Impact of choroid plexus size in prenatal diagnosis of normal and abnormal closure of fourth ventricle

OBJECTIVE

To assess the role of the choroid plexus (CP) of the fourth ventricle (4V) in fetuses with an open 4V and a normal cerebellar vermis.

METHODS

Two groups of patients were recruited in two fetal medicine referral centers. The prospectively collected control group included singleton pregnancies with a normal sonographic examination after first-trimester combined screening for chromosomal abnormalities and normal outcome, recruited in the period between 2019 and 2022. The study group was selected retrospectively by searching our databases to identify all cases with an isolated open 4V and normal anatomy and size of the cerebellar vermis. The inclusion criteria of the study group were: (1) gestational age between 20 and 22 weeks; (2) a brainstem-vermis angle ≥ 18° in the midsagittal plane with an otherwise normal cerebellum and vermis; (3) 4V-CP visible and seen separately from the vermis; (4) absence of other intra- and extracranial anomalies; and (5) available prenatal and/or postnatal magnetic resonance imaging (MRI) data.

RESULTS

In 169 cases of the control group, the 4V-CP was seen separately from the cerebellar vermis and was noticed to progressively fill the space caudal to the 4V, between the vermis and brainstem. From 12 to 22 weeks, the surface areas of the vermis and medial portion of the 4V-CP increased progressively with advancing gestation (P < 0.0001). Intra- and interobserver correlation analysis showed good reproducibility for the measurements. Among the cases with an open 4V and a normal vermis, it was retrospectively feasible to visualize the 4V-CP separately from the inferior part of the vermis in 41 fetuses. In five of these cases, the open 4V was due to a small CP. In all 41 fetuses, the diagnosis on MRI was isolated upward rotation of the cerebellar vermis, and no additional anomaly was found.

CONCLUSIONS

Closure of the 4V is dependent on the 4V-CP and not only the cerebellar vermis. In fact, a small CP may represent another cause of an open 4V. Therefore, separate visualization of the 4V-CP and cerebellar vermis is crucial to improve discrimination between the different causes of an open 4V at the anomaly scan and its clinical implications. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Pregnancy and perinatal outcomes of early vs late selective termination in dichorionic twin pregnancy: systematic review and meta-analysis

OBJECTIVE

To evaluate outcomes of dichorionic twin pregnancies undergoing early vs late selective termination of pregnancy (ST).

METHODS

MEDLINE, EMBASE, CINAHL and the Web of Science databases were searched electronically up to March 2022. The primary outcome of this study was pregnancy loss prior to 24 weeks' gestation. The secondary outcomes included preterm birth (PTB) before 37, 34, and 32 weeks, preterm prelabor rupture of membranes (PPROM), gestational age (GA) at delivery, Cesarean delivery, mean birth weight, 5-min Apgar score < 7, overall neonatal morbidity and neonatal survival. Only prospective or retrospective studies reporting data on the outcome of early (before 18 weeks) vs late (at or after 18 weeks) ST in dichorionic twin pregnancies were considered suitable for inclusion. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale for cohort studies. Random-effects head-to-head meta-analysis was used to analyze the data.

RESULTS

Seven studies reporting on 649 dichorionic twin pregnancies were included in this systematic review. The risk of pregnancy loss prior to 24 weeks was significantly lower in dichorionic twin pregnancies undergoing early compared with late ST (1% vs 8%; odds ratio (OR), 0.25 (95% CI, 0.10-0.65); P = 0.004). The risk of PTB was significantly lower in dichorionic twin pregnancies undergoing early compared with late ST when considering PTB before 37 weeks (19% vs 45%; OR, 0.36 (95% CI, 0.23-0.57); P < 0.00001), before 34 weeks (4% vs 19%; OR, 0.24 (95% CI, 0.11-0.54); P = 0.0005) and before 32 weeks (4% vs 20%; OR, 0.21 (95% CI, 0.05-0.85); P = 0.03). The mean birth weight was significantly greater in the early-ST group (mean difference (MD), 392.2 g (95% CI, 59.1-726.7 g); P = 0.02), as was the mean GA at delivery (MD, 2.47 weeks (95% CI, 0.04-4.91 weeks); P = 0.049). There was no significant difference between dichorionic twin pregnancies undergoing early compared with late ST in terms of PPROM (P = 0.27), Cesarean delivery (P = 0.38), 5-min Apgar score < 7 (P = 0.35) and neonatal survival of the non-reduced twin (P = 0.54).

CONCLUSIONS

The risk of pregnancy loss prior to 24 weeks and the rate of PTB before 37, 34 and 32 weeks were significantly higher in dichorionic twin pregnancies undergoing late vs early ST, thus highlighting the importance of early diagnosis of fetal anomalies in twin pregnancies. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

P-356 Clinical implications of first-trimester ultrasound dating in singleton pregnancies obtained through in vitro fertilization

Study question

Is there a correspondence between ultrasound estimation of gestational age (GAUS) and its calculation based on embryo transfer date (GAIVF), in in-vitro fertilization (IVF) pregnancies?

Summary answer

GAUS and GAIVF are not overlapping, being the first mildly greater than the latter, maybe due to anticipated ovulation and fertilization or accelerated embryo development.

What is known already

In IVF pregnancies the precise date of conception is known. However, it is possible that some factors (such as a time delay between conception and implantation, an early in-vitro embryo development, and the maternal environment itself with its altered hormonal milieu) may influence the early stages of embryonic development. Data regarding first-trimester fetal development in IVF pregnancies are in fact conflicting and both underestimation and overestimation of the true GA were reported when traditional charts were used for ultrasound pregnancy dating.

Study design, size, duration

A retrospective study was performed, including all singleton IVF pregnancies who underwent the first-trimester ultrasound scan for the screening of aneuploidies between January 2014 and June 2019. For each pregnancy GA was determined using two alternative methods: one based on the date of embryo transfer (GAIVF), and one based on ultrasound measurement of crown-rump length (CRL) (GAUS). GA were compared to search for any discrepancy. The impact of pregnancy dating on obstetric outcome was evaluated.

Participants/materials, setting, methods

All women with singleton pregnancies conceived by conventional IVF or intracytoplasmic sperm injection (ICSI), who performed first-trimester ultrasound scan for the screening of aneuploidies at the Department of Obstetrics and Gynecology ‘L. Mangiagalli', Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, were included. Exclusion criteria were as follows: multiple pregnancy (i.e., the evidence of more than one gestational sac at the first ultrasound scan), abnormal karyotype and/or congenital malformations detected either in pre- or postnatal period.

Main results and the role of chance

Overall, 249 women were selected: 111 pregnancies (45%) by conventional IVF, and 138 (55%) by ICSI. Among the included women, 127 (51%) pregnancies resulted from frozen-thawed embryo transfer. At first trimester ultrasound scan, the discrepancy in days between GAUS and GAIVF was ≥ 4 days in 32 cases (13%, 95%CI: 9-18%). It ranged within 2 and 3 days in 100 cases (40%, 95%CI: 34-47%). In 117 cases (47%, 95%CI: 41-53%) GAUS and GAIVF overlapped or showed a discrepancy of ± 1 day. Comparing GAUS and GAIVF at first trimester ultrasound scan, the median values of GA were 88 [86 - 91] days and 87 [85 - 90] days, respectively (p &lt; 0.001). The median difference was 1 [0 - 2] days, with GAUS systematically higher than GAIVF. This discrepancy persisted when subgroups were analyzed comparing different IVF procedures (conventional IVF versus ICSI, cleavage versus blastocyst transfer, frozen versus fresh transfer). The overall duration of pregnancy differed, with median values of 274 [269 - 281] days in GAUS group and 273 [268 - 280] days in GAIVF group, (p &gt; 0.001). No impact of the dating method on obstetric outcomes was observed, being no differences in the rate of preterm birth or abnormal fetal growth.

Limitations, reasons for caution

This is a retrospective study and thus exposed to the inaccuracies of this study design. Moreover, being a single-centre study, the sample size is relatively small. Finally, ultrasound evaluations were performed by multiple operators: although they are all certified, there is some inter-individual variability that may impact on the results.

Wider implications of the findings

Despite a known date of conception, it is difficult to assume that the oocyte retrieval date precisely resembles the date of natural ovulation and conception. IVF seems to anticipate fertilization. On these bases, it would be advisable to date IVF pregnancies using GAUS to realign them to natural pregnancies.

Trial registration number

Not Applicable

Risk of fetal loss after chorionic villus sampling in twin pregnancy derived from propensity score matching analysis

OBJECTIVE

To estimate the risk of fetal loss associated with chorionic villus sampling (CVS) in twin pregnancy, using propensity score analysis.

METHODS

This was a multicenter cohort study of women with twin pregnancy undergoing ultrasound examination at 11-13 weeks' gestation, performed in eight fetal medicine units in which the leadership were trained at the Harris Birthright Research Centre for Fetal Medicine in London, UK, and in which the protocols for screening, invasive testing and pregnancy management are similar. The risk of death of at least one fetus was compared between pregnancies that had and those that did not have CVS, after propensity score matching (1:1 ratio). This procedure created two comparable groups by balancing the maternal and pregnancy characteristics that lead to CVS being performed, similar to how randomization operates in a randomized clinical trial.

RESULTS

The study population of 8581 twin pregnancies included 445 that had CVS. Death of one or two fetuses at any stage during pregnancy occurred in 11.5% (51/445) of pregnancies in the CVS group and in 6.3% (515/8136) in the non-CVS group (P < 0.001). The propensity score algorithm matched 258 cases that had CVS with 258 non-CVS cases; there was at least one fetal loss in 29 (11.2%) cases in the CVS group and in 35 (13.6%) cases in the matched non-CVS group (odds ratio (OR), 0.81; 95% CI, 0.48-1.35; P = 0.415). However, there was a significant interaction between the risk of fetal loss after CVS and the background risk of fetal loss; when the background risk was higher, the risk of fetal loss after CVS decreased (OR, 0.46; 95% CI, 0.23-0.90), while, in pregnancies with a lower background risk of fetal loss, the risk of fetal loss after CVS increased (OR, 2.45; 95% CI, 0.95-7.13). The effects were statistically significantly different (P-value of the interaction = 0.005). For a pregnancy in which the background risk of fetal loss was about 6% (the same as in our non-CVS population), there was no change in the risk of fetal loss after CVS, but, when the background risk was more than 6%, the posterior risk was paradoxically reduced, and when the background risk was less than 6%, the posterior risk increased exponentially; for example, if the background risk of fetal loss was 2.0%, the relative risk was 2.8 and the posterior risk was 5.6%.

CONCLUSION

In twin pregnancy, after accounting for the risk factors that lead to both CVS and spontaneous fetal loss and confining the analysis to pregnancies at lower prior risk, CVS seems to increase the risk of fetal loss by about 3.5% above the patient's background risk. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Low torcular Herophili position and large brainstem-tentorium angle in fetuses with open spinal dysraphism at 11-13 weeks' gestation

OBJECTIVE

To evaluate whether in fetuses with open spina bifida (OSB) the tentorium can be seen to be displaced downwards and vertically oriented by the time of the 11-13-week scan and whether this is reflected in an alteration of the brainstem-tentorium (BST) angle.

METHODS

The study population was recruited between 2015 and 2020 from three fetal medicine referral centers and comprised a control group and a study group of pregnancies with OSB. The control group was recruited prospectively and included singleton pregnancies with a normal sonographic examination after first-trimester combined screening for chromosomal abnormalities and normal outcome. The study group was selected retrospectively and included all cases with OSB between 2015 and 2020. All cases underwent detailed ultrasound assessment at 11 + 0 to 13 + 6 weeks' gestation. The position of the torcular Herophili (TH) was identified in the midsagittal view of the fetal brain with the use of color Doppler and was considered as a proxy for the insertion of the tentorium on the fetal skull. The BST angle was calculated in the same view and was compared between the two groups.

RESULTS

Sixty normal fetuses were included in the control group and 22 fetuses with OSB in the study group. In both groups, the BST angle was found to be independent of gestational age or crown-rump length (P = 0.8815, R²  = 0.0003861 in the controls, and P = 0.2665, R²  = 0.00978 in the OSB group). The mean BST angle was 48.7 ± 7.8° in controls and 88.1 ± 1.18°, i.e. close to 90°, in fetuses with OSB. Comparison of BST-angle measurements between the control group and cases with OSB showed a statistically significant difference (P = 0.0153). In all fetuses with OSB, the downward displacement of the TH and tentorium was clearly visible at the 11-13-week scan.

CONCLUSIONS

In fetuses with OSB, the BST angle is significantly larger than in normal controls, with the tentorium being almost perpendicular to the brainstem. This sign confirms the inferior displacement of the tentorium cerebelli with respect to its normal insertion on the occipital clivus as early as the first trimester of pregnancy and is useful in the diagnosis of Chiari-II malformation at this early stage. In fetuses with OSB, the low position of the tentorium and TH is clearly visible, even subjectively, at the 11-13-week scan. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Position of the choroid plexus of the fourth ventricle in first- and second-trimester fetuses: a novel approach to early diagnosis of cystic posterior fossa anomalies

OBJECTIVE

To describe the sonographic appearance and position of the choroid plexus of the fourth ventricle (4V-CP) between 12 and 21 weeks' gestation in normal fetuses and in fetuses with Dandy-Walker malformation (DWM) or Blake's pouch cyst (BPC).

METHODS

The study population comprised 90 prospectively recruited normal singleton pregnancies and 41 pregnancies identified retrospectively from our institutional database that had a suspected posterior fossa anomaly at 12-13 weeks' gestation based on the ultrasound finding of abnormal hindbrain spaces. In all cases the final diagnosis was confirmed by prenatal and/or postnatal magnetic resonance imaging or postmortem examination. All pregnancies underwent a detailed ultrasound assessment, including a dedicated examination of the posterior fossa, at 12-13 weeks, 15-16 weeks and 20-21 weeks of gestation. Two-dimensional ultrasound images of the midsagittal and coronal views of the brain through the posterior fontanelle and three-dimensional volume datasets were obtained. Multiplanar orthogonal image correlation with volume contrast imaging was used as the reference visualization mode. Two independent operators, blinded to the fetal outcome, were asked to classify the 4V-CP as visible or not visible in both normal and abnormal cases, and to assess if the 4V-CP was positioned inside or outside the cyst in fetuses with DWM and BPC.

RESULTS

Of the 41 fetuses with apparently isolated cystic posterior fossa anomaly in the first trimester, eight were diagnosed with DWM, 29 were diagnosed with BPC and four were found to be normal in the second trimester. The position of the 4V-CP differed between DWM, BPC and normal cases in the first- and second-trimester ultrasound examinations. In particular, in normal fetuses, no cyst was present and, in the midsagittal and coronal planes of the posterior fossa, the 4V-CP appeared as an echogenic oval-shaped structure located inside the 4V apparently attached to the cerebellar vermis. In fetuses with DWM, the 4V-CP was not visible in the midsagittal view because it was displaced inferolaterally by the cyst. In contrast, in the coronal view of the posterior brain, the 4V-CP was visualized in all cases with DWM at 12-13 weeks, with a moderate decrease in the visualization rate at 15-16 weeks (87.5%) and at 20-21 weeks (75%). In the coronal view, the 4V-CP was classified as being outside the cyst in all DWM cases at 12-13 weeks and in 87.5% and 75% of cases at 15-16 and 20-21 weeks, respectively. In fetuses with BPC, the 4V-CP was visualized in all cases in both the midsagittal and coronal views at 12-13 weeks and in 100% and 96.6% of cases, respectively, at 15-16 weeks. In the coronal view, the 4V-CP was classified as being inside the cyst in 28 (96.6%), 27 (93.1%) and 25 (86.2%) cases at 12-13, 15-16 and 20-21 weeks, respectively. The medial segment of the 4V-CP was visualized near the inferior part of the vermis.

CONCLUSIONS

Our study shows that longitudinal ultrasound assessment of the 4V-CP and its temporal changes from 12 to 21 weeks is feasible. The 4V-CP is located inside the cyst, just below the vermis, in BPC and outside the cyst, inferolaterally displaced and distant from the vermian margin, in DWM, consistent with the pathogenesis of the two conditions. The position of the 4V-CP is a useful sonographic marker that can help differentiate between DWM and BPC as early as in the first trimester of pregnancy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization

OBJECTIVE

A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome.

METHODS

This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation.

RESULTS

A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization.

CONCLUSION

Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal loss after chorionic villus sampling in twin pregnancy

OBJECTIVE

To estimate the chorionic villus sampling (CVS)-related risk of fetal loss in twin pregnancy after adjustment for chorionicity, nuchal translucency thickness (NT), intertwin discordance in crown-rump length (CRL), maternal demographic characteristics and serum pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG).

METHODS

This was a multicenter study from eight fetal medicine units in which the leadership were trained at the Harris Birthright Research Centre for Fetal Medicine in London, UK, and in which the protocols for screening, invasive testing and pregnancy management are similar. Data were obtained prospectively from women with twin pregnancy undergoing routine ultrasound examination at 11-13 weeks' gestation. Multivariable logistic regression analysis with backward stepwise elimination was used to examine whether CVS provided a significant independent contribution to the prediction of risk of fetal loss after adjusting for maternal and pregnancy characteristics, including maternal age, racial origin and weight, method of conception, smoking status, parity, chorionicity, intertwin discordance in CRL, fetal NT ≥ 95^th percentile and free β-hCG and PAPP-A multiples of the median. Similarly, within the CVS group, multivariable logistic regression analysis was used to investigate the effect of the number of intrauterine needle insertions and size of the needle on the risk of fetal loss.

RESULTS

The study population of 8581 twin pregnancies undergoing ultrasound examination at 11-13 weeks' gestation included 316 dichorionic and 129 monochorionic twins that had CVS. First, in twin pregnancies undergoing CVS, compared to those not undergoing CVS, there was a 2-fold increased risk of fetal loss at < 24 weeks' gestation and of loss at any stage in pregnancy. Second, the factors providing a significant independent contribution to the prediction of miscarriage or fetal loss in twin pregnancy were increased maternal weight, black racial origin, monochorionicity, and more so monoamnionicity, large intertwin discordance in CRL and increased fetal NT, and, in the case of fetal loss at any stage, there was also a contribution from assisted conception and low serum PAPP-A. Third, after adjustment for maternal and pregnancy characteristics, CVS did not provide a significant contribution to the risk of fetal loss. Fourth, in twin pregnancies that had CVS, there was no significant contribution to fetal loss from the number of intrauterine needle insertions or needle size.

CONCLUSION

The 2-fold increased risk of fetal loss following CVS in twin pregnancy can, to a great extent, be explained by maternal and pregnancy characteristics rather than the invasive procedure itself. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Maternal exposure to air pollutants, PCSK9 levels, fetal growth and gestational age - An Italian cohort

OBJECTIVE

Exposure to airborne pollutants during pregnancy appears to be associated with uterine growth restriction and adverse neonatal outcome. Proprotein convertase subtilisin/kexin type (PCSK9), the key modulator of low-density lipoprotein (LDL) metabolism, increases following particulate matter (PM₁₀) exposure. Because maternal cholesterol is required for fetal growth, PCSK9 levels could be used to evaluate the potential impact of airborne pollutants on fetal growth.

DESIGN

A cohort of 134 healthy women during early pregnancy (11-12 weeks of gestational age) was studied.

RESULTS

A significant association between circulating PCSK9 levels and three tested air pollutants (PM₁₀, PM_2.5, nitric oxide (NO₂)) was found. Of importance, gestational age at birth was reduced by approximately 1 week for each 100 ng/mL rise in circulating PCSK9 levels, an effect that became more significant at the highest quartile of PM_2.5 (with a 1.8 week advance in delivery date for every 100 ng/mL rise in circulating PCSK9; p for interaction = 0.026). This finding was supported by an elevation of the odds ratio for urgent cesarean delivery for each 100 ng/mL rise in PCSK9 (2.99, 95% CI, 1.22-6.57), similar trends being obtained for PM₁₀ and NO₂.

CONCLUSIONS

The association between exposure to air pollutants during pregnancy and elevation in PCSK9 advances our understanding of the unforeseen influences of environmental exposure in terms of pregnancy associated disorders.

Access to emergency care units by socially vulnerable patients: a qualitative research

Background

The increasing prevalence of chronic diseases, the decline in medical demography, the ramp up of new information and diagnosis technologies, together with the growing health social inequalities urge decision makers to rethink the access to emergency care units (ECU) and reduce the rate of multiple admissions, especially for people living in vulnerable conditions. Beyond the medical causes of access to ECU, it is crucial to understand the psychosocial representations of patients and health professionals.

Methods

23 socially vulnerable patients who have already been admitted within the last 3 months and ECU health/social professionals were interviewed face-to-face by a psychosocial scientist using a semi-directed approach, in 3 hospitals. The thematic content of data was analyzed in order to identify salient social representations of access to ECU.

Results

27 themes emerged to understand the issue of the access to ECU, joining into 5 main categories: perceived needs for access to ECU, perception of precariousness, the relationship of patients and professionals with the healthcare system, the shared experience of aggressiveness in ECU, expectations in post-emergency support. As regards the needs for access to ICU, several issues were identified: exemption from making upfront payments, needs for listening, support, reinsurance, privacy and consideration of emergency professionals, referral by general practitioners (GP), difficult access to GP, needs for immediacy and timely healthcare services, permanent opening of ECU. As regards the experience of ECU professionals: ambivalent emotions towards socially vulnerable patients, a recurrence of passages leading to a reduced medical attention, a feeling of failure to care for vulnerable patients, coping strategies in caring for these patients.

Conclusions

Our results bring several leads to improve the organization and the management of healthcare in ECU and in primary care for socially vulnerable patients.

Key messages

To identify the psychosocial rationales of access to emergency care units provides several leads to build a more efficient healthcare policy and reduce the burden of overloaded services. To reduce the overburden of emergency services can only be achieved by a global approach of the access to both emergency and primary care and a better support after emergency discharge.

Role of magnetic resonance imaging in fetuses with mild or moderate ventriculomegaly in the era of fetal neurosonography: systematic review and meta-analysis

OBJECTIVES

To report the rate of additional central nervous system (CNS) anomalies detected exclusively on prenatal magnetic resonance imaging (MRI) in fetuses diagnosed with isolated mild or moderate ventriculomegaly (VM) on ultrasound, according to the type of ultrasound protocol adopted (dedicated neurosonography vs standard assessment of the fetal brain), and to explore whether the diagnostic performance of fetal MRI in detecting such anomalies is affected by gestational age at examination and laterality and degree of ventricular dilatation.

METHODS

MEDLINE, EMBASE, CINAHL and Clinicaltrials.gov were searched for studies reporting on the prenatal MRI assessment of fetuses diagnosed with isolated mild or moderate VM (ventricular dilatation of 10-15 mm) on ultrasound. Additional anomalies detected only on MRI were classified as callosal, septal, posterior fossa, white matter, intraventricular hemorrhage, cortical, periventricular heterotopia, periventricular cysts or complex malformations. The rate of additional anomalies was compared between fetuses diagnosed on dedicated neurosonography, defined as a detailed assessment of the fetal brain, according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines, and those diagnosed on standard fetal brain assessment. The rate of additional CNS anomalies missed on prenatal MRI and detected only at birth was calculated and compared between fetuses that had early (at or before 24 weeks' gestation) and those that had late (after 24 weeks) MRI. Subanalysis was performed according to the laterality (uni- vs bilateral) and degree (mild vs moderate, defined as ventricular dilatation of 10-12 and 13-15 mm, respectively) of ventricular dilatation. Whether MRI assessment led to a significant change in prenatal management was explored. Random-effects meta-analysis of proportions was used.

RESULTS

Sixteen studies (1159 fetuses) were included in the systematic review. Overall, MRI detected an anomaly not identified on ultrasound in 10.0% (95% CI, 6.2-14.5%) of fetuses. However, when stratifying the analysis according to the type of ultrasound assessment, the rate of associated anomalies detected only on MRI was 5.0% (95% CI, 3.0-7.0%) when dedicated neurosonography was performed compared with 16.8% (95% CI, 8.3-27.6%) in cases that underwent a standard assessment of the fetal brain in the axial plane. The overall rate of an additional anomaly detected only at birth and missed on prenatal MRI was 0.9% (95% CI, 0.04-1.5%) (I² , 0%). There was no difference in the rate of an associated anomaly detected only after birth when fetal MRI was carried out before, compared with after, 24 weeks of gestation (P = 0.265). The risk of detecting an associated CNS abnormality on MRI was higher in fetuses with moderate than in those with mild VM (odds ratio, 8.1 (95% CI, 2.3-29.0); P = 0.001), while there was no difference in those presenting with bilateral, compared with unilateral, dilatation (P = 0.333). Finally, a significant change in perinatal management, mainly termination of pregnancy owing to parental request, following MRI detection of an associated anomaly, was observed in 2.9% (95% CI, 0.01-9.8%) of fetuses undergoing dedicated neurosonography compared with 5.1% (95% CI, 3.2-7.5%) of those having standard assessment.

CONCLUSIONS

In fetuses undergoing dedicated neurosonography, the rate of a CNS anomaly detected exclusively on MRI is lower than that reported previously. Early MRI has an excellent diagnostic performance in identifying additional CNS anomalies, although the findings from this review suggest that MRI performed in the third trimester may be associated with a better detection rate for some types of anomaly, such as cortical, white matter and intracranial hemorrhagic anomalies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks' gestation

OBJECTIVE

To examine the performance of screening for early, preterm and term pre-eclampsia (PE) at 11-13 weeks' gestation by maternal factors and combinations of mean arterial pressure (MAP), uterine artery (UtA) pulsatility index (PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A).

METHODS

The data for this study were derived from three previously reported prospective non-intervention screening studies at 11 + 0 to 13 + 6 weeks' gestation in a combined total of 61 174 singleton pregnancies, including 1770 (2.9%) that developed PE. Bayes' theorem was used to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics, with various combinations of biomarker multiples of the median (MoM) values to derive patient-specific risks of delivery with PE at < 37 weeks' gestation. The performance of such screening was estimated.

RESULTS

In pregnancies that developed PE, compared to those without PE, the MoM values of UtA-PI and MAP were increased and those of PAPP-A and PlGF were decreased, and the deviation from normal was greater for early than late PE for all four biomarkers. Combined screening by maternal factors, UtA-PI, MAP and PlGF predicted 90% of early PE, 75% of preterm PE and 41% of term PE, at a screen-positive rate of 10%; inclusion of PAPP-A did not improve the performance of screening. The performance of screening depended on the racial origin of the women; on screening by a combination of maternal factors, MAP, UtA-PI and PlGF and using a risk cut-off of 1 in 100 for PE at < 37 weeks in Caucasian women, the screen-positive rate was 10% and detection rates for early, preterm and term PE were 88%, 69% and 40%, respectively. With the same method of screening and risk cut-off in women of Afro-Caribbean racial origin, the screen-positive rate was 34% and detection rates for early, preterm and term PE were 100%, 92% and 75%, respectively.

CONCLUSION

Screening by maternal factors and biomarkers at 11-13 weeks' gestation can identify a high proportion of pregnancies that develop early and preterm PE. © 2018 Crown copyright. Ultrasound in Obstetrics & Gynecology © 2018 ISUOG.

Prediction and prevention of small-for-gestational-age neonates: evidence from SPREE and ASPRE

OBJECTIVES

To examine the effect of first-trimester screening for pre-eclampsia (PE) on the prediction of delivering a small-for-gestational-age (SGA) neonate and the effect of prophylactic use of aspirin on the prevention of SGA.

METHODS

The data for this study were derived from two multicenter studies. In SPREE, we investigated the performance of screening for PE by a combination of maternal characteristics and biomarkers at 11-13 weeks' gestation. In ASPRE, women with a singleton pregnancy identified by combined screening as being at high risk for preterm PE (> 1 in 100) participated in a trial of aspirin (150 mg/day from 11-14 until 36 weeks' gestation) compared to placebo. In this study, we used the data from the ASPRE trial to estimate the effect of aspirin on the incidence of SGA with birth weight < 10^th , < 5^th and < 3^rd percentile for gestational age. We also used the data from SPREE to estimate the proportion of SGA in the pregnancies with a risk for preterm PE of > 1 in 100.

RESULTS

In SPREE, screening for preterm PE by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index and serum placental growth factor identified a high-risk group that contained about 46% of SGA neonates < 10^th percentile born at < 37 weeks' gestation (preterm) and 56% of those born at < 32 weeks (early); the overall screen-positive rate was 12.2% (2014 of 16 451 pregnancies). In the ASPRE trial, use of aspirin reduced the overall incidence of SGA < 10^th percentile by about 40% in babies born at < 37 weeks' gestation and by about 70% in babies born at < 32 weeks; in babies born at ≥ 37 weeks, aspirin did not have a significant effect on incidence of SGA. The aspirin-related decrease in incidence of SGA was mainly due to its incidence decreasing in pregnancies with PE, for which the decrease was about 70% in babies born at < 37 weeks' gestation and about 90% in babies born at < 32 weeks. On the basis of these results, it was estimated that first-trimester screening for preterm PE and use of aspirin in the high-risk group would potentially reduce the incidence of preterm and early SGA by about 20% and 40%, respectively.

CONCLUSION

First-trimester screening for PE by the combined test identifies a high proportion of cases of preterm SGA that can be prevented by the prophylactic use of aspirin. © 2018 Crown copyright. Ultrasound in Obstetrics & Gynecology © 2018 ISUOG.

Prospective comparative study of characteristics associated with influenza A and B in adults

OBJECTIVES

To describe and compare the epidemiological characteristics associated with influenza type A and B as well as the characteristics associated with influenza pneumonia. The secondary objective was to evaluate the performance of influenza rapid diagnostic tests (RDT) in the emergency department.

PATIENTS AND METHODS

Prospective study, including 251 adult patients admitted to the emergency department during the 2013-2014 influenza outbreaks for flu-like illness confirmed by RT-PCR.

RESULTS

A total of 106 patients were infected with influenza type B (42%) and 145 with influenza type A (58%). Mean age was 56 and the sex-ratio was 0.9. In a multivariate analysis, the only factor independently related with the type of influenza strain was the patient's age. Overall, 17% of influenza-infected patients were vaccinated and 38% presented with pneumonia, with no significant difference between strains. In a univariate analysis, the risk factors associated with the occurrence of pneumonia were age, vaccination, and chronic obstructive pulmonary disease. Only 22% of samples positive by RT-PCR for influenza B and 40% for influenza A were positive by RDT.

CONCLUSION

Influenza type A and type B had similar clinical and biological signs, including severity. Influenza type B should not be neglected. Any emergency department may use the RDT for its ease-of-use and rapidity. However, its low sensitivity should be taken into consideration when interpreting results.

ASPRE trial: performance of screening for preterm pre-eclampsia

OBJECTIVE

To examine the performance of screening for preterm and term pre-eclampsia (PE) in the study population participating in the ASPRE (Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention) trial.

METHODS

This was a prospective first-trimester multicenter study on screening for preterm PE in 26 941 singleton pregnancies by means of an algorithm that combines maternal factors, mean arterial pressure, uterine artery pulsatility index and maternal serum pregnancy-associated plasma protein-A and placental growth factor at 11-13 weeks' gestation. Eligible women with an estimated risk for preterm PE of > 1 in 100 were invited to participate in a double-blind trial of aspirin (150 mg per day) vs placebo from 11-14 until 36 weeks' gestation, which showed that, in the aspirin group, the incidence of preterm PE was reduced by 62%. In the screened population, the detection rates (DRs) and false-positive rates (FPRs) for delivery with PE < 37 and ≥ 37 weeks were estimated after adjustment for the effect of aspirin in those receiving this treatment. We excluded 1144 (4.2%) pregnancies because of loss to follow-up or study withdrawal (n = 716), miscarriage (n = 243) or termination (n = 185).

RESULTS

The study population of 25 797 pregnancies included 180 (0.7%) cases of preterm PE, 450 (1.7%) of term PE and 25 167 (97.6%) without PE. In combined first-trimester screening for preterm PE with a risk cut-off of 1 in 100, the DR was 76.7% (138/180) for preterm PE and 43.1% (194/450) for term PE, at screen-positive rate of 10.5% (2707/25 797) and FPR of 9.2% (2375/25 797).

CONCLUSION

The performance of screening in the ASPRE study was comparable with that of a study of approximately 60 000 singleton pregnancies used for development of the algorithm; in that study, combined screening detected 76.6% of cases of preterm PE and 38.3% of term PE at a FPR of 10%. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

New minimally invasive technique for cystoscopic laser treatment of fetal ureterocele

Prenatal ultrasound detection of fetal ureterocele with bilateral hydroureteronephrosis, obstruction of the bladder outlet and progressive amniotic fluid reduction have been associated with a significant risk of end-stage chronic renal disease after birth. Fetal cystoscopic laser incision of the ureterocele, using standard 3.5-mm fetoscopic access to the amniotic cavity and the fetal bladder with the aim of relieving the bladder outflow obstruction to preserve renal function, has been reported previously in a case with a favorable outcome. We report on two additional cases of fetal ureterocele treated by cystoscopic laser decompression. In the first case, a standard 3.3-mm uterine entry was used. In the second case, a new approach was adopted using an 'all-seeing needle' 1.6-mm endoscope. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Accuracy of competing-risks model in screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks' gestation

OBJECTIVE

To examine the diagnostic accuracy of a previously developed model for prediction of pre-eclampsia (PE) by a combination of maternal factors and biomarkers at 11-13 weeks' gestation.

METHODS

This was a prospective first-trimester multicenter study of screening for PE in 8775 singleton pregnancies. A previously published algorithm was used for the calculation of patient-specific risk of PE in each individual. The detection rates (DRs) and false-positive rates (FPRs) for delivery with PE < 32, < 37 and ≥ 37 weeks were estimated and compared with those for the dataset used for development of the algorithm.

RESULTS

In the study population, 239 (2.7%) cases developed PE, of which 17 (0.2%), 59 (0.7%) and 180 (2.1%) developed PE < 32, < 37 and ≥ 37 weeks, respectively. With combined screening by maternal factors, mean arterial pressure, uterine artery pulsatility index and serum placental growth factor, the DR was 100% (95% CI, 80-100%) for PE < 32 weeks, 75% (95% CI, 62-85%) for PE < 37 weeks and 43% (95% CI, 35-50%) for PE ≥ 37 weeks, at a 10% FPR. These DRs were similar to the estimated rates for the dataset used for development of the model: 89% (95% CI, 79-96%) for PE < 32 weeks, 75% (95% CI, 70-80%) for PE < 37 weeks and 47% (95% CI, 44-51%) for PE ≥ 37 weeks.

CONCLUSION

Assessment of a combination of maternal factors and biomarkers at 11-13 weeks provides effective first-trimester screening for preterm PE. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Sphenofrontal distance on three-dimensional ultrasound in euploid and trisomy-21 fetuses at 16-24 weeks' gestation

OBJECTIVE

To compare the distance between the sphenoid and frontal bones on three-dimensional (3D) ultrasound in euploid and trisomy-21 fetuses at 16-24 weeks' gestation.

METHODS

We acquired 3D volumes of the fetal profile from 80 normal and 30 trisomy-21 fetuses at 16-24 weeks' gestation. We used the multiplanar mode to obtain the mid-sagittal plane and measured the sphenofrontal distance as the shortest distance between the most anterior edge of the sphenoid bone and the lowest edge of the frontal bone.

RESULTS

In normal fetuses, the sphenofrontal distance increased linearly with gestational age, from 15.1 mm at 16 weeks to 18.2 mm at 24 weeks. In fetuses with trisomy 21, the mean sphenofrontal distance delta value was significantly smaller than in normal cases (-3.447 mm (95% CI, -5.684 to -1.211 mm); P < 0.01). The sphenofrontal distance was below the 5(th) and 1(st) percentiles of the normal range in 29 (96.7%) and 27 (90.0%) trisomy-21 fetuses, respectively.

CONCLUSIONS

The sphenofrontal distance is shorter at 16-24 weeks' gestation in fetuses with trisomy 21 than in normal fetuses. A reduction in the growth of the anterior cranial base contributes to the mid-facial hypoplasia observed in fetuses with trisomy 21. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Stomach position in prediction of survival in left-sided congenital diaphragmatic hernia with or without fetoscopic endoluminal tracheal occlusion

OBJECTIVE

To investigate the value of fetal stomach position in predicting postnatal outcome in left-sided congenital diaphragmatic hernia (CDH) with and without fetoscopic endoluminal tracheal occlusion (FETO).

METHODS

This was a retrospective review of CDH cases that were expectantly managed or treated with FETO, assessed from May 2008 to October 2013, in which we graded, on a scale of 1-4, stomach position on the four-chamber view of the heart with respect to thoracic structures. Logistic regression analysis was used to investigate the effect of management center (Paris, Brussels, Barcelona, Milan), stomach grading, observed-to-expected lung area-to-head circumference ratio (O/E-LHR), gestational age at delivery, birth weight in expectantly managed CDH, gestational ages at FETO and at removal and period of tracheal occlusion, on postnatal survival in CDH cases treated with FETO.

RESULTS

We identified 67 expectantly managed CDH cases and 47 CDH cases that were treated with FETO. In expectantly managed CDH, stomach position and O/E-LHR predicted postnatal survival independently. In CDH treated with FETO, stomach position and gestational age at delivery predicted postnatal survival independently.

CONCLUSION

In left-sided CDH with or without FETO, stomach position is predictive of postnatal survival.

[SECOND STAGE IN MINIINVASIVE FETAL SURGERY FOR SEVERE CONGENITAL DIAPHRAGMATIC HERNIA. CASE REPORT]

We present a case of miniinvasive fetal surgery for CDH treated at 28 and 34 weeks of gestation. The first step was successfully performed at 28 weeks with Fetal Endoscopic Tracheal Occlusion with ballon. The second step was performed at 34 weeks for balloon removal. The necessity of fetal cytogenetic assessment and array CGH was carried out to exclude gene disorders that could lead to poor long-term outcome. A planned SC and optimal neonatology management were followed by a surgical operation of the newborn. Experienced interdisciplinary team successfully provide a perinatal and postnatal surgery for severe CDH. The newborn was discharged from the hospital 3 weeks after the repairing operation in a good condition.

Fetal right ventricular contraction and relaxation times at 11-13 weeks' gestation on speckle tracking imaging

OBJECTIVE

To examine the contraction time and relaxation time of the right ventricle at 11-13 weeks' gestation in trisomy 21 and euploid fetuses by speckle tracking ultrasound imaging.

METHODS

Measurement of fetal nuchal translucency (NT) thickness, Doppler assessment for tricuspid regurgitation and reversed A-wave in the ductus venosus (DV) and fetal echocardiography were performed immediately before chorionic villus sampling for fetal karyotyping at 11-13 weeks' gestation. Digital videoclips of the four-chamber view of the fetal heart were recorded and analyzed offline using speckle tracking imaging software. The contraction time, which is the time between the highest and lowest peaks in the right ventricular area, and relaxation time, which is the time between the lowest and the subsequent highest area peak, were measured and expressed as a percentage of the duration of the cardiac cycle. Values in trisomy 21 and euploid fetuses were compared.

RESULTS

Mean contraction time and relaxation time in 119 euploid fetuses were 52.1% (95% CI, 51.6-52.8%) and 47.8% (95% CI, 47.2-48.4%), respectively. In 21 trisomy 21 fetuses, mean contraction time was significantly higher (57.0% (95% CI, 55.2-58.9%); P<0.01) and relaxation time lower (42.9% (95% CI, 41.1-44.8%); P<0.01) than in euploid fetuses. Multiple regression analysis showed that significant contributions to contraction time and relaxation time were provided by fetal karyotype, NT and tricuspid regurgitation, but not by reversed A-wave in the DV or the presence of a cardiac defect.

CONCLUSION

In first-trimester fetuses with trisomy 21 and in euploid fetuses with increased NT and tricuspid regurgitation there is evidence of increased right ventricular contraction time and shortening of the relaxation time.

Comparison of echocardiographic findings in fetuses at less than 15 weeks' gestation with later cardiac evaluation

OBJECTIVE

To compare the echocardiographic findings in fetuses at < 15 weeks' gestation with a later follow-up scan, and determine both the accuracy of early diagnosis and the frequency of findings that change between scans.

METHODS

For the period 2002 to the end of 2009, we searched our database for all patients who had had a detailed fetal echocardiogram at less than 15 completed weeks' gestation and a repeat scan at least 6 weeks later.

RESULTS

Of 1200 patients fulfilling our selection criteria, the cardiac findings were normal at both scans in 1069. In 46 cases the same cardiac abnormality was seen at both scans. There was a false-positive diagnosis at early scan in seven cases. In 50 cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 29 fetuses, there was discordance between the early and later morphological diagnosis, 15/29 being considered significant differences, with 10/15 representing true progression of findings between the early and later scans, rather than missed or incorrect diagnoses.

CONCLUSIONS

A high degree of accuracy in the identification of congenital heart disease can be achieved by early fetal echocardiography (sensitivity 84.8 (95% CI, 75.0-91.9)%, specificity 95.3 (95% CI, 93.9-96.4)%), although the identification of every case of tetralogy of Fallot and small atrioventricular septal defects presents particular diagnostic challenges at this gestational age. A small but significant group showed progression of findings during this stage of rapid fetal heart growth, particularly in obstructive lesions.

Fetal echocardiography at 11-13 weeks by transabdominal high-frequency ultrasound

OBJECTIVES

To assess the accuracy of fetal echocardiography at 11-13 weeks performed by well-trained obstetricians using a high-frequency linear ultrasound transducer.

METHODS

Fetal echocardiography was performed by obstetricians immediately before chorionic villus sampling for fetal karyotyping at 11-13 weeks. Digital videoclips of the examination stored by the obstetrician were reviewed offline by a specialist fetal cardiologist.

RESULTS

The obstetrician suspected 95 (95%) of the 100 cardiac defects identified by the fetal cardiologist and made the correct diagnosis in 84 (84%) of these cases. In 54 fetuses, the defect was classified as major and in 46 it was minor. In 767 (86.6%) cases, the heart was normal and in 19 (2.1%) the views were inadequate for assessment of normality or abnormality. A subsequent second-trimester scan in the normal group identified major cardiac defects in four cases. Therefore, the first-trimester scan by the obstetricians and cardiologists identified 54 (93.1%) of the 58 major cardiac defects.

CONCLUSIONS

A well-trained obstetrician using high-resolution ultrasound equipment can assess the fetal heart at 11-13 weeks with a high degree of accuracy.

Three-dimensional ultrasound fetal lung volumes and infant respiratory outcome: a prospective observational study

OBJECTIVE

To determine if fetal lung volumes (FLVs), determined by three-dimensional rotational ultrasound and virtual organ computer-aided analysis software (vocal), correlated with neonatal respiratory outcomes in surviving infants who had a high risk [fetuses with congenital diaphragmatic hernia (CDH)], lower risk [fetuses with anterior wall defects (AWDs)] and no risk (controls) of abnormal antenatal lung growth.

DESIGN

Prospective observational study.

SETTING

Tertiary fetal medicine and neonatal intensive care units.

POPULATION

Sixty fetuses (25 with CDH, 25 with AWDs and ten controls).

METHODS

FLVs were measured and expressed as the percentage of the observed compared with the expected for gestational age.

MAIN OUTCOME MEASURES

Neonatal respiratory outcome was determined by the duration of supplemental oxygen, mechanical ventilation and dependencies, and assessment of lung volume using a gas dilution technique to measure functional residual capacity (FRC).

RESULTS

The infants with CDH had lower FLV results than both the infants with AWDs (P=0.05) and the controls (P<0.05). The infants with CDH had longer durations of mechanical ventilation (P<0.001) and supplementary oxygen (P<0.001) dependence, compared with infants with AWDs. The infants with CDH had a lower median FRC than both the infants with AWDs (P<0.001) and the controls (P<0.001). FLV results correlated significantly with the durations of dependency on ventilation (r= -0.744, P<0.01) and oxygen (r= -0.788, P<0.001), and with FRC results (r=0.429, P=0.001).

CONCLUSIONS

These results suggest that FLVs obtained using three-dimensional rotational ultrasound might be useful in predicting neonatal respiratory outcome in surviving infants who had varying risks of abnormal lung growth. Larger and more comprehensive studies are needed to clarify the role that lung volume measurements have in assessing lung function and growth.

Nasal-bone length in euploid fetuses at 16-24 weeks' gestation by three-dimensional ultrasound

OBJECTIVE

To establish a normal range of nasal-bone length at 16-24 weeks' gestation by the use of three-dimensional (3D) ultrasound and to investigate the effect of deviations from the exact mid-sagittal plane on the measurement of nasal-bone length.

METHODS

We acquired 3D volumes of the fetal profile from 135 normal fetuses at 16-24 weeks' gestation. The multiplanar mode was used to obtain the exact mid-sagittal plane and to produce parasagittal and oblique views of the fetal face. Nasal-bone length was measured in each plane and the sonographic landmarks of each profile view were examined.

RESULTS

Nasal-bone length increased with gestational age from a mean of 4.1 mm at 16 weeks to 7.1 mm at 24 weeks. There was a tendency to underestimate nasal-bone length when the measurements were taken in parasagittal planes and to overestimate the measurements when they were taken in oblique views, compared to the exact mid-sagittal plane. The mean difference in nasal-bone length from the one in the mid-sagittal plane was 0.42 and 0.63 mm for parasagittal measurements at 1 and 2 mm, respectively, from the midline, -0.08 and -0.51 mm for oblique measurements at 10 degrees and 20 degrees rotation along the z-axis and -0.69 mm for rotation of 20 degrees along the z-axis and 10 degrees along the y-axis. The vomeral bone was the only sonographic landmark defining the exact mid-sagittal plane of the face that was not visible in the parasagittal and oblique planes.

CONCLUSIONS

Parasagittal and oblique scanning planes may produce different degrees of under- or over-estimation of nasal-bone length compared to measurements systematically taken in the exact mid-sagittal plane. Inclusion of the vomeral bone in the definition of the exact mid-sagittal plane of the face could improve the reproducibility of measurements of nasal-bone length.

Prenasal thickness in trisomy-21 fetuses at 16-24 weeks of gestation

OBJECTIVE

To construct a reference range for fetal prenasal thickness between 16 and 24 weeks of gestation and to evaluate the thickness in fetuses with trisomy 21.

METHODS

We acquired three-dimensional (3D) volumes of the fetal profile from 135 normal fetuses and 26 fetuses with trisomy 21 at 16-24 weeks' gestation. We used the multiplanar mode to obtain the exact mid-sagittal plane and measured the prenasal thickness as the shortest distance between the anterior edge of the lowest part of the frontal bone (at the junction with the nasal bone when present) and the skin anteriorly.

RESULTS

In the normal group prenasal thickness increased with gestation from a mean of 2.4 mm at 16 weeks to 4.6 mm at 24 weeks. Repeatability studies demonstrated that in 95% of the cases the difference between two measurements of prenasal thickness by the same operator and by different operators was less than 1 mm. In the trisomy-21 fetuses the mean prenasal thickness was significantly larger than in normal fetuses and in 19 (73.1%) cases it was above the 95(th) centile of the normal range. There was no significant difference in prenasal thickness between the trisomic fetuses with and without ventriculomegaly, nuchal edema, absent nasal bone or a cardiac defect.

CONCLUSIONS

The fetal profile is routinely examined during the second-trimester scan and therefore the skill needed to obtain the view necessary for the measurement of prenasal thickness is widely available. If the finding of our study--that in more than 70% of fetuses with trisomy 21 prenasal thickness is above the 95(th) centile--is confirmed in prospective screening studies this measurement alone could prove a highly sensitive method of second-trimester screening for trisomy 21.

Frontomaxillary facial angle in screening for trisomy 21 at 11 + 0 to 13 + 6 weeks

OBJECTIVE

Trisomy 21 is associated with a flat face, which can now be quantified by measurement of the frontomaxillary facial (FMF) angle. The aim of this study was to examine whether in trisomy 21 fetuses fetal nuchal translucency (NT) thickness and maternal serum free ss-human chorionic gonadotropin (ss-hCG) and pregnancy-associated plasma protein-A (PAPP-A) are independent of the FMF angle, and to estimate the performance of a first-trimester screening test for trisomy 21 that includes measurement of the FMF angle.

METHODS

This was a prospective study in singleton pregnancies at 11 + 0 to 13 + 6 weeks of gestation in which three-dimensional volumes of the fetal head were obtained and measurement of the FMF angle performed immediately before fetal karyotyping by chorionic villus sampling (CVS). The women chose to have CVS after risk assessment by a combination of maternal age, fetal NT thickness and maternal serum free ss-hCG and PAPP-A. Regression analysis was used to examine the significance of the association within the euploid and within the trisomy 21 fetuses between the deviation from the normal median in FMF angle and the deviation in NT, free ss-hCG and PAPP-A. We estimated the detection rate (DR) and false positive rate (FPR) of first-trimester screening for trisomy 21 by measuring the FMF angle in all cases and of an alternative policy in which first-stage screening is by fetal NT and maternal serum biochemistry in all patients, followed by second-stage assessment of FMF angle only in those with an intermediate risk (1 in 51 to 1 in 1000) after the first stage.

RESULTS

The FMF angle was measured in 782 euploid and 108 trisomy 21 fetuses. In the euploid fetuses the mean FMF angle decreased linearly with CRL from 83.5 degrees at a crown-rump length (CRL) of 45 mm to 76.4 degrees at a CRL of 84 mm. In the euploid fetuses the mean delta FMF angle was 0.0 (SD, 4.264) degrees and the respective values in the trisomy 21 fetuses were 7.172 (SD, 4.092) degrees . Incorporating the FMF angle in first-trimester combined screening increased the estimated DR from 90 to 94% at an FPR of 5% and from 85 to 92% at an FPR of 3%. In two-stage screening it would be necessary to measure the FMF angle in 12% of cases and the DRs would be 93 and 91% at FPRs of 5 and 3%, respectively.

CONCLUSIONS

Measurement of the FMF angle improves the performance of first-trimester screening for trisomy 21.

Frontomaxillary facial angle in trisomy 21 fetuses at 16-24 weeks of gestation

OBJECTIVES

To establish a normal range for the frontomaxillary facial (FMF) angle by three-dimensional (3D) ultrasound imaging and to examine the FMF angle in trisomy 21 fetuses at 16-24 weeks of gestation.

METHODS

We measured the FMF angle using 3D volumes of the fetal profile obtained with the transducer parallel to the long axis of the nose and at 45 degrees to the palate, which had been acquired from 150 normal fetuses and 23 fetuses with trisomy 21.

RESULTS

In the normal group there was no significant association between the FMF angle and gestational age; the mean FMF angle was 83.9 degrees (range, 76.9-90.2 degrees ) and the 95(th) centile was 88.5 degrees . In 15 (65.2%) of the fetuses with trisomy 21 the FMF angle was greater than 88.5 degrees . Repeatability studies demonstrated that in 95% of cases the difference between two measurements of FMF angle by the same operator and different operators was less than 5 degrees .

CONCLUSIONS

In the majority of second-trimester fetuses with trisomy 21 the FMF angle is increased.

Frontomaxillary and mandibulomaxillary facial angles at 11 + 0 to 13 + 6 weeks in fetuses with trisomy 18

OBJECTIVE

To define the relative position of the maxilla and mandible in fetuses with trisomy 18 at 11 + 0 to 13 + 6 weeks of gestation.

METHODS

A three-dimensional (3D) volume of the fetal head was obtained before karyotyping at 11 + 0 to 13 + 6 weeks of gestation in 36 fetuses subsequently found to have trisomy 18, and 200 chromosomally normal fetuses. The frontomaxillary facial (FMF) angle and the mandibulomaxillary facial (MMF) angle were measured in a mid-sagittal view of the fetal face.

RESULTS

In the chromosomally normal group both the FMF and MMF angles decreased significantly with crown-rump length (CRL). In the trisomy 18 fetuses the FMF angle was significantly greater and the angle was above the 95(th) centile of the normal range in 21 (58.3%) cases. In contrast, in trisomy 18 fetuses the MMF angle was significantly smaller than that in normal fetuses and the angle was below the 5(th) centile of the normal range in 12 (33.3%) cases.

CONCLUSIONS

Trisomy 18 at 11 + 0 to 13 + 6 weeks of gestation is associated with both mid-facial hypoplasia and micrognathia or retrognathia that can be documented by measurement of the FMF angle and MMF angle, respectively.

Frontomaxillary facial angle in fetuses with trisomy 13 at 11 + 0 to 13 + 6 weeks

OBJECTIVE

To investigate the frontomaxillary facial (FMF) angle in fetuses with trisomy 13 at 11 + 0 to 13 + 6 weeks of gestation.

METHODS

A three-dimensional (3D) volume of the fetal head was obtained before karyotyping at 11 + 0 to 13 + 6 weeks of gestation in 23 fetuses with trisomy 13. The FMF angle, defined as the angle between the upper surface of the maxilla and the frontal bone in a midsagittal view of the fetal face, was measured and compared to the angle in 500 chromosomally normal fetuses.

RESULTS

In 10 of 12 (83.3%) fetuses with trisomy 13 and holoprosencephaly, the FMF angle was above the 95(th) centile of the normal range. In the 11 fetuses with no holoprosencephaly, the FMF angle was not significantly different from normal. There was no significant difference in the FMF angle between the trisomy 13 fetuses with and without facial cleft.

CONCLUSIONS

In fetuses with trisomy 13, the FMF angle at 11 + 0 to 13 + 6 weeks of gestation is increased only in cases with associated holoprosencephaly.

Frontomaxillary facial angle in chromosomally normal fetuses at 11 + 0 to 13 + 6 weeks

OBJECTIVE

To establish the normal range of the frontomaxillary facial (FMF) angle at 11 + 0 to 13 + 6 weeks of gestation.

METHODS

In this prospective study, three-dimensional (3D) volumes of the fetal head were obtained from 500 pregnancies before fetal karyotyping by chorionic villus sampling (CVS), after screening by fetal nuchal translucency (NT) thickness and maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at 11 + 0 to 13 + 6 weeks. Only cases with a normal karyotype were included in this study. The FMF angle was measured off-line. In a subgroup of 150 cases the FMF angle was measured using 2D ultrasound before obtaining a 3D volume. In 50 cases the 3D volumes were used to measure the FMF angle by the same examiner twice and by another examiner once.

RESULTS

The mean FMF angle decreased with crown-rump length (CRL) from 84.3 degrees at CRL 45 mm to 76.5 degrees at CRL 84 mm. There was no significant association between the FMF angle and fetal NT or serum PAPP-A or beta-hCG. In the volumes with paired measurements, the difference between two measurements by the same or two sonographers was < 5% in 95% of the cases. In the cases with paired 3D and 2D ultrasound measurements, the difference in FMF angles was < 8% in 95% of the cases.

CONCLUSIONS

At 11 + 0 to 13 + 6 weeks the FMF angle decreases with fetal CRL but is not related to fetal NT or serum biochemistry. The measurement is reproducible and the results obtained by 3D and 2D ultrasound are similar.

Uterine vascularization and pregnancy outcome in patients undergoing intracytoplasmatic sperm injection: the role of nitric oxide

PURPOSE

To evaluate whether, after pituitary desensitisation, the impedance to flow in the uterine vessels may be an indicator of an ICSI programme outcome, and to test the relationship between intrafollicular nitric oxide and oocyte/embryo quality.

METHODS

Thirty-eight women, on the basis of impedance to flow at the level of uterine artery, evaluated on the first day of COH, were divided in patients with normal (Pulsatility Index--PI, 2.5; Group II, n=27) PI values. The patients were submitted to hormonal, ultrasonographic and Doppler evaluations. Plasma and follicular fluid concentrations of nitrites/nitrate (NO(2) (-)/NO(3) (-)) were assayed.

RESULTS

In the Group I, the impedance to flow remained lower than in Group II and was associated to good quality embryos and to a higher pregnancy rate. Follicular fluid NO(2) (-)/NO(3) (-) levels were inversely correlated with the embryo quality. The uterine artery PI and the pregnancy rate were inversely correlated. The PIs analysed on the day 1 of stimulation, were positively correlated with those registered on day 8 and on the day of ovum pick-up.

CONCLUSIONS

A Doppler analysis done on day 1 of controlled ovarian hyperstimulation may be an useful indicator of ART outcome.

Female precocious puberty, obesity and polycystic-like ovaries

OBJECTIVE

To evaluate the characteristics of obese girls with gonadotropin releasing hormone-dependent precocious puberty with and without polycystic-like ovaries.

METHODS

Forty-seven overweight (> 75(th) centile of the Italian reference data) girls with a diagnosis of isosexual precocious puberty underwent auxological analysis, hormonal assay and utero-ovarian sonographic and Doppler evaluation. On the basis of sonography the patients were subdivided into two groups, girls presenting normal ovaries (Group I; n = 31) and those with polycystic-like ovaries (Group II; n = 16).

RESULTS

The mean body weight was significantly higher (P = 0.003) in Group II than it was in Group I. In addition, the patients with polycystic-like ovaries fell within our definition of superobese (> or = 97(th) centile of the Italian reference data) in 44% of cases. The uterine and ovarian volumes were significantly greater in Group II compared with Group I patients. The Doppler evaluation showed intraparenchymal ovarian vascularization and low downstream impedance to flow in all patients in Group II.

CONCLUSIONS

Girls with precocious puberty and polycystic ovaries, compared with those without polycystic ovaries, have a higher incidence of body weight exceeding the 85(th) centile of the Italian reference data (obesity).

Transdermal HRT and Doppler findings in normotensive and hypertensive postmenopausal patients

OBJECTIVE

To evaluate the effects of transdermal hormone replacement therapy (HRT) on plasma viscosity, serum levels of thromboxane B2 (TXB2) and vascular impedance in the uterine, bladder wall, internal carotid and ophthalmic arteries in normotensive and hypertensive postmenopausal patients.

METHODS

Thirty postmenopausal patients underwent continuous estradiol transdermal supplementation at a dose of 50 microg/day and 12-day courses of medroxyprogesterone acetate 10 mg/day every 2 months. The women were divided into two groups according to their blood pressure: normotensive women (Group 1, n=14) and hypertensive subjects (Group 2, n=16). Before starting HRT and after 6 months of therapy, the patients underwent: transvaginal ultrasonographic examination of the pelvic organs; Doppler examination of the blood flow velocities in the uterine, bladder wall, internal carotid and ophthalmic arteries; and analysis of plasma viscosity and plasma TXB2.

RESULTS

After 6 months of HRT plasma viscosity had decreased in both groups (mean reduction in Group 1, (14+/-1)%, P=0.005; mean reduction in Group 2, (10+/-1)%, P=0.005) as had the TXB2 levels (mean reduction in Group 1, (93+/-2)%, P<0.001; mean reduction in Group 2, (92+/-3)%, P<0.001). The mean percentage reduction in plasma viscosity was smaller in hypertensive women than in normotensive women (P<0.05). There was also a significant reduction in vascular impedance in the uterine artery (mean reduction in Group 1, (16+/-1)%, P=0.005; mean reduction in Group 2, (19+/-1)%, P=0.005), the bladder wall arteries (mean reduction in Group 1, (23+/-2)%, P=0.005; mean reduction in Group 2, (18+/-1)%, P=0.005), the internal carotid artery (mean reduction in Group 1, (25+/-1)%, P=0.005; mean reduction in Group 2, (26+/-1)%, P=0.005) and the ophthalmic artery (mean reduction in Group 1, (24+/-2)%, P=0.005; mean reduction in Group 2, (16+/-1)%, P=0.005). The percentage reduction in vascular impedance did not differ significantly between the two groups.

CONCLUSIONS

Our results show that transdermal HRT is effective in reducing plasma viscosity, TXB2 levels and vascular impedance in the peripheral and central vessels both in normotensive and hypertensive postmenopausal patients.

Transdermal hormone replacement therapy and Doppler findings in normal and overweight postmenopausal patients

The aim of this study was to evaluate the effects of transdermal hormone replacement therapy on some biological cardiovascular risk factors, specifically the thromboxane B2 levels, plasma viscosity and the lipid profile. Furthermore, we investigated the Doppler flow modifications at the level of the uterine artery, the internal carotid, the ophthalmic and the bladder wall arteries, and we finally evaluated whether there were significant differences in the examined parameters between normal and overweight postmenopausal women. Forty-five postmenopausal women (mean age+/-standard deviation, 53.5+/-3.8 years) participated in the study and were divided into two groups (27 with a body mass index of < 25 kg/m2 and 18 with a body mass index of > 25 kg/m2). Patients were treated with a continous estradiol transdermal supplement and a 12-day course of medroxyprogesterone acetate every 2 months, and were studied at baseline and after 6 months (in the estrogen-only phase of the second cycle). Our results showed a beneficial effect of hormone substitution on plasma viscosity, thromboxane B2 levels and lipid profile after 6 months of therapy and significant improvements of Doppler flow parameters in the examined vessels. Furthermore, we observed a lower impact of the treatment in overweight women. In conclusion, obesity represents an additional cardiovascular risk condition and it can only partially be modified by the administration of hormone replacement therapy.

Pelvic ultrasound and color Doppler findings in different isosexual precocities

OBJECTIVE

To evaluate the role of ultrasound and color Doppler analyses in improving the differential diagnosis of pubertal precocities.

METHODS

Sixty-nine girls with premature (<8 years old) breast development and/or pubic hair growth underwent: auxological (height, weight, body mass index, skeletal maturation), hormonal (basal, gonadotropin releasing hormone (GnRH)-test, adrenocorticotropic hormone test), and sonographic (uterine and ovarian volume and endometrial echo) including color Doppler (uterine arteries) evaluations.

RESULTS

The uterine size was greater in girls with a pubertal response to the GnRH test (Group II, n = 16; 7.48 +/- 4.18 mL) than in those with a prepubertal response to the GnRH test (Group I, n = 17; 3.02 +/- 1.36 mL; P = 0.006), an isolated pubarche (Group III; n = 20; 2.58 +/- 1.32 mL; P < 0.001) or an isolated thelarche (Group IV, n = 16; 1.82 +/- 1.07 mL; P < 0.001). Endometrial echo was observed in 87.5%, 29.4% and 5% of girls, respectively, in Groups II, I and III. The Doppler analysis of the uterine arteries showed the lowest impedance to be in patients with a pubertal response to the GnRH test (Group II).

CONCLUSIONS

Sonographic and color Doppler parameters may improve the diagnosis of GnRH-dependent precocious puberty and may be useful to determine which girls need treatment.

N-substituted 4,7,7-trimethyl-3-(1-piperidinyl)bicyclo-[2.2.1]hept-2-ene 2-carboxamides and 2-carbothioamides with hypotensive activity

The synthesis of two series of N-substituted 4,7,7-trimethyl-3-(1-piperidinyl)bicyclo[2.2.1]hept-2-ene 2-carboxamides (I d-h) and 2-carbothioamides (I i-o), as well as of some N-aryl 4,7,7-trimethyl-3-(1-pyrrolidinyl)bicyclo[2.2.1]hept-2-ene 2-carboxamides (I a-c), by reaction of camphor piperidinoenamine and pyrrolidinoenamine with aryl isocyanates and isothiocyanates is described. On the whole compounds (I d-h) showed a weak hypotensive activity in rats.