidy evaluated. The factors recorded were; mean age, gestational weeks, AC indications, ultrasound findings (by Toshiba 140A and GE Voluson 730 Pro 4D ultrasound device) and fetal anomalies.

RESULTS

332 cases have had AC by an experienced specialist, in a two year period. The mean age of the cases was 32.20±6.03 years (22-44), and gestational weeks 16.45±1.46 (13-19). AC indications were; high double and/or triple test with ultrasound findings and abnormal ultrasound findings. In 8 (2.40%) cases there was no reproduction on cell culture. In 14 (4.21%) cases, different types of chromosomal anomalies were detected. In these cases, peripheral blood was taken from the parents and if, at least in one of them this situation was present, this would be accepted as normal. In 20 (6.02%) cases aneuploidy (numerical chromosomal anomalies) were detected and 11 of them (55.00%) were trisomy 21. In all of these aneuploidy cases, different types of ultrasound findings were detected; most of them had multiple ultrasound findings, and some of them had one anomaly. Of all 20 aneuploidy cases; termination of pregnancy was decided in 17 (85%) of them. 3 (15%) of these cases decided to carry on their pregnancy. Of the 3 cases; one baby was delivered spontaneously and live, one had died in utero and labor was induced and the third pregnancy is ongoing.

CONCLUSION

The importance of ultrasound in fetal anomaly screening is incontrovertible and positive ultrasound findings are the most important indications of amniocentesis. For this reason, before amniocentesis, we advise a detailed ultrasound examination by an experienced specialist.

Ultrasound for fetal assessment in early pregnancy

BACKGROUND

Diagnostic ultrasound is a sophisticated electronic technology, which utilises pulses of high frequency sound to produce an image. Diagnostic ultrasound examination may be employed in a variety of specific circumstances during pregnancy such as after clinical complications, or where there are concerns about fetal growth. Because adverse outcomes may also occur in pregnancies without clear risk factors, assumptions have been made that routine ultrasound in all pregnancies will prove beneficial by enabling earlier detection and improved management of pregnancy complications. Routine screening may be planned for early pregnancy, late gestation, or both. The focus of this review is routine early pregnancy ultrasound.

OBJECTIVES

To assess whether routine early pregnancy ultrasound for fetal assessment (i.e. its use as a screening technique) influences the diagnosis of fetal malformations, multiple pregnancies, the rate of clinical interventions, and the incidence of adverse fetal outcome when compared with the selective use of early pregnancy ultrasound (for specific indications).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009).

SELECTION CRITERIA

Published, unpublished, and ongoing randomised controlled trials that compared outcomes in women who experienced routine versus selective early pregnancy ultrasound (i.e. less than 24 weeks' gestation). We have included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for each included study. We used the Review Manager software to enter and analyse data.

MAIN RESULTS

Routine/revealed ultrasound versus selective ultrasound/concealed: 11 trials including 37505 women. Ultrasound for fetal assessment in early pregnancy reduces the failure to detect multiple pregnancy by 24 weeks' gestation (risk ratio (RR) 0.07, 95% confidence interval (CI) 0.03 to 0.17). Routine scan is associated with a reduction in inductions of labour for 'post term' pregnancy (RR 0.59, 95% CI 0.42 to 0.83). Routine scans do not seem to be associated with reductions in adverse outcomes for babies or in health service use by mothers and babies. Long-term follow up of children exposed to scan in utero does not indicate that scans have a detrimental effect on children's physical or cognitive development.

AUTHORS' CONCLUSIONS

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity. Caution needs to be exercised in interpreting the results of aspects of this review in view of the fact that there is considerable variability in both the timing and the number of scans women received.

WITHDRAWN: Ultrasound for fetal assessment in early pregnancy

BACKGROUND

Advantages of early pregnancy ultrasound screening are thought to be more accurate calculation of gestational age, earlier identification of multiple pregnancies, and diagnosis of non-viable pregnancies and certain fetal malformations.

OBJECTIVES

The objective of this review was to assess the use of routine (screening) ultrasound compared with the selective use of ultrasound in early pregnancy (ie before 24 weeks).

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (up to June 2001) were searched.

SELECTION CRITERIA

Adequately controlled trials of routine ultrasound imaging in early pregnancy.

DATA COLLECTION AND ANALYSIS

One reviewer assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Nine trials were included. The quality of the trials was generally good. Routine ultrasound examination was associated with earlier detection of multiple pregnancies (twins undiagnosed at 26 weeks, odds ratio 0.08, 95% confidence interval 0.04 to 0.16) and reduced rates of induction of labour for post-term pregnancy (odds ratio 0.61, 95% confidence interval 0.52 to 0.72). There were no differences detected for substantive clinical outcomes such as perinatal mortality (odds ratio 0.86, 95% confidence interval 0.67 to 1.12). Where detection of fetal abnormality was a specific aim of the examination, the number of terminations of pregnancy for fetal anomaly increased.

AUTHORS' CONCLUSIONS

Routine ultrasound in early pregnancy appears to enable better gestational age assessment, earlier detection of multiple pregnancies and earlier detection of clinically unsuspected fetal malformation at a time when termination of pregnancy is possible. However, the benefits for other substantive outcomes are less clear.

Fetal weight normograms for singleton pregnancies in a Jordanian population

BACKGROUND AND OBJECTIVES

Estimated intrauterine fetal weight (EIUFW) is important for reducing prenatal mortality and morbidity through early detection of faltering growth. Our objectives were to develop patterns of ultrasonically determined EIUFW by gestational age, for normal singleton pregnancies, and to assess the effect of a number of variables on EIUFW.

METHODS

Ultrasonically, EIUFW was obtained from 600 pregnant women who were at 20 to 42 weeks of gestation (WG). EIUFW was categorized into low weight and normal weight using the tenth and twentieth percentile as the cut-off points. Logistic regression was used to calculate the odds ratio and their 95% confidence limits for a number of risk factors hypothesized to be associated with low fetal weight. EIUFW percentiles (twenty-fifth, fiftieth, and seventy-fifth), by gestational age and sex, were calculated for singleton pregnancies.

RESULTS

Up to 32 WG there was no statistically significant difference between male and female fetuses in EIUFW. Between 32 and 39 WG males had significantly (P< .05) higher fetal weight than females. Charts of ultrasonically determined EIUFW by gestational age and sex for singleton pregnancies were created. A number of variables were significantly associated with EIUFW, such as pregnancy weight gain, maternal hemoglobin level, frequency of antenatal visits, smoking status, and fetal sex.

CONCLUSION

Weight gain during pregnancy should be encouraged for pregnant mothers who gain less than one kilogram per month in the second and third trimester. A prospective study on a national representative sample in Jordan is needed to generate our own standards for fetal growth.

Even a single third trimester antenatal fetal screening for congenital anomalies can be life saving

We report two cases of malrotation with extremely different outcomes based on the availability and non-availability of antenatal scanning. The first one had a single third trimester ultrasound which detected malrotation and helped in saving baby's life whereas the second baby without antenatal screening succumbed to midgut volvulus and its sequelae because of delayed presentation. In developing countries where most of the pregnancies may go unsupervised, a single third trimester scan for fetal anomalies by an experienced sonologist, in areas where routine antenatal screening program has failed or not feasible can help save the baby's life at least in surgically correctable anomalies. This may be an important strategy to reduce the infant mortality rate in the country.

Perinatal and neurodevelopmental outcome with isolated fetal ventriculomegaly: A systematic review

OBJECTIVE

To establish the perinatal and neurodevelopmental outcomes of fetuses diagnosed with isolated ventriculomegaly (IVM).

METHODS

A systematic review of cohort, case/control studies, case series and case reports of IVM (unilateral or bilateral enlargement of the lateral ventricle, >or=10 mm, with no additional diagnosis at the time of the initial ultrasound), identified by searching, without language restrictions, The Cochrane Library, MEDLINE and Embase databases in June 2004.

RESULTS

No cohort study was retrieved but 577 cases were identified in one case/control study and 29 case series/case reports. Of 207 cases with follow-up and known gestational age at diagnosis, normal developmental outcomes were found in 82%, mild impairments in 9% and moderate/severe impairments in 10%. Prenatal diagnosis could possibly have reduced the risk of moderate/severe impairments to 7%. In 137 cases followed to at least 20 months of age, 79% had normal neurodevelopment, 10% were mildly delayed and 11% had moderate/severe developmental delays.

CONCLUSIONS

Outcome was favorable in 85% of IVM cases, decreasing to 79% when cases were followed to at least 20 months of age. We recommend prospective cohort studies with new diagnostic modalities to better identify the underlying conditions relating to moderate/severe impairments in the remaining cases.

Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis

OBJECTIVE

In the context of the planned International Society of Ultrasound in Obstetrics and Gynecology-World Health Organization multicenter study for the development of fetal growth standards for international application, we conducted a systematic review and meta-analysis to evaluate the safety of human exposure to ultrasonography in pregnancy.

METHODS

A systematic search of electronic databases, reference lists and unpublished literature was conducted for trials and observational studies that assessed short- and long-term effects of exposure to ultrasonography, involving women and their fetuses exposed to ultrasonography, using B-mode or Doppler sonography during any period of pregnancy, for any number of times. The outcome measures were: (1) adverse maternal outcome; (2) adverse perinatal outcome; (3) abnormal childhood growth and neurological development; (4) non-right handedness; (5) childhood malignancy; and (6) intellectual performance and mental disease.

RESULTS

The electronic search identified 6716 citations, and 19 were identified from secondary sources. A total of 61 publications reporting data from 41 different studies were included: 16 controlled trials, 13 cohort and 12 case-control studies. Ultrasonography in pregnancy was not associated with adverse maternal or perinatal outcome, impaired physical or neurological development, increased risk for malignancy in childhood, subnormal intellectual performance or mental diseases. According to the available clinical trials, there was a weak association between exposure to ultrasonography and non-right handedness in boys (odds ratio 1.26; 95% CI, 1.03-1.54).

CONCLUSION

According to the available evidence, exposure to diagnostic ultrasonography during pregnancy appears to be safe.

Postterm pregnancy: how can we improve outcomes?

Postterm pregnancy is defined as one which has progressed to 42 0/7 weeks or beyond. The most common reason to be diagnosed with a postterm pregnancy is inaccurate pregnancy dating, but it is also associated with obesity, nulliparity, and a prior history of postterm pregnancy. The rate of postterm pregnancy appears to be decreasing whether due to improved pregnancy dating or an increase in induction of labor. Postterm pregnancy is associated with both maternal and neonatal morbidity and fetal and neonatal mortality; similarly pregnancies beyond 41 weeks' gestation are associated with increases in these perinatal complications. Prevention of postterm pregnancies may include stripping or sweeping the membranes and unprotected coitus. Management of such pregnancies may include induction of labor and fetal antenatal monitoring. Individual patient management should involve careful counseling regarding the risks and benefits of each of the components of care.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall the increasing risks of poor outcomes associated with prolonged pregnancy, demonstrate knowledge regarding gestational dating and use of cervical ripening agents in their care of pregnant women, and use evidence-based information when counseling their term patients regarding postterm pregnancy management.