Findings and differential diagnosis of fetal intracranial haemorrhage and fetal ischaemic brain injury: what is the role of fetal MRI?

Anatomic Approach to Fetal Hydrocephalus

Hydrocephalus is an imprecise term and refers to the imbalance of brain parenchyma and cerebral spinal fluid in the cranial vault. Ventriculomegaly, or enlargement of the ventricular system, is often the more precise term and is therefore preferred. Appropriate imaging and measurement techniques are critical to detect ventriculomegaly and grade its severity. There is a broad differential diagnosis with resultant highly variable clinical outcomes. Furthermore, some causes have a substantial recurrence risk in future pregnancies. Therefore, accurate diagnosis of the underlying cause is essential for pregnancy management and patient counseling. Understanding ventricular anatomy and correct measurement technique is needed for assessing and grading ventriculomegaly. This is achieved through an anatomically based approach to reach the differential diagnosis, with a focus on key decision points for delineating causes of ventriculomegaly. In particular, the posterior fossa is first assessed for structural or developmental abnormalities; then, midline brain development abnormalities and associated pathologic conditions are reviewed; and last, the cortical mantle is assessed for developmental or destructive processes. In each category, different entities are highlighted, with a particular focus on illustrating the US and MRI findings of the underlying condition and tips to differentiate similar-appearing entities. Ultimately, the informed fetal radiologist can use the proposed algorithmic approach to hydrocephalus to narrow the differential and thus provide vital diagnostic information for pregnancy counseling and management discussions. ©RSNA, 2025.

Communicating neurological prognosis in the prenatal period: a narrative review and practice guidelines

Clinicians may face an array of challenges in conducting fetal neurological consultations including prognostic uncertainty, a lack of training in fetal counseling, and limited opportunity to build rapport with families. In this setting, it is critical to employ high-quality, family-centered care to allow expectant parents to make informed decisions. Despite the challenges and gravity of these consultations, there remains limited data outlining best conduct and communication practices. This narrative review aims to summarize relevant literature around counseling within fetal neurology, focusing on three key themes: (1) discussing neurological prognosis and uncertainty, (2) navigating evolving decision making, (3) recognizing bias and understanding patient context. We provide practical recommendations to clinicians conducting fetal neurological counseling and outline future research priorities. IMPACT: Fetal neurological conditions can have a significant impact on child short- and long-term health outcomes. Prenatal consultations are an important venue to discuss information regarding fetal prognosis and decision making with expectant parents. However, there is limited evidence supporting best communication practices within this setting. This review summarizes current literature around expectant parent prognostic communication preferences and outlines practical recommendations and priorities for future research.

Intracranial hemorrhage and additional anomalies detected on prenatal magnetic resonance imaging: A large, retrospective study in two tertiary medical institutions

Objectives

To clarify the prenatal magnetic resonance (MR) imaging characteristics of fetal intracranial haemorrhages (ICHs) in a large cohort and correlate them with birth outcomes.

Methods

We retrospectively reviewed MR images of fetuses with ICH on screening ultrasound (US) on picture archiving communication system (PACS) servers within a nearly ten-year period from two medical tertiary centres. The indications, main abnormal findings and coexistent anomalies were recorded by two experienced radiologists with census readings.

Results

We recruited 126 cases (average gestational week, 28.0 ± 5.0 weeks) with prenatal MR imaging, including 116 singleton pregnancies and 10 monochromic twin pregnancies. Predominant coexistent anomalies were ventriculomegaly (35.7 %), holoprosencephaly or porencephaly (13.4 %) and enlarged posterior fossa/or posterior fossa cyst (8.7 %) in the lesion-based evaluation. The number of haemorrhagic lesions and the occurrence of the detected complications did not show a correlation with the size of the haematoma. The mass effect of ICH was more commonly observed in the fetus with large for gestational age (GA) than that with small for GA.

Conclusions

Prenatal MR imaging could better show ICH morphology and associated abnormal findings. As a complementary tool of US, MR imaging could help with prenatal counselling and treatment selection after birth.

Fetal intracranial hemorrhage and infarct: Main sonographic and MRI characteristics: A review article

Early detection of fetal intracranial hemorrhage and infarct during pregnancy is crucial for preventing lethal and debilitating complications in neonatal life. Every radiologist must be aware of the imaging features of these conditions to refer patients to specialists. Sonographic and MRI features of fetal intracranial hemorrhage and infarct have been discussed in many previous articles. The aim of this article is to organize and categorize these findings into a practical guideline for improved application in diagnosing these diseases. The use of MRI sequences, such as DWI and multiplanar EPI should be developed for suspected prenatal infarct and intracranial hemorrhage and can serve as additional tools for early detection. In this review article, we first explain possible etiologic factors contributing to the development of fetal IVH and infarct. Then we discuss the different imaging features of these disorders on sonography and MRI separately, as well as their differential diagnosis. Finally, the mortality and morbidity associated with these two concerning fetal abnormalities will be addressed.

Revisiting the Pathophysiology of Intracranial Hemorrhage in Fetuses with Chiari II Malformation: Novel Imaging Biomarkers of Disease Severity?

BACKGROUND AND PURPOSE

Intracranial hemorrhage (ICH) has emerged as a notable concern in Chiari II malformation (CM II), yet its origins and clinical implications remain elusive. This study aims to validate the in utero prevalence of ICH in CM II and investigate contributing factors, and visualize the findings in a network format.

MATERIALS AND METHODS

A single-center retrospective review of fetal MRI scans obtained in fetuses with CM II (presenting January 2007 to December 2022) was performed for ICH utilizing EPI-T2* blood-sensitive sequence. Fetuses with aqueduct stenosis (AS) were included as a control group. The incidence of ICH and corresponding gestational ages were compared between CM II and AS cases, and morphometric measurements (inner/outer CSF spaces, posterior fossa, venous structure) were compared among the 4 1:1 age-matched groups: CM II+ICH, CM II-ICH, AS+ICH, and AS-ICH. Additionally, a co-occurrence network was constructed to visualize associations between phenotypic features in ICH cases.

RESULTS

A total of 101 fetuses with CM II and 90 controls with AS at a median gestational age of 24.4 weeks and 22.8 weeks (P = .138) were included. Prevalence of ICH in fetuses with CM II was higher compared with the AS cases (28.7% versus 18.9%, P = .023), accompanied by congested veins (deep vein congestion mainly in young fetuses, and cortical veins may also be affected in older fetuses). ICH was notably correlated with specific anatomic features, essentially characterized by reduced outer CSF spaces and clivus-supraocciput angle. The co-occurrence network analysis reveals complex connections including bony defects, small posterior fossa dimensions, vermis ectopia, reduced CSF spaces, as well as venous congestion and venous sinus stenosis as pivotal components within the network.

CONCLUSIONS

The high prevalence of ICH-detected by fetal MRI-among fetuses with CM emphasizes the pathophysiologic importance of venous congestion, ICH, and vasogenic edema. As indicators of disease severity, these features may serve as helpful additional imaging biomarkers for the identification of potential candidates for fetal surgery.

Prenatal sonographic diagnosis and postnatal outcomes of fetal intracranial hemorrhage: Two case report

Intracranial hemorrhage (ICH) in pregnancy, estimated at 1 in 10,000 cases, presents significant diagnostic challenges prenatally despite advanced imaging techniques such as ultrasonography (US) and magnetic resonance imaging (MRI). Detecting ICH is crucial for pregnancy management and future treatment decisions aimed at improving fetal survival and reducing brain damage. This report presents the diagnosis and outcomes of 2 cases of prenatal ICH. The first case involves a 30-year-old pregnant woman with irregular prenatal care diagnosed with ICH at 32 weeks of gestation via US and MRI. She chose to continue the pregnancy, delivering a 3160 g male infant at 36 weeks via cesarean section. Following NICU care including resuscitation and ventriculoperitoneal shunt placement, the infant was discharged. Subsequent examinations showed a reduction in ventricle size. In the second case, a 27-year-old woman taking acenocoumarol for a mechanical heart valve developed fetal subdural hemorrhage detected by US and MRI. She opted to terminate the pregnancy, resulting in a stillborn male infant weighing 1530 g. Fetal ICH presents with varying severity and prognostic implications, diagnosed and graded using US. Fetal cranial MRI may help clarify the etiology. Management remains controversial, with termination of pregnancy potentially warranted in severe cases due to poor prognosis. Further research is needed to refine management and improve outcomes in fetal ICH.

Prenatal diagnosis and postnatal outcome of fetal intracranial hemorrhage: a single-center experience

OBJECTIVE

To assess prenatal ultrasonographic findings and postnatal outcomes in fetuses with intracranial hemorrhage (ICH).

METHODS

This retrospective study included fetuses prenatally diagnosed with ICH between December 2012 and August 2023. Maternal characteristics, prenatal ultrasonographic findings, and postnatal outcomes were reviewed.

RESULTS

Twenty-seven fetuses with ICH were reviewed. Intracranial hemorrhage was classified as grade 3 and 4 in 24 fetuses. Twenty-two fetuses had ICH, four had ICH with subdural hemorrhage, and one had ICH with subarachnoid hemorrhage. Ventriculomegaly was the most common ultrasonographic finding, and was observed in 22 of the 27 (81.5%) fetuses. Seven fetuses were lost to follow-up, and four intrauterine fetal deaths occurred. The remaining 16 fetuses were delivered at a median gestational age of 35+2 weeks. The infants were followed-up for 40.1 months (range, 4-88). Nine of the 16 infants underwent ventriculoperitoneal placement. One infant underwent brain surgery for severe epilepsy. Motor impairment, including cerebral palsy, was observed in 13 infants (81.2%). Neurologic impairment occurred in six infants (37.5%), developmental delay in nine (56.2%), and epilepsy in 11 (68.7%).

CONCLUSION

Fetal ICH is a rare complication diagnosed during pregnancy, which results in subsequent fetal neurological sequelae or death. This study demonstrated that the common ultrasonographic findings in fetal ICH were progressive ventriculomegaly and increased periventricular echogenicity. Fetuses diagnosed with prenatal ICH, especially those affected by higher-grade ICH, may be at an increased risk of long-term neurodevelopmental problems.

The association between fetal intracranial hemorrhages detected on MRI and neurodevelopment

PURPOSE

Fetal intracranial hemorrhage is rarely identified in prenatal imaging. When identified, sparse data regarding neurodevelopmental outcomes worsens prenatal dilemmas. This MRI-based study aimed to assess prenatal characteristics and neurodevelopmental outcomes of fetal intracranial hemorrhage.

METHODS

A historical cohort study which identified fetal intracranial hemorrhage in 22 individual fetal MRI scans, as part of the assessment of abnormal prenatal sonographic findings. Severity was graded by the grading system commonly used in neonates, with modifications. Prenatal data was collected. Neurodevelopmental outcome was assessed clinically by Vineland-II Adaptive Behavior Scales.

RESULTS

Eight fetuses had intraventricular hemorrhage grade I-II, twelve had intraventricular hemorrhage grade III-IV, and two had infratentorial hemorrhage. The most prevalent risk factors were maternal chronic diseases and chronic use of medications. There was male predominance. Pregnancy was terminated in eleven cases. No surviving child who participated in the Vineland assessment had a grade IV hemorrhage. Vineland scores were normal in 9/11 children and moderately low in 2/11. The mean composite score of the cohort was not different from the mean score expected for age. Clinically, one child had hypotonia.

CONCLUSIONS

Prognosis for fetuses with ICH without parenchymal involvement is potentially more favorable than expected from the intraventricular hemorrhage grading-scale adopted from the preterm neonates. Parenchymal involvement may predict a worse outcome, but it is not the sole predicting feature. This information may be valuable during prenatal counseling.

Rare cause of jaundice in a term newborn

Neonatal jaundice is a frequently observed occurrence in full-term newborns and typically manifests between 48 and 96 hours following birth. Early-onset jaundice is primarily induced by pathological factors, namely sepsis, hemolysis and an excessive accumulation of bilirubin resulting from the breakdown of red blood cells.We present a case involving a full-term newborn with an uneventful perinatal history, who exhibited jaundice within the initial day of life and was subsequently admitted to the neonatal intensive care unit to commence intensive phototherapy. Initial screenings for sepsis and blood group incompatibility yielded negative results. However, despite 6 hours of phototherapy, the bilirubin levels did not decrease, prompting an investigation into central nervous system haemorrhage, which uncovered the presence of a haemorrhagic stroke.After a worsening in neurological status with neonatal crisis and need for phenobarbital, a life-saving craniotomy was performed. Clinical evolution was good with no additional crisis detected after the early neonatal period and improvement in motor function at 2-month-old follow-up.

Longitudinal MRI in the context of in utero surgery for open spina bifida: A descriptive study

INTRODUCTION

Fetal surgery for open spina bifida (OSB) requires comprehensive preoperative assessment using imaging for appropriate patient selection and to evaluate postoperative efficacy and complications. We explored patient access and conduct of fetal magnetic resonance imaging (MRI) for prenatal assessment of OSB patients eligible for fetal surgery. We compared imaging acquisition and reporting to the International Society of Ultrasound in Obstetrics and Gynecology MRI performance guidelines.

MATERIAL AND METHODS

We surveyed access to fetal MRI for OSB in referring fetal medicine units (FMUs) in the UK and Ireland, and two NHS England specialist commissioned fetal surgery centers (FSCs) at University College London Hospital, and University Hospitals KU Leuven Belgium. To study MRI acquisition protocols, we retrospectively analyzed fetal MRI images before and after fetal surgery for OSB.

RESULTS

MRI for fetal OSB was accessible with appropriate specialists available to supervise, perform, and report scans. The average time to arrange a fetal MRI appointment from request was 4 ± 3 days (range, 0-10), the average scan time available was 37 ± 16 min (range, 20-80 min), with 15 ± 11 min (range, 0-30 min) extra time to repeat sequences as required. Specific MRI acquisition protocols, and MRI reporting templates were available in only 32% and 18% of units, respectively. Satisfactory T2-weighted (T2W) brain imaging acquired in three orthogonal planes was achieved preoperatively in all centers, and 6 weeks postoperatively in 96% of FSCs and 78% of referring FMUs. However, for T2W spine image acquisition referring FMUs were less able to provide three orthogonal planes presurgery (98% FSC vs. 50% FMU, p < 0.001), and 6 weeks post-surgery (100% FSC vs. 48% FMU, p < 0.001). Other standard imaging recommendations such as T1-weighted (T1W), gradient echo (GE) or echoplanar fetal brain and spine imaging in one or two orthogonal planes were more likely available in FSCs compared to FMUs pre- and post-surgery (p < 0.001).

CONCLUSIONS

There was timely access to supervised MRI for OSB fetal surgery assessment. However, the provision of images of the fetal brain and spine in sufficient orthogonal planes, which are required for determining eligibility and to determine the reversal of hindbrain herniation after fetal surgery, were less frequently acquired. Our evidence suggests the need for specific guidance in relation to fetal MRI for OSB. We propose an example guidance for MRI acquisition and reporting.

Postmortem diagnosis of severe factor X deficiency in a fetus with intracranial hemorrhage resulting in intrauterine death

In patients with severe congenital factor X deficiency, spontaneous intracranial hemorrhage (ICH) is particularly frequent in early childhood. We describe a case of fetal death at 26 weeks due to massive ICH. Gene panel analysis of postmortem samples revealed homozygosity for a pathologic F10 gene variant (c.1210T>C, p.Cys404Arg), which impedes correct folding of the catalytic serine protease domain and, therefore, causes a significant reduction in FX levels. The parents, not consanguineous but of the same ethnic community, were found to be heterozygous for this variant and did not have any personal or family history of abnormal bleeding. To the best of our knowledge, this is the first reported case of severe FX deficiency resulting in ICH diagnosed through postmortem genetic analysis. It illustrates the importance of exploring the etiology of fetal or neonatal ICH, which may impact future pregnancies, and the treatment of a potential coagulopathy in the child.

Romiplostim use in pregnant women with immune thrombocytopenia

Treatment for immune thrombocytopenia (ITP) in pregnancy is hampered by the lack of fetal safety evidence of maternally-administered medications. The Pregnancy Surveillance Program (PSP) collected patient information from 2017-2020 for pregnancy, birth outcomes, and adverse events (AEs) for 186 women exposed to romiplostim from 20 days before pregnancy to the end of pregnancy. Timing of exposure was available in 128 women. Seventy-one mothers (38%) had prepregnancy exposure to romiplostim; intrapartum exposure was known for the first (for many mothers when they discovered their pregnancy), second, and third trimesters for 74 (40%), 22 (12%), and 44 (24%) mothers, respectively, with 15 mothers exposed during >1 trimester. Among the 86 mothers with known pregnancy outcomes, 46 (53%) had at least one pregnancy-related serious AE (SAE); approximately 2/3 of SAEs were due to underlying ITP. Of 92 mothers with known birth outcomes, 60 (65%) had a normal pregnancy and 16 (17%) had complications, with both categories including term and preterm births; there were 12 (14%) spontaneous miscarriages/stillbirths, 3 (3%) ectopic pregnancies, and 1 (1%) molar pregnancy. Most abnormal births resulted from abnormal pregnancies. There were five neonatal/postnatal AEs of note: inguinal hernia, cytomegalovirus infection, trisomy 8 (third trimester single-dose romiplostim exposure), single umbilical artery without known anomalies, and development of autism at age 2 years. Seven of 12 infants with neonatal thrombocytopenia had resolution of thrombocytopenia before discharge; all 12 were discharged. Review of pregnancies in women exposed to romiplostim did not reveal any specific safety concerns for mothers, fetuses, or infants.

Early detection of ischemic brain injuries by diffusion-weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies

BACKGROUND

This study aimed to investigate the additional advantages of magnetic resonance imaging (MRI), particularly diffusion-weighted imaging (DWI) over fetal ultrasound in the detection of acute ischemic cerebral injuries in complicated monochorionic (MC) pregnancies that underwent selective reduction by radiofrequency ablation (RFA).

METHODS

This prospective cohort study was conducted on 40 women with complicated MC pregnancies who were treated by RFA. Fetal brain imaging by DWI and conventional MRI was performed either in the early (within 10 days after RFA) or late phase (after 3-6 weeks) in the surviving fetuses to detect both acute and chronic ischemic injuries. The presence of anemia after RFA was also evaluated by Doppler ultrasound.

RESULTS

Overall, 13 of the total 43 fetuses (30.23%) demonstrated MRI abnormalities with normal brain ultrasound results including germinal matrix hemorrhage (GMH), extensive cerebral ischemia, and mild ventriculomegaly. Although seven fetuses with GMH eventually survived, fetuses that demonstrated ischemic lesions and ventriculomegaly on MRI died in the uterus.

CONCLUSION

The absence of abnormal cerebral lesions or anemia on ultrasound and Doppler exams does not necessarily rule out fetal brain ischemia. Performing early MRI, particularly DWI seems to be a reasonable option for detection of early intracranial ischemic changes and better management of complicated multiple pregnancies which were treated by RFA.

Fetal MRI Neuroradiology: Indications

Fetal MRI is a safe, noninvasive examination of the fetus and placenta, a complement to ultrasonography. MRI provides detailed CNS evaluation, including depicting parenchymal architecture and posterior fossa morphology, and is key in prenatal assessment of spinal dysraphism, neck masses, and ventriculomegaly. Fetal MRI is typically performed after 22 weeks gestation, and ultrafast T1 and T2-weighted MRI sequences are the core of the exam, with advanced sequences such as diffusion weighted imaging used for specific questions. The fetal brain grows and develops rapidly, and familiarity with gestational age specific norms is essential to MRI interpretation.

Neonatal hemorrhage stroke and severe coagulopathy in a late preterm infant after receiving umbilical cord milking: A case report

BACKGROUND

Umbilical cord milking (UCM) is an alternative placental transfusion method for delayed umbilical cord clamping in routine obstetric practice, allowing prompt resuscitation of an infant. Thus, UCM has been adopted at some tertiary neonatal centers for preterm infants to enhance placental-to-fetal transfusion. It is not suggested for babies less than 28 wk of gestational age because it is associated with severe brain hemorrhage. For late preterm or term infants who do not require resuscitation, cord management is recommended to increase iron levels and prevent the development of iron deficiency anemia, which is associated with impaired motor development, behavioral problems, and cognitive delays. Concerns remain about whether UCM increases the incidence of intraventricular hemorrhage. However, there are very few reports of late preterm infants presenting with neonatal hemorrhage stroke (NHS) and severe coagulopathy after receiving UCM. Here, we report a case of a late preterm infant born at 34 wk of gestation. She abruptly deteriorated, exhibiting signs and symptoms of NHS and severe coagulopathy after receiving UCM on the first day of life.

CASE SUMMARY

A female preterm infant born at 34 wk of gestation received UCM after birth. She was small for her gestational age and described as vigorous with Apgar scores of 9 and 10 at one minute and five minutes of life, respectively. After hospitalization in the neonatal intensive care unit, she showed hypoglycemia and metabolic acidosis. The baby was administered glucose and sodium bicarbonate infusions. Intramuscular vitamin K1 was also used to prevent vitamin K deficiency. The baby developed umbilical cord bleeding and gastric bleeding on day 1 of life; a physical examination showed bilateral conjunctival hemorrhage, and a blood test showed thrombocytopenia, prolonged prothrombin time, prolonged activated partial thromboplastin time, low fibrinogen, raised D-dimer levels and anemia. A subsequent cranial ultrasound and computed tomography scan showed a left parenchymal brain hemorrhage with extension into the ventricular and subarachnoid spaces. The patient was diagnosed with NHS in addition to disseminated intravascular coagulation (DIC). Fresh frozen plasma (FFP) and prothrombin complex concentrate were given for coagulopathy. Red blood cell and platelet transfusions were provided for thrombocytopenia and anemia. A bolus of midazolam, intravenous calcium and phenobarbital sodium were administered to control seizures. The baby’s clinical condition improved on day 5 of life, and the baby was hospitalized for 46 d and recovered well without seizure recurrence. Our case report suggests that preterm infants who receive UCM should undergo careful clinical assessment for intracranial hemorrhage, NHS and severe coagulopathy that may develop under certain circumstances. Supportive management, such as intensive care, FFP and blood transfusion, is recommended when the development of massive NHS and associated DIC is suspected.

CONCLUSION

Our case report suggests that for late preterm infants who are small for gestational age and who receive UCM for alternative placental transfusion, neonatal health care professionals should be cautious in assessing the development of NHS and severe coagulopathy. Neonatal health care professionals should also be more cautious in assessing the complications of late preterm infants after they receive UCM.

Perinatal and long-term outcome of fetal intracranial hemorrhage: systematic review and meta-analysis

OBJECTIVE

Fetal intracranial hemorrhage (ICH) is associated with an increased risk of perinatal mortality and morbidity. Healthcare professionals often find it challenging to counsel parents due to its rarity and diverse presentation. The aim of this systematic review and meta-analysis was to investigate the perinatal outcome of fetuses with ICH.

METHODS

MEDLINE, EMBASE, ClinicalTrials.gov and The Cochrane Library databases were searched. Inclusion criteria were studies reporting the outcome of fetuses, newborns and infants diagnosed with ICH. The primary outcome was perinatal death (PND), defined as the sum of intrauterine (IUD) and neonatal death (NND). The secondary outcomes were stillbirth, NND, IUD, termination of pregnancy, need for surgery/shunting at birth, cerebral palsy (defined according to the European Cerebral Palsy Network and classified as diplegia, hemiplegia, quadriplegia, dyskinetic or mixed), neurodevelopmental delay and intact survival. All outcomes were explored in the included fetuses with ICH. A subgroup analysis according to the location of the hemorrhage (intra-axial and extra-axial) was also planned. Meta-analysis of proportions was used to combine data, and pooled proportions and their 95% CI were reported.

RESULTS

Sixteen studies (193 fetuses) were included in the meta-analysis. PND occurred in 14.6% (95% CI, 7.3-24.0%) of fetuses with ICH. Among liveborn cases, 27.6% (95% CI, 12.5-45.9%) required shunt placement or surgery after birth and 32.0% (95% CI, 22.2-42.6%) had cerebral palsy. Furthermore, 16.7% (95% CI, 8.4-27.2%) of cases had mild neurodevelopmental delay, while 31.1% (95% CI, 19.0-44.7%) experienced severe adverse neurodevelopmental outcome. Normal neurodevelopmental outcome was reported in 53.6% of fetuses. Subgroup analysis according to the location of ICH showed that PND occurred in 13.3% (95% CI, 5.7-23.4%) of fetuses with intra-axial bleeding and 26.7% (95% CI, 5.3-56.8%) of those with extra-axial bleeding. In fetuses with intra-axial hemorrhage, 25.2% (95% CI, 11.0-42.9%) required shunt placement or surgery after birth and 25.5% (95% CI, 15.3-37.2%) experienced cerebral palsy. In fetuses with intra-axial hemorrhage, mild and severe neurodevelopmental delay was observed in 14.9% (95% CI, 12.0-27.0%) and 32.8% (95% CI, 19.8-47.4%) of cases, respectively, while 53.2% (95% CI, 37.0-69.1%) experienced normal neurodevelopmental outcome. The incidence of mortality and postnatal neurodevelopmental outcome in fetuses with extra-axial hemorrhage could not be estimated reliably due to the small number of cases.

CONCLUSIONS

Fetuses with a prenatal diagnosis of ICH are at high risk of perinatal mortality and adverse neurodevelopmental outcome. Postnatal shunt placement or surgery was required in 28% of cases and cerebral palsy was diagnosed in approximately one-third of infants. Due to the rarity of ICH, multicenter prospective registries are warranted to collect high-quality data. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic Value of Sylvian Fissure Hyperechogenicity in Fetal SAH

BACKGROUND AND PURPOSE

Fetal SAH is an intracranial malformation. The typical diagnostic features of fetal SAH in ultrasound have not been reported. This study aimed to evaluate the diagnostic value of Sylvian fissure hyperechogenicity by prenatal ultrasound in fetuses with SAH.

MATERIALS AND METHODS

The features on ultrasound and MR imaging of 10 fetuses with SAH were reviewed and summarized. The diagnostic value of the Sylvian fissure in fetal SAH by prenatal ultrasound was evaluated.

RESULTS

The typical and most obvious manifestations of SAH during the prenatal period were hyperechogenicity in the subarachnoid cavity, especially in the Sylvian fissure; all 10 cases (10/10) had such manifestations. Other manifestations included a hyperecho in other sulci (6/10), especially in the subfrontal sulcus, superior temporal sulcus, or parieto-occipital sulcus; a hyperecho in the cisterns (8/10), especially in the suprasellar cistern, posterior cranial fossa, cisterna ambiens, or quadrigeminal cistern; and a hyperecho around the anterior and posterior longitudinal fissures (2/10). Combined hemorrhage in the parenchymal layer or ventricles (9/10) was found. In addition, Doppler ultrasound showed that the peak flow velocity in the MCA increased in 6 cases (6/10).

CONCLUSIONS

The homogeneous hyperechogenicity of the Sylvian fissure is an important clue for detecting and diagnosing fetal SAH by prenatal ultrasound. A diagnostic approach has been proposed for fetal SAH, which has great significance in further prognosis.

Chest imaging in pregnant patients with COVID-19: Recommendations, justification, and optimization

Evaluation of COVID-19 related complication is challenging in pregnancy, due to concerns about ionizing radiation risk to mother and the fetus. Although there are instances when diagnostic imaging is clinically warranted for COVID-19 evaluation despite the minimal risks of radiation exposure, often there are concerns raised by the patients and sometimes by the attending physicians. This article reviews the current recommendations on indications of chest imaging in pregnant patients with COVID-19, the dose optimization strategies, and the risks related to imaging exposure during pregnancy. In clinical practice, these imaging strategies are key in addressing the complex obstetrical complications associated with COVID-19 pneumonia.

Fetal intracranial hemorrhage and maternal vitamin K deficiency induced by total parenteral nutrition: A case report

RATIONALE

Fetal brain hemorrhage is rare. It is caused mainly by maternal trauma or fetal coagulation disorder, but in some cases, vitamin K deficiency may be the cause.

PATIENT CONCERNS

We describe the case of a pregnant woman with bowel obstruction who was susceptible to vitamin K deficiency due to oral diet restriction, decreased intestinal absorption, and limited intravenous vitamin K supplementation.

DIAGNOSIS

After 18 days of intermittent total parenteral nutrition, acute onset of severe fetal brain hemorrhage developed.

INTERVENTIONS

After acute onset of fetal brain hemorrhage, the patient underwent an emergency cesarean section at 25 + 3 weeks of gestation due to fetal non-reassuring fetal monitoring.

OUTCOMES

The Apgar score at birth was 0/0, and despite cardiopulmonary resuscitation, neonatal death was confirmed. After the baby was delivered, we checked the maternal upper abdominal cavity and found a massive adhesion in the small bowel to the abdominal wall near the liver and stomach with an adhesion band. The adhesion band, presumably a complication of previous hepatobiliary surgery, appeared to have caused small bowel obstruction. Adhesiolysis between the small bowel and abdominal wall was performed.

LESSONS

This case demonstrates that even relatively short-term total parenteral nutrition can cause severe fetal brain hemorrhage. Vitamin K supplementation is required for mothers who are expected to be vitamin K deficient, especially if they are on total parenteral nutrition for more than 3 weeks.

Indications for magnetic resonance imaging of the fetal central nervous system: recommendations from the European Society of Paediatric Radiology Fetal Task Force

Fetal central nervous system MRI is a well-established method to complement a high-quality fetal ultrasound and to clarify sonographically detected abnormalities in complex pregnancies. However, there is still worldwide heterogeneity and confusion regarding the indications of fetal central nervous system MRI, which has roots in differences among countries regarding the performance of ultrasound examinations and legislation on pregnancy termination. The purpose of this article is to clarify the indications for fetal central nervous system MRI by focusing on the ultrasound findings that guide further investigation with MRI and highlight the strengths and the weaknesses of each modality on imaging the fetal central nervous system.

Fetal intracranial hemorrhage associated with maternal coagulopathy and vitamin K deficiency after biliary drain placement: A case report and literature review

Introduction

Fetal intracranial hemorrhage (ICH) is a rare but serious prenatal diagnosis. Predisposing factors include maternal trauma and fetal coagulation dysfunction. Maternal vitamin K deficiency has been described as an etiology. We present a case of maternal vitamin K deficiency associated with fetal ICH after percutaneous biliary drain (PBD) placement in a complicated cholecystectomy with injury to the common bile duct.

Case presentation

A 21-year-old woman, G2P1, presented at 23 weeks and 3 days of gestation with epigastric pain, nausea and vomiting. Right upper quadrant ultrasound diagnosed cholelithiasis. The patient was managed conservatively and discharged. She returned four days later, at 24 weeks of gestation, with worsening symptoms and ultrasound showing acute cholecystitis. She underwent laparoscopic cholecystectomy. Increasing bilirubin and imaging showed a transected biliary duct that required percutaneous biliary drain (PBD) placement. The patient was discharged and followed up at a high-risk obstetric clinic. Prenatal ultrasound showed bilateral ventriculomegaly with features of ICH. Maternal vitamin K deficiency was confirmed with PIVKA-II testing. The patient received vitamin K supplementation with normalization of the coagulopathy. Delivery occurred at 36 weeks of gestation via cesarean delivery after preterm premature rupture of membranes for fetal macrocrania. The neonate was discharged to a hospice.

Discussion

Maternal and neonatal etiologies for ICH include malabsorption and coagulopathy. Maternal vitamin K deficiency should be considered when coagulopathy is present. This case highlights that maternal vitamin K deficiency due to biliary diversion and malabsorption increases the risk of fetal ICH, which impacts pregnancy and neonatal outcomes.

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Maternal vitamin K deficiency due to biliary diversion and malabsorption may predisp fetal intracranial hemorrhage.

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Fetal intracranial hemorrhage may impact pregnancy and neonatal outcomes, particularly if severe.

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Monitoring maternal coagulation may aid in the diagnosis of maternal vitamin K deficiency.

Detecting Fetal Central Nervous System Anomalies Using Magnetic Resonance Imaging and Ultrasound

Background:

Most fetal abnormalities can be detected on ultrasound, the evaluation of fetal CNS abnormalities can be limited by various factors, including obesity, polyhydramnios, multiple pregnancies, and increased cranial ossification during the third trimester.

Objective:

This study aimed to evaluate the ability to detect fetal central nervous system (CNS) anomalies using in utero magnetic resonance imaging (iuMRI) and ultrasound (US) techniques.

Methods:

This prospective study was approved by the institutional review board (Ref: 2968/QĐ-ĐHYHN dated 11 July 2019), and the requirement to obtain the informed consent of patients was waived. This study included 66 fetuses with diagnosed or suspected CNS abnormalities based on the results of a prenatal screening US performed at the antenatal diagnosis center of the Central Obstetrics and Gynecology Hospital. All pregnant women with a suspected diagnosis of abnormal fetal CNS on US underwent 1.5-Tesla iuMRI within 14 days of the US at Hanoi Medical University Hospital between June 2019 and June 2020. Cohen’s kappa coefficient (κ) was used to determine the agreement between US and iuMRI findings.

Results:

A total of 66 pregnant women were examined, including 66 fetuses, for which 79 abnormalities were detected by US and 98 abnormalities were detected by iuMRI. The average gestational age was 29 weeks and 6 days. The comparison of iuMRI and US findings revealed similar diagnoses for 71 abnormalities (67%) and different diagnoses for 35 abnormalities (33%). The level of agreement between US and iuMRI was almost perfect for ventriculomegaly and cystic lesions, with κ values 0.87 and 0.84, respectively. The level of agreement between US and iuMRI was the weakest for hemorrhage, with a κ value 0 (no agreement), and cortical abnormalities, with a κ value of 0.46 (weak agreement).

Conclusion:

The level of agreement between US and iuMRI diagnoses was almost perfect for the detection of ventriculomegaly and was weakest for the detection of hemorrhage and cortical abnormalities, which were abnormalities detected by iuMRI but not by ultrasound.

Agreement between prenatal ultrasound and 3.0T magnetic resonance imaging in the assessment of anomalies of the central nervous system: A single-center experience in Slovakia

OBJECTIVE

To assess the concordance of in-utero magnetic resonance imaging (MRI) findings at 3.0T in fetuses with suspect abnormalities of the central nervous system (CNS) on ultrasonography.

METHODS

A retrospective study was done on 222 pregnant women indicated for fetal MRI, with the examination performed within 2 weeks from indication. The inclusion criteria for patients were age 18 years or older with the fetus at 18 weeks of gestation or more. Fetal CNS pathologies were divided into six categories: ventriculomegaly; supratentorial midline abnormalities (ACC); supratentorial space-occupying lesions; abnormalities of the posterior fossa; destructive cerebral lesions; and cortical formation abnormalities (CFA). Chance-adjusted agreement was assessed using unweighted Cohen's kappa (κ).

RESULTS

The best agreement between ultrasound and MRI was observed in ventriculomegaly (κ=0.817; 95% confidence interval [CI] 0.76-0.88). There was only a moderate agreement in ACC (κ=0.483; 95% CI 0.35-0.61). CFA pathologies had a poor agreement between the modalities (κ=0.140; 95% CI -0.03 to 0.31).

CONCLUSION

Ultrasonography has good overall agreement with MRI in diagnosing fetal CNS anomalies. CFA had the most disagreement between ultrasound and MRI. The prognostic implication of these findings can be used for parental neuro-counseling but should be investigated further.

Fetal Neuroimaging Update

OBJECTIVES

To review the current imaging techniques available for the evaluation of the fetal brain.

FINDINGS

Ultrasound remains the initial screening modality with routine scanning typically performed at 18-20 weeks gestation. When a central nervous system (CNS) abnormality is noted by ultrasound, MRI is increasingly being used to further clarify findings. Fetal MRI has the unique ability to provide high detailed anatomical information of the entire human fetus with high contrast resolution. This technique has grown due to the development of rapid single shot image acquisition sequences, improvement of motion correction strategies and optimizing shimming techniques.

CONCLUSIONS

The assessment of fetal CNS anomalies continues to improve. Advanced MRI techniques have allowed for further delineation of CNS anomalies and have become a cornerstone in the assessment of fetal brain well-being. Those interpreting fetal studies need to be familiar with the strengths and limitations of each exam and be sensitive to the impact discussing findings can have regarding perinatal care and delivery planning. Collaboration with neurologists, neurosurgeons, geneticists, counselors, and maternal fetal specialists are key in providing the best care to the families we treat.

Fetal MRI for dummies: what the fetal medicine specialist should know about acquisitions and sequences

Fetal MRI is an increasingly used tool in the field of prenatal diagnosis. While US remains the first line screening tool, as an adjuvant imaging tool, MRI has been proven to increase diagnostic accuracy and change patient counseling. Further, there are instances when US may not be sufficient for diagnosis. As a multidisciplinary field, it is important that every person involved in the referral, diagnosis, counseling and treatment of the patients is familiar with the basic principles, indications and findings of fetal MRI. The purpose of the current paper is to equip radiologists and non-radiologists with basic MRI principles and essential topics in patient preparation and provide illustrative examples of when fetal MRI may be used. This aims to aid the referring clinician in better selecting and improve patient counseling prior to arrival in the radiology department and, ultimately, patient care.

Fetal MRI, lower acceptance by women in research vs. clinical setting

AIM

To determine acceptance of pregnant women to undergo fetal magnetic resonance imaging (MRI) examination in research and clinical setting.

METHODS

A prospective study included a research group [part of a study comparing brain ultrasound (US) to MRI in fetuses at risk for acquired brain damage] and a clinical group [fetuses with suspected (brain) anomalies after structural US examination] from 2011 to 2014. All women were advised to use sedatives. MRI declinations, use of sedation, MRI duration and imaging quality were compared between both groups.

RESULTS

Study participation was accepted in 57/104 (55%) research cases. Fetal MRI was performed in 34/104 (33%) research and 43/44 (98%) clinical cases. Reasons to decline study participation were MRI related in 41%, and participation was too burdensome in 46%. Acceptance was highest for indication infection and lowest in alloimmune thrombocytopenia and monochorionic twin pregnancy. Sedatives were used in 14/34 research and 43/43 clinical cases. Scan duration and quality were comparable (21 and 20 min in research and clinical cases, respectively, moderate/good quality in both groups).

CONCLUSIONS

Pregnant women consider MRI more burdensome than professionals realize. Two-third of women at risk for fetal brain damage decline MRI examination. Future studies should evaluate which information about fetal MRI is supportive.