Sonographic Findings in Fetal Viral Infections: A Systematic Review

Ultrasonographic Signs of Cytomegalovirus Infection in the Fetus-A Systematic Review of the Literature

BACKGROUND

congenital cytomegalovirus (cCMV) infection during pregnancy is a significant risk factor for fetal and neonatal morbidity and mortality. CMV detection is based on the traditional ultrasound (US) and MRI (magnetic resonance) approach.

METHODS

the present review used the PRISMA protocol for identification of studies associated with CMV infection and sonographic analysis. Various search terms were created using keywords which were used to identify references from Medline, Pubmed, PsycInfo, Scopus and Web of Science.

RESULTS

sonographic analysis of the cCMV infection identified several of the key features associated with fetuses. The presence of abnormal patterns of periventricular echogenicity, ventriculomegaly and intraparenchymal calcifications is indicative of CMV infection in the fetus. Hyperechogenic bowels were seen frequently. These results correlate well with MRI data, especially when targeted transvaginal fetal neurosonography was carried out.

CONCLUSIONS

ultrasonography is a reliable indicator of fetal anomalies, due to cCMV. Fetal brain and organ changes are conclusive indications of infection, but many of the ultrasonographic signs of fetal abnormality could be due to any viral infections; thus, further research is needed to demarcate CMV infection from others, based on the ultrasonographic approach. CMV infection should always be an indication for targeted fetal neurosonography, optimally by the transvaginal approach.

Hypoplastic left heart syndrome with prenatally diagnosed foramen ovale restriction: diagnosis, management and outcome

OBJECTIVE

Despite advances in prenatal diagnosis and postnatal intervention/surgery methods, patients with Hypoplastic Left Heart Syndrome (HLHS) and coexisting foramen oval restriction still achieve high mortality rates. Our objective was to determine survival predictors and to find answers to, why restriction develops in some, but not others.

METHODS

We performed a retrospective analysis of prenatal history and postnatal sequel of 22 patients with HLHS and foramen ovale restriction between 2008 and 2017.

RESULTS

There were 11 survivors and 11 nonsurvivors. The most significant difference between the two groups pertained to the average time of foramen ovale restriction diagnosis which was 33 weeks for survivors and 28 weeks for nonsurvivors (p = .0416) and the duration of in-utero restriction (9 versus 5 weeks, p = .0213). Twenty patients (20/22) exhibited possible signs of infection.

CONCLUSIONS

(1) Earlier development and longer presence of foramen ovale restriction in the setting of HLHS is associated with higher short-term mortality regardless of the degree of restriction. (2) Ratio of forward pulmonary vein flow to reverse flow (f/r) expressed as a velocity-time integral (VTI) is a good emergent intervention predictor, but it does not correlate with foramen ovale size and maximal velocity, nor does it influence survival rates. (3) Ultrasonographic signs of possible infection of the fetus is a potential risk factor of foramen ovale restriction development in patients with HLHS.

No. 274-Management of Varicella Infection (Chickenpox) in Pregnancy

OBJECTIVE

To review the existing data regarding varicella zoster virus infection (chickenpox) in pregnancy, interventions to reduce maternal complications and fetal infection, and antepartum and peripartum management .

METHODS

The maternal and fetal outcomes in varicella zoster infection were reviewed, as well as the benefit of the different treatment modalities in altering maternal and fetal sequelae.

EVIDENCE

Medline was searched for articles and clinical guidelines published in English between January 1970 and November 2010.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).

RECOMMENDATIONS

Performance of a Multiplex Nested Polymerase Chain Reaction in Detecting 7 Pathogens Containing DNA in Their Genomes Associated With Congenital Infections

CONTEXT.—

Infections are the leading cause of perinatal and infant mortality in low-income and low-resource countries, which have a higher prevalence of infections. Definitive diagnosis of congenital and perinatal infections is largely dependent upon the results of laboratory tests.

OBJECTIVE.—

To develop a multiplex nested polymerase chain reaction (PCR) technique for the simultaneous detection of 7 pathogens containing DNA in their genomes in suspected cases of congenital infection.

DESIGN.—

Eligible participants were pregnant women with positive immunoglobulin M antibodies raised to one of the pathogens in the prenatal serologic screening, associated or not with fetal ultrasound abnormalities or positive fetal serology. Neonates whose mothers did not attend prenatal care were included when they presented with symptomatology and laboratory parameters suggestive of infection. The detection rate of the multiplex nested PCR was compared with maternal, fetal, and neonatal serology, as well as placental immunohistochemistry and noncommercial amplifications.

RESULTS.—

Of 161 suspected cases, the multiplex nested PCR detected 60 (37.3%), whereas the tests available in hospital laboratories detected 13 of 60 (21.7%) of the cases detected by the multiplex nested PCR, demonstrating a 4.6 times higher detection rate for the multiplex nested PCR (Fisher exact test, P < .001). Positive amplifications were to Toxoplasma gondii (32 cases), cytomegalovirus (14 cases), parvovirus B19 (5 cases), and adenovirus (5 cases). In 4 cases, 2 pathogens were simultaneously detected. All types of biological matrices were suitable for amplification. Sequencing of multiplex nested PCR products confirmed the molecular findings.

CONCLUSIONS.—

The multiplex nested PCR significantly increased the number of diagnosed congenital infections. Given the scarcity of DNA recovered from amniotic fluid and some neonatal samples, this multiplex nested PCR allows the simultaneous detection of 7 pathogens associated with congenital infections in a reliable, faster, cost-effective, and more sensitive way.

Rare etiology of arthrogryposis multiplex congenita at term: congenital cytomegalovirus infection

Background

Arthrogryposis multiplex congenita is the presence of multiple congenital contractures of two or more body parts. Congenital cytomegalovirus (CMV) infection is a rare etiology of arthrogryposis.

Case presentation

We report a case of intrauterine fetal akinesia and arthrogryposis multiplex congenita delivered at term with subsequent neonatal demise. Placental pathology and autopsy revealed congenital CMV infection.

Conclusions

Evaluation for potential CMV infection is an important part of the arthrogryposis evaluation which is often missed due to lack of maternal infectious symptoms during pregnancy.

Prenatal diagnosis of premature chromatid separation/mosaic variegated aneuploidy (PCS/MVA) syndrome

Premature chromatid separation/mosaic variegated aneuploidy (PCS/MVA) syndrome is a rare genetic disorder. In this case report, we describe the prenatal diagnosis of PCS/MVA syndrome in a 24-year-old, gravida 1, para 1, woman who was referred to us in her second trimester due to fetal growth restriction and extreme microcephaly (-5.0 standard deviations). Amniocentesis and chromosomal analysis confirmed PCS in 80% of cultured fetal cells. PCS findings were positive in 9% of paternal cells and 11% of maternal cells, indicative that both were PCS carriers. Genetic analysis confirmed that the fetus carried a combined heterozygote of maternal G > A point mutation of the promoter area of the BUB1B gene and a paternal Alu sequence insertion between intron 8 and exon 9 of the BUB1B gene. As PCS/MVA syndrome is associated with the development of various malignancies in early life, prenatal diagnosis is important for effective planning of post-natal care.

Adverse Perinatal Conditions Associated With Prenatally Detected Fetal Echogenic Bowel in Nova Scotia

OBJECTIVE

This study sought to estimate the association of adverse perinatal outcomes with pregnancies complicated by fetal echogenic bowel.

METHODS

Data for pregnancies complicated with echogenic bowel identified in the second trimester were derived from the tertiary referral IWK Health Centre (Halifax, NS) Viewpoint Ultrasound Database augmented by medical chart review. The study was undertaken between 2003 and 2014. Rates of positive cytomegalovirus and toxoplasmosis infection were determined using maternal serology and amniocentesis results. Rates of intrauterine growth restriction, abnormal karyotype, cystic fibrosis, antenatal bleeding, and bowel abnormalities were also determined. Neonatal information included newborn urine culture results and postnatal genetic testing. Univariate analyses compared rates of infection with isolated echogenic bowel and echogenic bowel with other ultrasound findings, with statistical significance set at P <0.05.

RESULTS

There were 422 pregnancies identified prenatally with echogenic bowel (82% had isolated echogenic bowel). Of these, 92 (22%) had at least one of the foregoing associated abnormalities. Three percent of women had serologic test results positive for cytomegalovirus or toxoplasmosis, with <1% documented newborn infections. Cystic fibrosis and other genetic diagnoses were observed in 8%, intrauterine growth restriction in 14%, antenatal bleeding in 19%, and bowel abnormalities in 3% of the cases of echogenic bowel. Pregnancies with isolated echogenic bowel had an 80% reduction in risk for these significant outcomes, in contrast to a four- to 11-fold increased risk of specific outcomes when additional ultrasound findings were present.

CONCLUSION

An overall rate of adverse conditions of 22% with prenatally detected echogenic bowel serves to inform women and health care providers and emphasizes the importance of careful screening fetal ultrasound studies and timely referral for comprehensive assessment with findings of echogenic bowel for evaluation for associated findings.

How Does Imaging of Congenital Zika Compare with Imaging of Other TORCH Infections?

The acronym TORCH is used to refer to congenital infections, such as toxoplasmosis, other infections (such as syphillis, varicella-zoster, and parvovirus B19), cytomegalovirus, and herpes simplex virus. The classic findings in patients with TORCH infections include rash in the mother during pregnancy and ocular findings in the newborn. Zika virus has emerged as an important worldwide congenital infection. It fits well with other congenital TORCH infections since there is a rash in the mother and there are commonly ocular abnormalities in the newborn. TORCH infections are recognized to have neurologic effects, such as ventriculomegaly, intraventricular adhesions, subependymal cysts, intracerebral calcifications, and microcephaly; however, the Zika virus is intensely neurotropic. Thus, it targets neural progenitor cells, leading to a more severe spectrum of central nervous system abnormalities than is typically seen in other TORCH infections, while relatively sparing the other organ systems. In this review, nonspecific findings of congenital infections initially will be described, then individual TORCH infections will be described and compared with the imaging findings associated with congenital Zika virus infection. For the radiologist, awareness of imaging features of common congenital infections may facilitate early diagnosis and may, at times, lead to prompt initiation of therapy. Online supplemental material is available for this article.

Characterizing the Pattern of Anomalies in Congenital Zika Syndrome for Pediatric Clinicians

Importance

Zika virus infection can be prenatally passed from a pregnant woman to her fetus. There is sufficient evidence to conclude that intrauterine Zika virus infection is a cause of microcephaly and serious brain anomalies, but the full spectrum of anomalies has not been delineated. To inform pediatric clinicians who may be called on to evaluate and treat affected infants and children, we review the most recent evidence to better characterize congenital Zika syndrome.

Observations

We reviewed published reports of congenital anomalies occurring in fetuses or infants with presumed or laboratory-confirmed intrauterine Zika virus infection. We conducted a comprehensive search of the English literature using Medline and EMBASE for Zika from inception through September 30, 2016. Congenital anomalies were considered in the context of the presumed pathogenetic mechanism related to the neurotropic properties of the virus. We conclude that congenital Zika syndrome is a recognizable pattern of structural anomalies and functional disabilities secondary to central and, perhaps, peripheral nervous system damage. Although many of the components of this syndrome, such as cognitive, sensory, and motor disabilities, are shared by other congenital infections, there are 5 features that are rarely seen with other congenital infections or are unique to congenital Zika virus infection: (1) severe microcephaly with partially collapsed skull; (2) thin cerebral cortices with subcortical calcifications; (3) macular scarring and focal pigmentary retinal mottling; (4) congenital contractures; and (5) marked early hypertonia and symptoms of extrapyramidal involvement.

Conclusions and Relevance

Although the full spectrum of adverse reproductive outcomes caused by Zika virus infection is not yet determined, a distinctive phenotype-the congenital Zika syndrome-has emerged. Recognition of this phenotype by clinicians for infants and children can help ensure appropriate etiologic evaluation and comprehensive clinical investigation to define the range of anomalies in an affected infant as well as determine essential follow-up and ongoing care.

Antenatal risk factors for symptomatic congenital CMV disease following primary maternal CMV infection

OBJECTIVES

This study aimed to evaluate antenatal risk factors associated with symptomatic congenital cytomegalovirus (CMV) disease, following in utero vertical infection.

METHODS

This study included a retrospective cohort of 155 neonates with congenital CMV infection, following primary maternal CMV infection during pregnancy, and were divided to symptomatic (n=95) and asymptomatic (n=60) newborns.

RESULTS

Young maternal age (29.1±5.12 vs. 31.6±5.36 years, P=0.005), high risk occupation for viral exposure (20.0% vs. 11.7%, P=0.04), CMV IgG seroconversion at diagnosis (83.1% vs. 63.3%, P=0.005) and abnormal fetal MRI (11.6% vs. 0%, P=0.003) were found to be prognostic risk factors associated with symptomatic CMV disease of the newborn. Maternal febrile illness at diagnosis, IgG avidity, US findings and the timing of maternal infection were not associated with the occurrence of neonatal symptoms.

CONCLUSIONS

Knowledge of the reported risk factors may assist in counseling parents with intra uterine CMV infection.

Fetal cardiac biometry and function in HIV-infected pregnant women exposed to HAART therapy

OBJECTIVE

Previous studies have suggested that antiretroviral therapy in human immunodeficiency virus (HIV)-infected pregnant women can cause alterations in cardiac structure and function in fetuses or children, although the results are not very clear. The aim of this study is to assess whether or not these alterations are present in the heart of fetuses of HIV-infected pregnant women, undergoing treatment with highly active antiretroviral therapy (HAART).

STUDY DESIGN

We performed a prospective study on 29 consecutive HIV-positive pregnant women treated with HAART and 70 consecutive HIV-negative pregnant women as controls. Fetal cardiac biometry and function was evaluated by echocardiography at 30-32 weeks of gestation. Fetal biometry, estimated fetal weight and umbilical artery Doppler were also measured.

RESULTS

We found E/A tricuspid ratio values slightly increased (0.84 vs 0.80, p = 0.03) and diastolic length shortened (49.7 vs 51.7%, p = 0.03) in the HIV-infected group. The rest of the biometric and functional cardiac parameters were not different between both groups. There were no cases of vertical transmission of HIV infection.

CONCLUSION

In HIV-infected pregnant women treated with HAART, no significant changes are showed in fetal cardiac parameters.

Placental Volumetry by 2-D Sonography with a New Mathematical Formula: Prospective Study on the Shell of a Spherical Sector Model

The aim of this study was to determine the utility of a new mathematical model in volumetric assessment of the placenta using 2-D ultrasound. Placental volumetry was performed in a prospective cross-sectional survey by virtual organ computer-aided analysis (VOCAL) with the help of a shell-off method in 346 uncomplicated pregnancies according to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. Furthermore, placental thickness, length and height were measured with the 2-D technique to estimate placental volume based on the mathematical formula for the volume of "the shell of the spherical sector." Fetal size was also assessed by 2-D sonography. The placental volumes measured by 2-D and 3-D techniques had a correlation of 0.86. In the first trimester, the correlation was 0.82, and later during pregnancy, it was 0.86. Placental volumetry using "the circle-shaped shell of the spherical sector" mathematical model with 2-D ultrasound technique may be introduced into everyday practice to screen for placental volume deviations associated with adverse pregnancy outcome.

Prenatal isolated mild ventriculomegaly is associated with persistent ventricle enlargement at ages 1 and 2

BACKGROUND

Enlargement of the lateral ventricles is thought to originate from abnormal prenatal brain development and is associated with neurodevelopmental disorders. Fetal isolated mild ventriculomegaly (MVM) is associated with the enlargement of lateral ventricle volumes in the neonatal period and developmental delays in early childhood. However, little is known about postnatal brain development in these children.

METHODS

Twenty-eight children with fetal isolated MVM and 56 matched controls were followed at ages 1 and 2 years with structural imaging on a 3T Siemens scanner and assessment of cognitive development with the Mullen Scales of Early Learning. Lateral ventricle, total gray and white matter volumes, and Mullen cognitive composite scores and subscale scores were compared between groups.

RESULTS

Compared to controls, children with prenatal isolated MVM had significantly larger lateral ventricle volumes at ages 1 and 2 years. Lateral ventricle volume at 1 and 2 years of age was significantly correlated with prenatal ventricle size. Enlargement of the lateral ventricles was associated with increased intracranial volumes and increased gray and white matter volumes. Children with MVM had Mullen composite scores similar to controls, although there was evidence of delay in fine motor and expressive language skills.

CONCLUSIONS

Children with prenatal MVM have persistent enlargement of the lateral ventricles through the age of 2 years; this enlargement is associated with increased gray and white matter volumes and some evidence of delay in fine motor and expressive language development. Further study is needed to determine if enlarged lateral ventricles are associated with increased risk for neurodevelopmental disorders.

Management of varicella infection (chickenpox) in pregnancy

OBJECTIVE

To review the existing data regarding varicella zoster virus infection (chickenpox) in pregnancy, interventions to reduce maternal complications and fetal infection, and antepartum and peripartum management.

METHODS

The maternal and fetal outcomes in varicella zoster infection were reviewed, as well as the benefit of the different treatment modalities in altering maternal and fetal sequelae.

EVIDENCE

Medline was searched for articles and clinical guidelines published in English between January 1970 and November 2010.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).

RECOMMENDATIONS

1. Varicella immunization is recommended for all non-immune women as part of pre-pregnancy and postpartum care. (II-3B) 2. Varicella vaccination should not be administered in pregnancy. However, termination of pregnancy should not be advised because of inadvertent vaccination during pregnancy. (II-3D) 3. The antenatal varicella immunity status of all pregnant women should be documented by history of previous infection, varicella vaccination, or varicella zoster immunoglobulin G serology. (III-C) 4. All non-immune pregnant women should be informed of the risk of varicella infection to themselves and their fetuses. They should be instructed to seek medical help following any contact with a person who may have been contagious. (II-3B) 5. In the case of a possible exposure to varicella in a pregnant woman with unknown immune status, serum testing should be performed. If the serum results are negative or unavailable within 96 hours from exposure, varicella zoster immunoglobulin should be administered. (III-C) 6. Women who develop varicella infection in pregnancy need to be made aware of the potential adverse maternal and fetal sequelae, the risk of transmission to the fetus, and the options available for prenatal diagnosis. (II-3C) 7. Detailed ultrasound and appropriate follow-up is recommended for all women who develop varicella in pregnancy to screen for fetal consequences of infection. (III-B) 8. Women with significant (e.g., pneumonitis) varicella infection in pregnancy should be treated with oral antiviral agents (e.g., acyclovir 800 mg 5 times daily). In cases of progression to varicella pneumonitis, maternal admission to hospital should be seriously considered. Intravenous acyclovir can be considered for severe complications in pregnancy (oral forms have poor bioavailability). The dose is usually 10 to 15 mg/kg of BW or 500 mg/m² IV every 8 h for 5 to 10 days for varicella pneumonitis, and it should be started within 24 to 72 h of the onset of rash. (III-C) 9. Neonatal health care providers should be informed of peripartum varicella exposure in order to optimize early neonatal care with varicella zoster immunoglobulin and immunization. (III-C) Varicella zoster immunoglobulin should be administered to neonates whenever the onset of maternal disease is between 5 days before and 2 days after delivery. (III-C).

Prenatal neurologic anomalies: sonographic diagnosis and treatment

The low prevalence of fetal CNS anomalies results in a restricted level of exposure to, and limited experience for most obstetricians involved in, prenatal ultrasound. Sonographic guidelines for screening the fetal brain in a systematic way may increase the detection rate of fetal CNS anomalies, thus promoting correct referral to tertiary care centers offering patients a multidisciplinary approach to the condition. The aim of this review is to elaborate on the prenatal sonographic diagnosis and outcome of various CNS malformations. Detailed neurosonographic investigation has become available through high-resolution vaginal ultrasound probes and the development of a variety of 3-dimensional (3D) ultrasound modalities, such as ultrasound tomographic imaging. In addition, fetal magnetic resonance imaging is particularly helpful in the detection of gyration and neurulation anomalies, and disorders of the gray and white matter. Isolated mild ventriculomegaly is a rather common finding with good overall outcome. With an increasing diameter of the atria, however, and especially with the presence of associated malformations, long-term neurodevelopmental and behavioral outcome is disturbed in about 15% or more of cases. In view of recent developments in fetal therapy for neural tube defects, there is a clear need for a high level of ultrasound screening, work-up and counseling in tertiary care centers to identify those cases that might benefit from in utero intervention. The failure of prosencephalic midline induction and development results in midline defects ranging from alobar holoprosencephaly to isolated corpus callosum defects. The detection of callosal abnormaties is enhanced by 3D ultrasound, but counseling on neurodevelopmental outcome remains challenging. The Dandy-Walker spectrum includes isolated megacisterna magna, Blake's pouch cyst, hypoplasia of the vermis and Dandy-Walker malformation. Except for complete agenesis of the vermis associated with fourth ventricle cyst formation, data on long-term outcomes for the various conditions is largely lacking. Congenital cytomegalovirus (CMV) results in the highest incidence of children born with, or developing, long-term neurologic conditions. If proof of fetal infection has been delivered, microcephaly, cortical malformations, and intraparenchymal cysts show a strong correlation with poor outcome. Fetuses with CMV-related ultrasound abnormalities might benefit from maternal transplacental treatment. The aneurysm of the vein of Galen, a vascular malformation of the brain, often results in high cardiac output failure. After neonatal arterial embolization, survival is about 50% with normal neurologic development in 36% of cases. Over 50% of intracranial tumors are teratomata, presenting as fast-growing heterogeneous solid-cystic masses with calcifications. Most intracranial hemorrhages are related to the ventricular system, and prognosis is often poor, particularly in cases involving parenchymal and subdural bleeding. Proliferation disorders of the brain are often characterized by microcephaly. Their etiology is heterogeneous and prenatal diagnosis is often made late in gestation.

Perinatal outcomes of fetal echogenic bowel

OBJECTIVE

To investigate perinatal outcomes of fetal echogenic bowel (FEB).

METHOD

This is a retrospective observational study of FEB cases from Jan 2005-Dec 2010. Data from ultrasound and fetal medicine investigations, uterine artery Doppler (UAD), intra-partum care and neonatal outcome were obtained from Fetal Medicine, Obstetric and Neonatal Databases.

RESULTS

There were 139 cases presenting at 21(+5) (15(+1) -35(+5) ) weeks gestation. Overall, 106/139 (76.2%) were live born (LB), 8/139 (5.8%) were complicated by intra-uterine deaths (IUD), 11/139 (7.9%) had termination of pregnancy (TOP) and 14/139 (10.1%) were lost to follow-up after 28 weeks gestation. Six had chromosomal/genetic abnormalities, two had congenital cytomegalovirus, none had cystic fibrosis.Uterine artery Doppler was normal in 106/130 (81.5%) cases. In this group, there were no cases of fetal growth restriction (FGR), 95/106 (89.6%) were LB, 1/106 (0.94%) had an IUD. In the abnormal UAD group, 17/24 (70.1%) developed FGR, 11/24 (45.8%) were LB, 4/24 (16.7%) had TOP, 7/24 (29.2%) had IUD.In total, 20/106 (18.9%) live births were admitted for specialist neonatal care, 12/20 (60%) for prematurity. Only one had primary bowel pathology.

CONCLUSION

Pregnancies with FEB and screen positive UAD are at risk of adverse perinatal outcome. Primary bowel pathology is rare following the finding of FEB.

Prenatal sonographic diagnosis of congenital varicella syndrome

Congenital varicella syndrome is a rare disorder occurring in less than 1% of maternal varicella during early pregnancy but is associated with high fetal morbidity and mortality. This case report aimed to describe the sonographic features of congenital varicella syndrome following maternal varicella. Well-documented maternal chicken pox was made at 12 weeks of gestation and prenatal ultrasound was performed at 16 weeks. Striking sonographic features included hydropic changes and disseminated calcifications in multiple organs, especially liver and myocardium. Elective termination of pregnancy was done at 17 weeks. The presence of disseminated calcifications could suggest the diagnosis of congenital varicella syndrome.

When are amniotic fluid viral PCR studies indicated in prenatal diagnosis?

OBJECTIVE

To determine which prenatal ultrasound findings indicate the need to also obtain PCR studies for viral genome in women undergoing midtrimester amniocentesis.

METHODS

This was a retrospective observational study on women that underwent amniotic fluid karyotyping and viral PCR testing for history or ultrasound based indication. Amniotic fluid was tested for adenovirus, cytomegalovirus, respiratory syncytial virus, enterovirus, Epstein-Barr virus, and parvovirus B19 using multiplex PCR study with multiple appropriate controls. Ultrasound findings were coded as normal or abnormal with 34 categories of ultrasound abnormality stratified into 18 subgroups. Relationships between these subgroups and karyotype/PCR results were tested by Pearson chi-square method or Fisher's exact test and overall logistic regression analysis.

RESULTS

Amniotic fluid samples from 1191 patients were obtained for the study. Abnormal karyotype was detected in 5.4% of cases (64/1191), and PCR was positive in 6.5% of cases (77/1191). Abnormal fetal ultrasonographic findings were observed in 28.4% of cases (338/1191). There was an association between intrauterine growth restriction, nonimmune hydrops fetalis, hand/foot anomalies or neural tube defects (NTDs), and PCR positivity. NTDs were associated with PCR positivity in fetuses with normal karyotype and nuchal thickening, cardiac or ventral wall defects were specifically associated with aneuploidy.

CONCLUSION

Amniotic fluid viral PCR testing should be considered for fetuses with intrauterine growth restriction, nonimmune hydrops fetalis, hand/foot anomalies, or NTDs. After aneuploidy is excluded, NTDs are associated with PCR positivity.

Fetal outcome and amniocentesis results in pregnancies complicated by varicella infection

OBJECTIVE

To evaluate the outcome of infants born to mothers with varicella zoster virus (VZV) infection in pregnancy who had second trimester amniocentesis for detection of placental transfer.

METHODS

We interviewed women who had had VZV infection in pregnancy and who underwent diagnostic amniocentesis to detect transplacental infection using both polymerase chain reaction (PCR) and cell culture methods to characterize their children's clinical and psychomotor development.

RESULTS

Twenty women who had a diagnosis of primary VZV during pregnancy were available for interview. The mean gestational age at which primary VZV was acquired was 11±3.5 weeks. One infant had hypospadias and developmental delay. He was born to an epileptic mother who had been treated during pregnancy with sodium valproate and clonazepam. Another infant had abnormal brainstem auditory-evoked potentials. All other infants were reported to have normal clinical and psychomotor development.

CONCLUSION

In cases of varicella infection during pregnancy, negative studies of amniotic fluid using PCR may contribute to decision making.

[Arguments for an infectious cause of IUGR]

Intra-uterine growth retardation (IUGR) is a frequent cause of consultation in antenatal care unit. The prognosis relies on the etiology: vascular, chromosomic, genetic, or infectious. Because of chronic fetal distress, hypotrophy increase morbidity, mortality and neurosensorial long term effect. Usually, infection is involved in 5 to 15% of the IUGR, mainly by Cytomegalovirus (CMV), Varicella Zoster virus, rubella, toxoplasmosis, herpes and syphilis. Maternal sera and amniotic liquid analysis make the diagnosis possible but fetal ultrasound scan is used to find other features. Most of the abnormalities are unspecific but their combination can worsen fetal prognosis. Infection should always be ruled out in the assessment of IUGR.

Is routine TORCH screening and urine CMV culture warranted in small for gestational age neonates?

BACKGROUND

congenital infections are associated with a wide variety of clinical symptoms, including small for gestational age (SGA).

AIMS

to determine the co-occurrence of SGA and congenital TORCH infections, as diagnosed by TORCH serologic tests and/or cytomegalovirus (CMV) urine culture.

STUDY DESIGN

we performed a retrospective study of all neonates admitted to our neonatal intensive care unit from January 2004 to February 2010 in whom SGA was diagnosed and TORCH serologic tests and/or CMV urine cultures were performed.

RESULTS

TORCH serologic tests (in neonatal or maternal serum) and/or a CMV urine culture were performed in 112 neonates with SGA. None of the neonates tested positive for Toxoplasma gondii, Rubella, and Herpes simplex virus. Positive CMV urine culture was detected in 2% (2/112) of neonates, but their CMV IgM titers were negative.

CONCLUSIONS

the co-occurrence of TORCH congenital infection in infants with SGA is rare. Routine TORCH screening in neonates with isolated SGA does not seem warranted and should be limited to CMV urine cultures.

Microcephaly: a radiological review

Microcephaly results from inadequate brain growth during development. It may develop in utero, and therefore be present at birth, or may develop later as a result of perinatal events or postnatal conditions. The aetiology of microcephaly may be congenital (secondary to cerebral malformations or metabolic abnormalities) or acquired, most frequently following an ischaemic insult. This distinct radiological and pathological entity is reviewed with a specific focus on aetiology.

Viruses and other infections in stillbirth: what is the evidence and what should we be doing?

In Australia, as in other developed countries, approximately 40-50% of stillbirths are of unknown aetiology. Emerging evidence suggests stillbirths are often multifactorial. The absence of a known cause leads to uncertainty regarding the risk of recurrence, which can cause extreme anguish for parents that may manifest as guilt, anger or bewilderment. Further, clinical endeavours to prevent recurrences in future pregnancies are impaired by lack of a defined aetiology. Therefore, efforts to provide an aetiological diagnosis of stillbirth impact upon all aspects of care of the mother, and inform many parts of clinical decision making. Despite the magnitude of the problem, that is 7 stillbirths per 1000 births in Australia, diagnostic efforts to discover viral aetiologies are often minimal. Viruses and other difficult to culture organisms have been postulated as the aetiology of a number of obstetric and paediatric conditions of unknown cause, including stillbirth. Reasons forwarded for testing stillbirth cases for infectious agents are non-medical factors, including addressing all parents' need for diagnostic closure, identifying infectious agents as a sporadic cause of stillbirth to reassure parents and clinicians regarding risk for future pregnancies, and to reduce unnecessary testing. It is clear that viral agents including rubella, human cytomegalovirus (CMV), parvovirus B19, herpes simplex virus (HSV), lymphocytic choriomeningitis virus (LCMV), and varicella zoster virus (VZV) may cause intrauterine deaths. Evidence for many other agents is that minimal or asymptomatic infections also occur, so improved markers of adverse outcomes are needed. The role of other viruses and difficult-to-culture organisms in stillbirth is uncertain, and needs more research. However, testing stillborn babies for some viral agents remains a useful adjunct to histopathological and other examinations at autopsy. Modern molecular techniques such as multiplex PCR, allow searches for multiple agents. Now that such testing is available, it is important to assess the clinical usefulness of such testing.

Ultrasound of the placenta: a systematic approach. Part I: Imaging

Diagnostic ultrasound has been in use in clinical obstetrics for close to half-a-century. However, in the literature, examination of the placenta appears to be treated with less attention than the fetus or the pregnant uterus. This is somewhat unexpected, given the obvious major functions this organ performs during the entire pregnancy. Examination of the placenta plays a foremost role in the assessment of normal and abnormal pregnancies. A methodical sonographic evaluation of the placenta should include: location, visual estimation of the size (and, if appearing abnormal, measurement of thickness and/or volume), implantation, morphology, anatomy, as well as a search for anomalies, such as additional lobes and tumors. Additional assessment for multiple gestations consists of examining the intervening membranes (if present). The current review considers the various placental characteristics, as they can be evaluated by ultrasound, and the clinical significance of abnormalities of these features. Numerous and varied pathologies of the placenta can be detected by routine ultrasound. It is incumbent on the clinician performing obstetrical ultrasound to examine the placenta in details and in a methodical fashion because of the far reaching clinical significance and potentially avoidable severe consequences of many of these abnormalities.

In utero imaging of the placenta: importance for diseases of pregnancy

Maurice Panigel demonstrated by X-rays, almost 40 years ago, placental maternal blood jets in non-human primates. Although to researchers the importance of the placenta is evident, in clinical obstetrical imaging, the fetus takes precedence. The placenta is imaged almost as an after thought and mostly to determine its location in the uterus. In animal species, the placenta was imaged with techniques which would be considered too invasive (or too costly for routine use) in humans, many pioneered by Panigel: radioangiography, radioisotopes scintigraphy, thermography, magnetic resonance imaging (MRI) and spectroscopy, positive emission tomography (PET) and single photon emission computed tomography (SPECT). Ultrasound allows for detailed, and, as far as is known, safe analyses of not only placental structure in the human but also its function. Earlier, only 2-dimensional grey-scale was available and more than 20 years ago, placental grading was popular. Later, colour imaging and spectral Doppler analysis of blood velocity both in the umbilical artery and within the placenta as well as the uterus and fetal vessels became essential and, more recently, the use of ultrasound contrast agents has been described, albeit not yet in a clinical setting. Three-dimensional ultrasound permits evaluation of the placenta in several planes, more precise depiction of internal vasculature as well as more accurate volume assessment. Several medical disorders of the pregnant woman or her fetus begin or end in the placenta, and ultrasound is the optimal investigation method. Obvious examples include pre-eclampsia and other forms of hypertension in pregnancy, less than optimal fetal growth (i.e. intrauterine growth restriction), triploidy (and its placental manifestation: partial mole), non-immune hydrops as well as several infectious processes. Ultrasound is also particularly suited to evaluate specific placental conditions, such as abnormal placentation (placenta previa and accrete for instance), gestational trophoblastic disease and placental tumors (e.g. chorioangioma).