Childhood cardiac function after prenatal diagnosis of intracardiac echogenic foci

Society for Maternal-Fetal Medicine Consult Series #57: Evaluation and management of isolated soft ultrasound markers for aneuploidy in the second trimester: (Replaces Consults #10, Single umbilical artery, October 2010; #16, Isolated echogenic bowel diagnosed on second-trimester ultrasound, August 2011; #17, Evaluation and management of isolated renal pelviectasis on second-trimester ultrasound, December 2011; #25, Isolated fetal choroid plexus cysts, April 2013; #27, Isolated echogenic intracardiac focus, August 2013)

Soft markers were originally introduced to prenatal ultrasonography to improve the detection of trisomy 21 over that achievable with age-based and serum screening strategies. As prenatal genetic screening strategies have greatly evolved in the last 2 decades, the relative importance of soft markers has shifted. The purpose of this document is to discuss the recommended evaluation and management of isolated soft markers in the context of current maternal serum screening and cell-free DNA screening options. In this document, "isolated" is used to describe a soft marker that has been identified in the absence of any fetal structural anomaly, growth restriction, or additional soft marker following a detailed obstetrical ultrasound examination. In this document, "serum screening methods" refers to all maternal screening strategies, including first-trimester screen, integrated screen, sequential screen, contingent screen, or quad screen. The Society for Maternal-Fetal Medicine recommends the following approach to the evaluation and management of isolated soft markers: (1) we do not recommend diagnostic testing for aneuploidy solely for the evaluation of an isolated soft marker following a negative serum or cell-free DNA screening result (GRADE 1B); (2) for pregnant people with no previous aneuploidy screening and isolated echogenic intracardiac focus, echogenic bowel, urinary tract dilation, or shortened humerus, femur, or both, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive (GRADE 1B); (3) for pregnant people with no previous aneuploidy screening and isolated thickened nuchal fold or isolated absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening through cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference (GRADE 1B); (4) for pregnant people with no previous aneuploidy screening and isolated choroid plexus cysts, we recommend counseling to estimate the probability of trisomy 18 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive (GRADE 1C); (5) for pregnant people with negative serum or cell-free DNA screening results and an isolated echogenic intracardiac focus, we recommend no further evaluation as this finding is a normal variant of no clinical importance with no indication for fetal echocardiography, follow-up ultrasound imaging, or postnatal evaluation (GRADE 1B); (6) for pregnant people with negative serum or cell-free DNA screening results and isolated fetal echogenic bowel, urinary tract dilation, or shortened humerus, femur, or both, we recommend no further aneuploidy evaluation (GRADE 1B); (7) for pregnant people with negative serum screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and discussion of options for no further aneuploidy evaluation, noninvasive aneuploidy screening through cell-free DNA, or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference (GRADE 1B); (8) for pregnant people with negative cell-free DNA screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend no further aneuploidy evaluation (GRADE 1B); (9) for pregnant people with negative serum or cell-free DNA screening results and isolated choroid plexus cysts, we recommend no further aneuploidy evaluation, as this finding is a normal variant of no clinical importance with no indication for follow-up ultrasound imaging or postnatal evaluation (GRADE 1C); (10) for fetuses with isolated echogenic bowel, we recommend an evaluation for cystic fibrosis and fetal cytomegalovirus infection and a third-trimester ultrasound examination for reassessment and evaluation of growth (GRADE 1C); (11) for fetuses with an isolated single umbilical artery, we recommend no additional evaluation for aneuploidy, regardless of whether results of previous aneuploidy screening were low risk or testing was declined. We recommend a third-trimester ultrasound examination to evaluate growth and consideration of weekly antenatal fetal surveillance beginning at 36 0/7 weeks of gestation (GRADE 1C); (12) for fetuses with isolated urinary tract dilation A1, we recommend an ultrasound examination at ≥32 weeks of gestation to determine if postnatal pediatric urology or nephrology follow-up is needed. For fetuses with urinary tract dilation A2-3, we recommend an individualized follow-up ultrasound assessment with planned postnatal follow-up (GRADE 1C); (13) for fetuses with isolated shortened humerus, femur, or both, we recommend a third-trimester ultrasound examination for reassessment and evaluation of growth (GRADE 1C).

Effectiveness of Chromosomal Microarray Analysis for Prenatal Diagnosis of Fetal Echogenic Intracardiac Focus: A Single-Center Experience

BACKGROUND

Echogenic intracardiac focus (EIF) is a common ultrasound finding during pregnancy. However, the correlation between fetal EIF and cardiac abnormality remains in dispute until now. The study aimed to examine the association of fetal EIF with chromosomal abnormality by means of chromosomal microarray analysis (CMA).

MATERIALS AND METHODS

A total of 192 pregnant women with fetal EIF undergoing amniocentesis or umbilical cord blood puncture were recruited and assigned into groups A (8 cases with isolated EIF alone), B (75 cases with EIF and other cardiac malformations) and C (109 cases with EIF and extracardiac malformations). All fetuses underwent karyotyping analysis and CMA simultaneously. The detection of chromosomal abnormality and copy number variations (CNVs) were compared.

RESULTS

Chromosomal karyotyping identified 5 fetuses with chromosomal abnormality, including 3 cases with trisomy 21, one fetus with Turner's syndrome, and one fetus with chromosome 8 mosaicism, while CMA detected 6 additional fetuses with CNVs, including 2 fetuses with pathogenic CNVs and 4 fetuses with variants of uncertain significance (VOUS). There was no significant difference among groups A (0), B (5.33%) and C (6.42%) in terms of the prevalence of chromosomal abnormality (P> 0.05). Among the 4 fetuses with VOUS, pregnancy continued in 2 fetuses, and pregnancy was terminated in other 2 fetuses.

CONCLUSION

An isolated EIF may not correlate with chromosomal abnormality. However, CMA is recommended in fetuses with CMA complicated by other abnormal cardiac ultrasound findings, which facilitates the prediction of fetal outcomes during the genetic counseling and precision assessment of prognosis.

Application of Copy Number Variation Detection to Fetal Diagnosis of Echogenic Intracardiac Focus During Pregnancy

Echogenic intracardiac focus (EIF) is one of the most common ultrasound soft markers (USMs) in prenatal screening. However, the association of EIF with chromosomal abnormalities is still controversial. From January 2018 to April 2020, a total of 571 fetuses with USMs in our center were enrolled, among which 150 (26.27%) presented EIFs. We analyzed the karyotype anomalies and copy number variations (CNVs) in fetuses who presented EIFs by comparing their ultrasound indications, maternal ages and gestational stages. There were no statistically significant differences in the incidence of chromosomal abnormalities between fetuses with EIFs and the fetuses with USMs (4.00 vs. 7.71%, p = 0.112). Additionally, the incidence of chromosomal abnormalities was not related to maternal age (4.10% in maternal age below 35 yeas vs. 3.57% in maternal age above 35, p = 1.000). Interestingly, after 28 weeks of gestation, fetuses with EIFs showed more chromosomal abnormalities (20.00%) than that in the group before 28 weeks of gestation (2.22%, p = 0.014), and this result was attributed to the detection of pathogenic CNVs. After birth, 25 of children conducted cardiac development re-examination. Among them, 9 (36%, 9/25) were diagnosed with congenital heart disease, primarily patent foramen oval and ventricular septal defects (7/9, 77.77%). We concluded that the appearance of EIFs in early or mid-trimester would not indicate an increased risk of fetal chromosomal abnormalities. However, the persistence of EIFs in late trimester was associated with a higher risk of pathology-related CNVs and its persistent appearance may indicate heart development defects after birth. Thus, our results suggest that CNV detection has its advantages in prenatal diagnosis, especially for those with EIFs that persist in the third trimester.

Isolated intracardiac echogenic focus on routine ultrasound: implications for practice

Ultrasound is widely used as a screening tool for fetal anomalies. An intracardiac echogenic focus (ICEF) is associated with fetal aneuploidy, particularly trisomy 21, when found with other minor abnormalities known as soft markers. However, when found in isolation, intracardiac echogenic foci are morphologic variations with little or no pathologic significance for the fetus. Ambiguity about the significance of ICEF and other soft markers and the lack of preparation prior to ultrasound can result in unnecessary worry for women and their partners. A variety of tools exist that providers can use to help pregnant women and their partners make informed decisions about ultrasound and fetal screening.

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

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

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

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

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

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

Follow-up of sonographically detected soft markers for fetal aneuploidy

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

Evaluation of tissue Doppler-derived myocardial performance index in fetuses with intracardiac echogenic focus

OBJECTIVE

To compare cardiac function between fetuses with and without intracardiac echogenic foci (IEFs) by conventional echocardiography and tissue Doppler (TD) imaging.

METHODS

Fetuses having IEF and no additional cardiac or extracardiac anomaly between 20 and 28 weeks (median 22 weeks) of gestation (n = 61) were compared with healthy fetuses between 18 and 29 weeks (median 23 weeks) of gestation (n = 55). Pulmonary artery and aortic peak velocities, atrioventricular (AV) early diastole (E) and atrial contraction (A) velocities and E/A ratios were measured. TD-derived myocardial performance index (MPI) was also measured.

RESULTS

Tricuspid valve E/A ratios, which were 0.634 ± 0.07 versus 0.639 ± 0.06 (p = 0.697), mitral valve E/A ratios, which were 0.604 ± 0.08 versus 0.612 ± 0.07 (p = 0.600), aorta peak velocities, which were 0.709 ± 0.11 versus 0.697 ± 0.11 (p = 0.592) and pulmonary artery peak velocities, which were 0.699 ± 0.12 versus 0.694 ± 0.11 (p = 0.800) in the study and the control groups, respectively. TD-derived measurements in the study and control groups included tricuspid valve MPI, which were 0.452 ± 0.08 versus 0.473 ± 0.09 (p = 0.221) and mitral valve MPI values, which were 0.444 ± 0.1 versus 0.445 ± 0.09 (p = 0.965), respectively, and this difference was not statistically significant.

CONCLUSION

An isolated IEF is not associated with abnormal cardiac function. We suggest that the presence of an isolated IEF should not be an indication for fetal cardiac function examination either with conventional Doppler or TD imaging techniques, unless there is a coexisting cardiac or extracardiac anomaly.

Fetal echogenic cardiac foci: prospective postnatal electrocardiographic follow-up

OBJECTIVE

To determine postnatal electrocardiographic abnormalities in fetuses with echogenic cardiac foci (ECF) and no congenital heart disease (CHD).

STUDY DESIGN

A total of 41 fetuses with ECF and no CHD, were prospectively followed after birth with serial echocardiograms, electrocardiogram (ECG) and 24-h ECG (Holter). The primary outcome was presence of significant abnormalities in the ECG or Holter.

RESULT

ECF diagnosed at a mean (s.d.) of 25.6 (4.6) weeks gestation, were located in the ventricles and in the atria in 39 (95.1%), and 2 fetuses (4.9%), respectively. Postnatal follow-up was for 8.1 (4.6) months (range 1 to 24). None of the infants had any clinically significant abnormality in the ECG or Holter. ECF resolved in 10 infants (24.3%) by 24 months of age. There was no difference between infants with resolved or persistent ECF in various ECG or Holter measurements compared.

CONCLUSION

Fetuses with ECF and no CHD have no significant postnatal electrocardiographic abnormalities, irrespective of ECF persistence or resolution.

Intracardiac echogenic foci have no hemodynamic significance in the fetus

Intracardiac echogenic foci (ECFs), probably representing microcalcifications of the papillary muscles, are a common finding in fetal ultrasonic screening examinations. Their significance is unclear, and their value as markers for chromosomal anomalies is debatable. It also is unknown whether ECFs predict abnormal cardiac performance. This prospective study analyzed and compared the systolic and diastolic properties of the heart in 28 fetuses with ECFs and 70 fetuses without ECFs using both conventional and novel myocardial deformation methods. The findings suggest that left-sided ECFs do not predict depressed left- or right-side systolic or diastolic properties in the fetus. A longitudinal study that would follow ECF fetuses into their childhood is warranted to confirm the findings of this study.

Echogenic intracardiac foci: associated with increased risk for fetal trisomy 21 or not?

OBJECTIVE

The purpose of this study was to evaluate the impact of an echogenic intracardiac focus (EIF) on the risk for fetal trisomy 21 (T21) in populations with differing prevalence of T21.

METHODS

A retrospective cohort study of pregnancies presenting to our prenatal ultrasound units over 16 years (1990-2006) was conducted. Contingency table analysis of the presence of an EIF and diagnosis of fetal T21 was performed. The groups analyzed included the following: (1) all fetuses with EIF plus other sonographic markers, (2) EIF as an isolated sonographic marker, (3) those younger than 35 years with an isolated finding of EIF, and (4) a group with an isolated finding of EIF excluding those at increased risk for T21 on serum screening.

RESULTS

Echogenic intracardiac foci were found in 2223 of 62,111 pregnancies (3.6%), and T21 was diagnosed in 218 pregnancies (0.4%). The presence of an EIF along with other markers was associated with a statistically significant risk for T21 (positive likelihood ratio [LR], 4.4; 95% confidence interval [CI], 3.2-6.0; P < .05). An isolated EIF was not associated with a statistically significant increased risk for T21 in patients younger than 35 years (positive LR, 1.7; 95%, CI 0.7-4.1) and those without abnormal serum screening results for aneuploidy (positive LR, 1.6; 95% CI, 0.8-3.1).

CONCLUSIONS

The finding of an isolated EIF on prenatal sonography does not significantly increase the risk for fetal T21 in populations not otherwise at an increased risk for the disorder. An isolated EIF should be considered an incidental finding in patients younger than 35 years and in those without abnormal serum aneuploidy screening results.

Isolated fetal intracardiac hyperechogenic focus associated with neonatal outcome and triple test results

OBJECTIVE

To investigate the relationship between isolated intracardiac hyperechogenic focus (IHF) in the mid trimester of pregnancy with neonatal outcomes and triple test results.

MATERIALS AND METHODS

The study included low-risk pregnant women who came for routine follow-up to our antenatal clinic between years 2000 and 2005. A detailed structural survey by ultrasound (USG) of the fetal heart was performed on each fetus in the mid-trimester of pregnancy. All patients had mid-trimester triple tests performed between the 16th and 18th weeks' of pregnancy. We recruited a total of 40 pregnancies that had fetal IHF in the level II USG examination and a control group of 100 healthy pregnant women those which were followed-up during the same period. Twenty-nine fetuses (72.5%) had left, 8 (20%) had right whereas 3 (7.5%) had bilateral ventricular IHF. We compared the perinatal and neonatal outcomes and triple test results of the fetuses that had right and left IHF, and the controls.

RESULTS

Cytogenetic amniocentesis was performed to 6 (15%) women in the study and 5 (5%) in the control group and all were normal. During follow-up IHF spontaneously disappeared in 30 fetuses [right (n: 5), left (n: 23) or bilateral (n: 2)]. We did not observe any cardiac problem in the postnatal period in all newborns. Only one infant (2.5%) in the study group was admitted to neonatal intensive care unit because of prematurity. Median delivery weeks (P = 0.023), head circumference (P = 0.013), 5-min Apgar score (P = 0.021] and apnea (P = 0.042) were significantly higher in fetuses with right IHF. Compared to the controls, median delivery weeks (P = 0.038) was significantly higher in fetuses with right IHF, but head circumference (P = 0.004), 1-min (P = 0.003) and 5-min (P < 0.001) Apgar scores were lower in fetuses with left IHF. However no difference was observed in second-trimester serum human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP) and estriol (E(3)) levels, in the three groups. There was no correlation between serum HCG, AFP and E(3) levels and the presence of IHF.

CONCLUSIONS

Isolated IHF in the fetal heart in the mid-trimester of pregnancy seems not associated with adverse neonatal outcome and does not correlate with triple test results.

Clinical implications of the prenatal sonographic finding of fetal myocardial echogenic foci

OBJECTIVE

The purpose of this study was to investigate the clinical implications of fetal echogenic foci limited to the myocardium of the ventricular wall (EMF) or intraventricular septum detected during prenatal sonography.

METHODS

A retrospective review of fetuses found to have EMF during prenatal sonography from April 1990 through December 2003 was undertaken. Videotapes and reports were reviewed to determine the indication for sonography, gestational age, location, sonographic characteristics of the masses, and additional fetal findings. Sources of outcome data included neonatal and pediatric records and echocardiographic reports.

RESULTS

Five fetuses were identified. Indications for sonographic evaluation included fetal growth (n = 4) and follow-up twin-twin transfusion syndrome (n = 1). Mean gestational age +/- SD at diagnosis was 23.7 +/- 8.0 weeks (range, 17.1-36.4 weeks). The EMF identified were within the right ventricular myocardium (n = 2), intraventricular septum (n = 1), left ventricular myocardium (n = 1), and myocardium of the cardiac apex (n = 1). All foci appeared sonographically "bright as bone." The foci ranged in size from 0.1 x 0.1 to 1.2 x 0.9 cm. Neonatal echocardiographic findings were reported as normal for each of the cases. Follow-up examinations available for up to 2.5 years of age showed normal cardiac function.

CONCLUSIONS

The prenatal identification of EMF is unlikely to lead to notable short-term pathologic conditions because the fetuses in this investigation had unremarkable neonatal and pediatric echocardiograms and normal cardiac function.

Latest advances and topics in fetal echocardiography

PURPOSE OF REVIEW

Fetal diagnosis and the supporting specialties of perinatology, neonatology, and surgery have made rapid strides in the last decade. Numerous centers are focusing on this multifaceted niche area as the medical field realizes its vast promise and potential. The authors review some of the major advancements in thought and practice in the field of fetal echocardiography while attempting to give a less detailed overview for the less involved perinatologist.

RECENT FINDINGS

First trimester fetal echocardiography has been an area of recent interest as transducer technology improves. As a result, optimum timing of first and subsequent scans and the population profile they are to be applied to have become an issue that begs consensus. Three-dimensional and four-dimensional fetal echocardiography have also received a boost for the same reasons, and both are being studied for feasibility and accuracy. Fetal tissue Doppler and spectral Doppler imaging are potential areas for exploration; the early steps have been taken. Awareness of associated ultrasound markers, such as exaggerated nuchal translucency, as clues to the presence of congenital heart disease is important, even if controversial.

SUMMARY

The issue of missed prenatal diagnosis is disturbing, especially when it arises against a background of tremendous skill and technologic support. Strategies to minimize mistakes in this critical aspect need to be agreed on by the involved teams and put in place in a multidisciplinary manner if they are to have an important impact.

Controversial ultrasound findings

This article has reviewed a few of the more controversial findings in the field of obstetric ultrasound. For each one evidence-based strategies for the management of affected pregnancies have been suggested, derived from what the authors believe is the best information available. In some cases, this information is very limited, which can make counseling these patients extremely difficult. Some physicians find using specific likelihood ratios helpful in these complex discussions. An example of the relative likelihood ratios for several markers of trisomy 21 is illustrated in Table 10. Although the management of each of the findings discussed in this article is different, a few generalizations can be made. To begin with, the detection of any abnormal finding on ultrasound should prompt an immediate detailed ultrasound evaluation of the fetus by someone experienced in the diagnosis of fetal anomalies. If there is more than one abnormal finding on ultrasound, if the patient is over the age of 35, or if the multiple marker screen is abnormal, an amniocentesis to rule out aneuploidy should be recommended. Of the six ultrasound findings reviewed here, the authors believe that only echogenic bowel as an isolated finding confers a high enough risk of aneuploidy to recommend an amniocentesis in a low-risk patient. The other findings in isolation in a low-risk patient seem to confer only a modest increased risk of aneuploidy, if any, and this risk is certainly less than the risk of unintended loss from amniocentesis. Wherever possible, modifiers of this risk, such as maternal age, history, and first and second multiple marker screening, should be used to define more clearly the true risk of aneuploidy. As obstetric ultrasound moves forward, particularly into the uncharted waters of clinical use of three- and four-dimensional ultrasound, one can expect a whole new crop of ultrasound findings with uncertain clinical significance. Clinicians are well advised to await well-designed studies to determine the clinical significance of these findings before altering clinical care.

Are intracardiac echogenic foci markers of congenital heart disease in the fetus with chromosomal abnormalities?

OBJECTIVE

To determine whether intracardiac echogenic foci (ICEF) are markers of congenital heart disease (CHD) in fetuses with chromosomal abnormalities.

METHODS

We identified all fetuses with chromosomal abnormalities undergoing targeted sonography at 17 weeks' to 21 weeks 6 days' gestation in a single perinatal center from January 1, 1994, to June 30, 2003. Offspring with and without CHD were compared for the presence or absence of ICEF.

RESULTS

Two (8%) of 25 fetuses with ICEF had CHD versus 38 (33.3%) of 114 fetuses without ICEF (P = .006). Similarly, 1 (5.5%) of 18 fetuses with trisomy 21 and ICEF had CHD compared with 16 (37.2%) of 43 fetuses with trisomy 21 without ICEF (P = .009).

CONCLUSIONS

Intracardiac echogenic foci in fetuses with chromosomal abnormalities, including those with trisomy 21, are not useful markers for CHD.

Prenatal screening and the assessment of risk: the view from the other side

Since the introduction, in 1984, of maternal serum screening for fetal aneuploidy, obstetrical practitioners and their patients have learned to cope with the challenges and limitations of risk estimation. In the instance where the "odds" are not entirely reassuring, the hazards of invasive, yet definitive, testing are weighed against the costs of uncertainty. Non-invasive prenatal screening has improved dramatically over the past 20 years, with early administration, high sensitivity, and low false positive rates as the benchmarks. With a wide array of tests at her disposal, the woman who chooses to undergo prenatal screening for aneuploidy presumably does so in the context of counselling and consent, and with the assurance that the tests offered, having evolved through the rigours of large-scale clinical trials, are as good as they can possibly be. Or does she? The following is a highly personal account of one woman's experience with prenatal screening, in particular, with the "Pandora's box" of ultrasonic soft markers for aneuploidy. The author challenges the experts in the field to ensure that all "advancements" meet the standards described above.