First Trimester Ultrasound Diagnosis of Lethal Multiple Pterygium Syndrome

Fetal arthrogryposis: Challenges and perspectives for prenatal detection and management

Antenatal identification of fetuses with multiple congenital contractures or arthrogryposis multiplex congenita (AMC) may be challenging. The first clinical sign is often reduced fetal movement and/or contractures, as seen on prenatal ultrasounds. This can be apparent at any point, from early to late pregnancy, may range from mild to severe involvement, with or without associated other structural anomalies. Possible etiologies and their prognosis need to be interpreted with respect to developmental timing. The etiology of AMC is highly heterogeneous and making the specific diagnosis will guide prognosis, counseling and prenatal and perinatal management. Current ultrasound practice identifies only approximately 25% of individuals with arthrogryposis prenatally before 24 weeks of pregnancy in a general obstetrics care population. There are currently no studies and guidelines that address the question of when and how to assess for fetal contractures and movements during pregnancy. The failure to identify fetuses with arthrogryposis before 24 weeks of pregnancy means that physicians and families are denied reproductive options and interventions that may improve outcome. We review current practice and recommend adjusting the current prenatal imaging and genetic diagnostic strategies to achieve early prenatal detection and etiologic diagnosis. We suggest exploring options for in utero therapy to increase fetal movement for ongoing pregnancies.

Continuous fetal head flexion as a marker for prenatal diagnosis of lethal multiple pterygium syndrome: a case report

Lethal multiple pterygium syndrome (LMPS) is a fatal hereditary disease associated with abnormalities such as pterygium-induced congenital contractures. Fetal hydrops is present in more than half of all patients with LMPS, and all patients with LMPS are either stillborn or die in the early neonatal period. Ultrasonography findings for the prenatal diagnosis of LMPS include the detection of cutaneous webbing at multiple joints, multiple joint contractures, absent limb movement, and increased nuchal translucency. Here, we describe a patient who was diagnosed as having LMPS due to continuous fetal head flexion, despite the absence of the usual characteristics of the condition, including pterygium at the joints. Thus, continuous fetal head flexion can be a useful marker for prenatally diagnosing LMPS.

Three-dimensional Ultrasound in Detection of Fetal Anomalies

In the history of 3D/4D ultrasound technology, the great achievement was high definition (HD) live technology. This technology is a novel ultrasound technique that improves the 3D/4D images. HDlive ultrasound has resulted in remarkable progress in visualization of early embryos and fetuses and in the development of sonoembryology. HDlive uses an adjustable light source and software that calculates the propagation of light through surface structures in relation to the light direction. The virtual light source produces selective illumination, and the respective shadows are created by the structures where the light is reflected. This combination of light and shadows increases depth perception and produces remarkable images that are more natural than those obtained with classic three-dimensional (3D) ultrasound. The virtual light can be placed in the front, back, or lateral sides, where viewing is desired until the best image is achieved. A great advantage is that the soft can be applied to all images stored in the machine's memory. With HDlive ultrasound, both structural and functional developments can be assessed from early pregnancy more objectively and reliably and, indeed, the new technology has moved embryology from postmortem studies to the in vivo environment. Practically, in obstetrical ultrasound, HDlive could be used during all three trimesters of pregnancy.

How to cite this article

Pooh RK, Kurjak A. Three-dimensional Ultrasound in Detection of Fetal Anomalies. Donald School J Ultrasound Obstet Gynecol 2016;10(3):214-234.

Pathology of the stillborn infant for the general pathologist: part 2

As the information obtained from previable fetal and stillbirth autopsies is used not only to explain the loss to the parents, but for future pregnancy planning, general pathologists need to be comfortable in dealing with these autopsies. The importance of an adequate fetal examination has been emphasized in a recent policy on the subject by the American Board of Pathology http://www.abpath.org/FetalAutopsyPoli'cy.pdf. This second review paper covers the approach to hydrops fetalis. The approach to the nonanomalous and anomalous fetus was covered in the first part of this series.

Prenatal Diagnosis of Lethal Multiple Pterygium Syndrome Using Two-and Three-Dimensional Ultrasonography

Lethal multiple pterygium (LMP) is a series of disorders of fetal formation with a heterogeneous range of manifestations that generally include cystic hygroma, pulmonary hypoplasia, cleft palate, cryptorchidism, joint contractures, fetal akinesia, heart defects, growth restriction, and intestinal malrotation. The prenatal diagnosis of this syndrome is suspected when two-dimensional ultrasound (2DUS) scan shows several malformations.. The three-dimensional ultrasound (3DUS) in rendering mode permits the spatial visualization of these malformations, allowing better understanding of this anomaly by parents. We report a case of a fetus in the second trimester with multiple abnormalities suggestive of LMP that were identified using 2DUS, and emphasize the importance of 3DUS in counseling the parents.

Diagnosis of fetal limb abnormalities before 15 weeks: cause for concern

OBJECTIVES

The purposes of this study were (1) to identify cases of limb abnormalities identified before 15 weeks and correlate with outcomes and (2) to assess first-trimester nuchal translucency examinations to determine how frequently the upper and lower limbs were identified.

METHODS

A retrospective review was conducted of sonographic studies up to 15 weeks' gestational age from 2003 to 2010 at our high-risk fetal center. Data were collected regarding fetal gestational age, limb abnormalities, associated anatomic abnormalities, pregnancy outcomes, karyotypes, autopsy results, and the utility of transabdominal sonography, transvaginal sonography, and 3-dimensional sonography. A retrospective analysis of 100 consecutive first-trimester examinations was also conducted to assess the sensitivity of transabdominal sonography in visualization of limb buds.

RESULTS

A total of 15 cases were identified with a mean gestational age of 12 weeks 6 days. Club hand was the most common abnormality seen (8 cases), followed by absence of long bones (5 cases), a missing limb (5 cases), club foot (5 cases), shortening of long bones (2 cases), abnormal hands (2 cases), clenched hands (2 cases), and overlapping digits (1 case). Trisomy 18 was present in 9 cases. Transabdominal sonography allowed for detection of all limb buds in 100 consecutive nuchal translucency examinations and 9 of 15 cases of limb abnormalities. Four of the cases resulted in fetal death, and the remaining 11 cases were terminated.

CONCLUSIONS

Fetal limb abnormalities can be detected on sonography before 15 weeks' gestational age and are often associated with serious congenital conditions, especially trisomy 18. Transabdominal sonography alone can show most of these abnormalities, although transvaginal and 3-dimensional sonography can provide additional information. Targeted evaluation of fetal limbs during sonography before 15 weeks should be considered in high-risk populations.

Increased nuchal translucency in euploid fetuses--what should we be telling the parents?

Nuchal translucency (NT) measurement between 11 and 14 weeks' gestation is an undisputed marker for aneuploidies. When conventional karyotyping is normal, enlarged NT is a strong marker for adverse pregnancy outcome, associated with miscarriage, intrauterine death, congenital heart defects, and numerous other structural defects and genetic syndromes. The risk of adverse outcome is proportional to the degree of NT enlargement. Although the majority of structural anomalies are amenable to ultrasound detection, unspecified genetic syndromes involving developmental delay may only emerge after birth. Concern over these prenatally undetectable conditions is a heavy burden for parents. However, following detection of enlarged NT the majority of babies with normal detailed ultrasound examination and echocardiography will have an uneventful outcome with no increased risk for developmental delay when compared to the general population. Counseling should emphasize this to help parents restore hope in normal pregnancy outcome and infant development.

Recent Advances in 3D Assessment of Various Fetal Anomalies

Recent advances of ultrasound technology including 3D/4D sonography have revealed embryonal/fetal morphology, intrauterine vascularity and fetal behavior from early gestation. Modern ‘sonoembryology’ allows the definition of in vivo anatomy including visualization of dynamic features, which cannot be characterized in fixed specimens after embryonic death in embryology. Furthermore, recent highresolutional ultrasound technologies have remarkably approached accurate prenatal diagnoses with vivid and distinct sonographic depiction. Nowadays, the antenatal diagnosis is no longer ‘maybe’ nor ambiguous, owing to progressive 3D/4D ultrasound which have contributed to the field of embryology, fetal physiology and pathology.