Controversial ultrasound findings

What is the meaning of a 'genomic result' in the context of pregnancy?

Prenatal genetic testing and analysis in the past was usually only offered when a particular fetal phenotype was noted or suspected, meaning that filtering and interpretation of genetic variants identified could be anchored in attempts to explain an existing health concern. Advanced genomic testing is now increasingly used in "low-risk" pregnancies, producing information on genotype adrift of the phenotypic data that is necessary to give it meaning, thus increasing the difficulty in predicting whether and how particular genetic variants might affect future development and health. A challenge to healthcare scientists, clinicians, and parents therefore is deciding what qualities prenatal genotypic variation should have in order to be constructed as a 'result.' At the same time, such tests are often re requested in order to make binary decisions about whether to continue a pregnancy or not. As a range of professional organizations develop guidelines on the use of advanced genomic testing during pregnancy, we highlight the particular difficulties of discovering ambiguous findings such as variants with uncertain clinical significance, susceptibility loci for neurodevelopmental problems and susceptibility to adult-onset diseases. We aim to foster international discussions about how decisions around disclosure are made and how uncertainty is communicated.

Chromosomal microarray analysis for the detection of chromosome abnormalities in fetuses with echogenic intracardiac focus in women without high-risk factors

To investigate the association between pathogenic copy number variants (p-CNVs) and abnormal karyotypes detected by chromosomal microarray analysis (CMA) and echogenic intracardiac focus (EIF).This was a retrospective study of fetuses with EIF with CMA data at the Prenatal Diagnosis Center of the West China Second University Hospital of Sichuan University between September 2014 and May 2017. Fetuses were assigned to the isolated EIF and non-isolated EIF groups according to the presence of other ultrasound abnormalities.Among 244 pregnant women, there were 143 cases of isolated EIF and 101 of non-isolated EIF. CMA revealed chromosome abnormality (n = 9 (3.7%): trisomy 21, n = 4; sexual trisomy, n = 2; and p-CNV, n = 3), variants of unknown significance (VOUS, n = 19), and benign CNV (b-CNV, n = 216). Among the fetuses with isolated EIF, 5 had chromosomal abnormalities (3.5%). Among the fetuses with non-isolated EIF, four had chromosomal abnormalities (4.0%). All fetuses with trisomy 21 were in the non-isolated group. The frequency of labor induction was 66.7% (6/9) among the fetuses with chromosome abnormality and 21.1% (4/19) among those with VOUS. Among those with chromosomal abnormalities, one (11.1%) had congenital heart disease.In pregnant women without high-risk factors for chromosomal abnormalities, ultrasound abnormalities, including EIF, could be an indication for CMA. Ultrasound abnormalities (including EIF) and chromosome abnormality could indicate a high risk of CHD. The presence of EIF and at least another ultrasound abnormality could indicate a high risk of trisomy 21.

Isolated single umbilical artery is an independent risk factor for perinatal mortality and adverse outcomes in term neonates

OBJECTIVE

To determine whether an isolated single umbilical artery (iSUA) is an independent risk factor for perinatal mortality in term neonates with normal estimated fetal weight (EFW) prior to delivery.

METHOD

A population-based study was conducted, including all deliveries occurring between 1993 and 2013, in a tertiary medical center. Pregnancies with and without iSUA were compared. Multiple gestations, chromosomal, and structural abnormalities were excluded from the cohort. Only pregnancies delivered at term with normal EFW evaluated prior to delivery were included. Stratified analysis was performed using multiple logistic regression models to evaluate the risk of adverse outcomes and perinatal mortality for iSUA fetuses.

RESULTS

During the study period, 233,123 deliveries occurred at "Soroka" University Medical Center, out of which 786 (0.3 %) were diagnosed with iSUA. Different pregnancy complications were more common with iSUA fetuses including: placental abruption (OR = 3.4), true knot of cord (OR = 3.5) and cord prolapse (OR = 2.8). Induction of labor and cesarean delivery were also more common in these pregnancies (OR = 1.5 and OR = 1.9, respectively). iSUA neonates had lower Apgar scores at 1 and 5 min (OR = 1.8, OR = 1.9, respectively) compared to the control group and perinatal mortality rates were higher both antenatally (IUFD, OR = 8.1) and postnatally (PPD, OR = 6.1).

CONCLUSION

iSUA appears to be an independent predictor of adverse perinatal outcomes in term neonates.

Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging (MRI) in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and MRI in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost effectiveness, and to identify research opportunities. This article is the executive summary of the workshop.

Prenatal diagnosis of musculoskeletal conditions

Ultrasonography is a safe, cost-effective tool used to prenatally detect common musculoskeletal conditions, including clubfoot, skeletal dysplasias, limb-length discrepancies, spinal abnormalities, and hand and other upper extremity deformities. With increased detection of such abnormalities, prenatal parental counseling by orthopaedic surgeons is being requested more frequently. Counseling is important for family education on prognosis and treatment options. A thorough understanding of the common musculoskeletal conditions diagnosed on prenatal ultrasonography, classification of these conditions, and the correlations of these classifications to postnatal severity allows the orthopaedic surgeon to conduct well-informed counseling sessions with families. Accurate information and counseling aids parents in understanding their child's diagnosis, assists clinicians in planning treatment algorithms, and optimizes family preparedness.

Second trimester ultrasound markers of fetal aneuploidy

Although it is widely accepted that the best time to screen for chromosomal abnormalities is the first trimester, ultrasound evaluation of the fetus in the second trimester has also been shown to be useful for this purpose. A multitude of markers of varying strength has been developed over the past 30 years. In addition, the optimal time to diagnose fetal anomalies with confidence is also the mid second trimester. Therefore, performance of obstetrical ultrasound at this point in gestation continues to be an important component of prenatal care.

Fetal imaging: Executive summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and magnetic resonance imaging in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost-effectiveness and to identify research opportunities. This article is the executive summary of the workshop.

Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging (MRI) in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and MRI in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost effectiveness, and to identify research opportunities. This article is the executive summary of the workshop.

Follow-up of sonographically detected soft markers for fetal aneuploidy

Sonographic soft markers of fetal Down syndrome were first reported in the 1980s. With improvements in aneuploidy screening, detection rates of 90% and higher are possible, and such screening is offered to women of all ages. The utility of sonographic detection and reporting of soft markers, particularly to women at low risk of fetal aneuploidy, is controversial. Some soft markers have no additional significance beyond an association with aneuploidy, while some potentially indicate other pathology, and therefore require sonographic follow-up or other evaluation. The definitions of soft markers vary among reported series, and any practice using such markers to adjust the risk of aneuploidy should carefully determine the most appropriate definitions as well as likelihood ratios and how to apply these in practice.

Echogenic focus in the fetal left ventricular cavity: is it a false tendon?

OBJECTIVE

To draw attention to the left ventricular false tendon which can be misinterpreted as echogenic focus in the fetus.

METHODS

The study group consisted of 9 fetuses out of the 161 who had been misdiagnosed for left ventricular false tendon as echogenic focus by obstetricians. Fetal echocardiography and 2-D color Doppler echocardiography were performed in the pre-postnatal period. The standard fetal echocardiographic views (4,5 chamber views, long axis view of the left ventricle, short axis view of the ventricles and great arteries, three vessels and trachea view, long axis views of the duct and aortic arch) were obtained for each case.

RESULTS

Of the 161 fetuses with echogenic focus in the left ventricle which underwent fetal echocardiography, 9 (5.6%) were diagnosed with false tendons present in the left ventricular cavity with no other cardiovascular anomaly. Six out of 9 patients underwent amniocentesis as follows: for age of over 35 years (two patients), abnormal double-triple screening tests plus echogenic focus (two patients) and soft ultrasonographic markers including echogenic focus (two patients). These fetuses revealed no cardiovascular and other systemic pathology or dysmorphism except for false tendons in the left ventricular cavity.

CONCLUSION

False tendon should be taken into account as differential diagnosis of left ventricular echogenic focus in the fetus. Misinterpretation of false tendon as echogenic focus may cause unnecessary fetal invasive approach and maternal anxiety, especially when it arises with a background of borderline fetal findings and knowledge.

Imaging clues in the prenatal diagnosis of syndromes and aneuploidy

Advances in fetal sonography and MRI have increased both the range and diagnostic accuracy of detectable fetal anomalies, with many anomalies detectable earlier in pregnancy. The presence of structural anomalies greatly raises the risk that the fetus has a syndrome or abnormal karyotype. In addition, new techniques in maternal serum screening have greatly increased the ability to identify pregnant patients at risk for anomalies and syndromes. This paper reviews maternal first- and second-trimester serum screening and imaging and covers many of the most common fetal karyotypic and structural anomalies.

Advances in prenatal screening: the ethical dimension

Prenatal screening strategies are undergoing rapid changes owing to the introduction of new testing techniques. The overall tendency is towards broadening the scope of prenatal testing through increasingly sensitive ultrasound scans and genome-wide molecular tests. In addition, non-invasive prenatal diagnosis is likely to be introduced in the near future. These developments raise important ethical questions concerning meaningful reproductive choice, the autonomy rights of future children, equity of access and the proportionality of testing.

Anterior choroid plexus cysts: distinction from germinolysis by high-resolution sonography

BACKGROUND

The aim of the present paper was to develop criteria identifying anterior choroid plexus cysts (ACPC) and distinguish these from germinolytic pseudocysts.

METHODS

Cerebral sonography was performed in 2200 neonates with mean gestational age 40 completed weeks (range 23-42 weeks) and mean birthweight of 3450 g (range 340-4610 g). In the last 300 neonates cystic formations in the caudothalamic groove were studied prospectively using a high-resolution ultrasound system with linear scanhead, and the previous results were re-evaluated.

RESULTS

In 22 neonates choroid plexus cysts outside the typical location in the choroid plexus glomus could be attributed to the anterior part of the choroid plexus in the lateral ventricles (prospectively analyzed in 16 of 300 neonates: 5% prevalence on high-resolution sonography). ACPC were located medial and behind germinolytic pseudocysts and best realized during sweep of the scanhead through the caudothalamic groove. In contrast to germinolytic pseudocysts, they had a spherical form, no septation and a thick, partial double wall. Larger cysts seemed to bounce.

CONCLUSIONS

ACPC are not rare and are identified by their location, form, and movement.

Isolated choroid plexus cyst or echogenic cardiac focus on prenatal ultrasound: is genetic amniocentesis indicated?

OBJECTIVE

The purpose of this study was to determine whether or not genetic amniocentesis is warranted when isolated choroid plexus cysts (CPC) or echogenic cardiac foci (EF) are noted on prenatal ultrasound.

STUDY DESIGN

We performed a retrospective analysis on patients from our perinatal database. All obstetric patients with CPC or EF noted on second-trimester perinatology ultrasound from April, 1998 to November, 2004 were included. Information regarding ultrasound findings and neonatal outcome were analyzed.

RESULTS

During the study period, 515 patients with CPC or EF were evaluated. Of these, 429 (83.3%) had isolated CPC or EF and 86 (16.7%) had additional risk factors. The incidence of abnormal karyotype was 0 versus 2.3%, respectively (P = .03). The additional risk factors considered were: advanced maternal age, abnormal serum triple marker screening, and/or other abnormal ultrasound findings. Furthermore, during the study period there were 20,122 live births and 27 (0.1%) cases of aneuploidy diagnosed postnatally. Of these, none had isolated CPC or EF on prenatal ultrasound.

CONCLUSION

CPC or EF noted on prenatal ultrasound warrants referral for careful consultative ultrasound evaluation. In the absence of other risk factors, however, genetic amniocentesis for isolated CPC or EF does not appear to be necessary.

Differential Diagnosis of Intracranial Cystic Lesions at Head US: Correlation with CT and MR Imaging

The differential diagnosis of intracranial cystic lesions at head ultrasonography (US) includes a broad spectrum of conditions: (a) normal variants, (b) developmental cystic lesions, (c) cysts due to perinatal injury, (d) vascular cystlike structures, (e) hemorrhagic cysts, and (f) infectious cysts. These lesions vary in prevalence from common (cavum of the septum pellucidum, subependymal cyst, choroid plexus cyst) to rare (vein of Galen malformation). US can provide important information about the anatomic location, size, and shape of the lesions as well as their mass effect on adjacent structures. Differential diagnosis may be difficult because there is substantial overlap of US features between many of these conditions. However, if careful attention is paid to the location and characteristics of the cyst, a more specific diagnosis may be suggested. Understanding the spectrum of appearances of the various intracranial cystic lesions at head US improves the diagnostic yield, enables one to understand their pathogenesis, and facilitates patient care.