Intrathoracic fluid may be a normal finding at around 8 gestational weeks

OBJECTIVE

To describe the observation of embryonic thoracic fluid at around 8 weeks' gestation and to discuss the likely etiology.

METHODS

This was a retrospective study of patients referred between August 2005 and May 2006 to our units in France and in the USA for a dating scan between 6 and 10 weeks. Included in our series were all embryos presenting with an ultrasound finding suggestive of an early pericardial fluid collection, i.e. a large anechoic fluid collection surrounding the heart. The gestational age, fetal heart rate and maternal age at this first scan were recorded, along with nuchal translucency thickness as measured at the 12-week scan and the second-trimester anomaly scan results.

RESULTS

Five cases were included in this study. In all five patients, the anechoic fluid collection was visualized at 8 weeks, and by the time of the nuchal scan it had disappeared completely. The nuchal translucency thickness was normal in all cases and all five embryos had normal cardiac examinations during the second trimester and were normal at birth.

CONCLUSIONS

The observation on ultrasound at 8 weeks' gestation of a large anechoic fluid collection surrounding the heart that disappears by week 12 is suggestive of a transient pericardial collection.

Prenatal diagnosis of wormian bones

The prenatal diagnosis of wormian bones has not been made previously. We report four fetuses with wormian bones but none of the associated anomalies. The diagnosis, differential diagnosis, associated anomalies, and prognosis of this entity are discussed.

Air-contrast sonohysterography as a first step assessment of tubal patency

We assessed the use of air as a sonographic contrast agent in the investigation of tubal patency by sonohysterography. We examined 115 women assessed for infertility. After saline sonohysterography, small amounts of air were insufflated, and the tubal passage of bubbles was monitored. In five patients (excluded from the results), cervical stenosis prevented the procedure. Ninety-one tubes (right side) and 86 tubes (left side) were definitively patent; 5 and 7, respectively, were probably patent; and 12 and 16, respectively, were nonvisualized. Nine patients had polyps, 3 had synechiae, and 2 had submucosal fibroids. None of the patients had infectious complications. Air-sonohysterography and laparoscopy with chromopertubation showed agreement in 79.4%. In 17.2% of patients, the tubes were considered nonvisualized by air-sonohysterography when they were patent. The sensitivity was 85.7% and specificity 77.2%. In conclusion, air-sonohysterography is a comfortable, simple, and inexpensive first line of tubal patency investigations yielding high accuracy.

Prenatal diagnosis of alobar holoprosencephaly at 10 weeks of gestation

Alobar holoprosencephaly is an intracranial abnormality characterized by failure of proper cleavage of the prosencephalon, accompanied by incomplete midfacial development. The prenatal sonographic diagnosis of alobar holoprosencephaly was first described in 1984; however, there have been only two reports of alobar holoprosencephaly diagnosed in the first trimester. We report a case of alobar holoprosencephaly diagnosed at 10 weeks of gestation.

Fetal biometry of skeletal dysplasias: a multicentric study

Twenty-three diagnostic centers worldwide contributed 127 cases of 17 skeletal dysplasias. Discriminant analysis showed that the femur length was the best biometric parameter to distinguish among the five most common disorders in this series (thanatophoric dysplasia, osteogenesis imperfecta type II, achondrogenesis, achondroplasia and hypochondroplasia). Fifty-four percent of fetuses with femur length below 30% of the mean for gestational age had achondrogenesis. Seventy-eight percent of measurements between 40 and 60% of the mean for gestational age represented either thanatophoric dysplasia or osteogenesis imperfecta type II. Fetuses who had over 80% of the mean for gestational age had predominantly hypochondroplasia, achondroplasia, and osteogenesis imperfecta type III.

The accuracy of prenatal ultrasonography in detecting congenital anomalies

OBJECTIVES

The purpose of this study was to evaluate the accuracy of prenatal ultrasonography in detecting congenital anomalies.

STUDY DESIGN

We studied all singleton births or fetal deaths with one or more congenital defects delivered during the study period who had had one or more ultrasonographic examinations performed at or after 16 weeks' gestation and a random sample of defect-free newborns similarly examined by ultrasonography. Congenital anomalies reported on either the infants' postdelivery medical record or the fetal autopsy report were our standard. Prenatal ultrasonographic findings reported during gestation and therefore "blind" to the postdelivery outcome were then compared with the standard.

RESULTS

The overall sensitivity of ultrasonography in detecting defects was 53%. The overall specificity was 99%. Ultrasonography proved to be highly sensitive (89%) for prevalent lethal malformations. However, serious cardiac defects, microcephalus, and many musculoskeletal deformities were missed by ultrasonography.

CONCLUSION

Ultrasonography is sensitive in detecting many lethal malformations. However, a negative prenatal ultrasonographic examination does not provide absolute assurance that a fetus is defect free.

Fetal biometry of skeletal dysplasias: a multicentric study

Twenty-three diagnostic centers worldwide contributed 127 cases of 17 skeletal dysplasias. Discriminant analysis showed that the femur length was the best biometric parameter to distinguish among the five most common disorders in this series (thanatophoric dysplasia, osteogenesis imperfecta type II, achondrogenesis, achondroplasia and hypochondroplasia). Fifty-four percent of fetuses with femur length below 30% of the mean for gestational age had achondrogenesis. Seventy-eight percent of measurements between 40 and 60% of the mean for gestational age represented either thanatophoric dysplasia or osteogenesis imperfecta type II. Fetuses who had over 80% of the mean for gestational age had predominantly hypochondroplasia, achondroplasia, and osteogenesis imperfecta type III.

Pitfall in the diagnosis of nuchal cystic hygroma

We present a case of spontaneous resolution of a nuchal cystic hygroma in a fetus with a normal karyotype. This unusual case is important in the counseling of patients with affected fetuses, since the transitory nature of the disease is not well known.

Prenatal diagnosis of fetal cephalocele: a sonographic spectrum

We present the findings in a series of 15 fetuses diagnosed as having a cephalocele. Eleven cephaloceles were located in the occipital region and two each at the vertex and the frontonasal region. Eleven fetuses were diagnosed before 24 week's gestation. Nine families opted for an interruption. Of the two fetuses that went to term, one had a benign meningocele and is growing normally at 18 months, the other died in the neonatal period of associated cardiac anomalies. Of the four fetuses diagnosed after 24 weeks, one is normal (after surgery) at 9 months, two are severely handicapped, and one died in the immediate postpartum period.

Automatic segmentation of ultrasound images using morphological operators

A method for the automatic measurement of femur length in fetal ultrasound images is presented. Fetal femur length measurements are used to estimate gestational age by comparing the measurement to a typical growth chart. Using a real-time ultrasound system, sonographers currently indicate the femur endpoints on the ultrasound display station with a mouse-like device. The measurements are subjective, and have been proven to be inconsistent. The automatic approach described exploits prior knowledge of the general range of femoral size and shape by using morphological operators, which process images based on shape characteristics. Morphological operators are used first to remove the background (noise) from the image, next to refine the shape of the femur and remove spurious artifacts, and finally to produce a single pixel-wide skeleton of the femur. The skeleton endpoints are assumed to be the femur endpoints. The length of the femur is calculated as the distance between those endpoints. A comparison of the measurements obtained with the manual and with the automated techniques is included.

Persistent right umbilical vein: an ominous prenatal finding?

The persistence of a right umbilical vein is an uncommon finding, with only a dozen cases reported since 1826. The persistent right umbilical vein may replace the normal left umbilical vein or be supernumerary. The anomaly is associated with numerous and occasionally lethal malformations. In this series, only three of six fetuses (and another two in the literature) had no associated anomalies. All the others had a variety of associated lesions ranging from minor to lethal. The appearance at ultrasound is easy to recognize: The intrahepatic portion of the umbilical vein is lateral to the gallbladder, and the portal vein curves toward the stomach, instead of parallel to it. Since the recognition of the persistent right umbilical vein is simple and does not require additional scanning (it is visible in the section used to measure the abdominal perimeter), the author suggests using it as an indicator for more in-depth scanning.

In utero detection of cardiac failure from an aneurysm of the vein of Galen

The detection of a vein of Galen aneurysm in a hydrocephalic fetus is presented. The differential diagnosis for the midline cystic structure was made on the basis of the presence of high-velocity flow on Doppler ultrasonographic examination.

Cordocentesis for rapid karyotyping

Pure fetal blood was obtained by cordocentesis in 101 fetuses of 96 patients at 15 to 38 weeks' gestation. Rapid karyotype was obtained within 2 to 4 days by fetal lymphocyte culture. Chromosomal abnormality was detected in 12 (11.9%) fetuses. Abnormal karyotype was found in 5 of 44 fetuses with structural malformations, 3 of 13 fetuses with intrauterine growth retardation or oligohydramnios, 1 of 3 fetuses with nonimmune hydrops fetalis, 2 (one monozygotic set) of 10 discordant twins, 1 of 12 isoimmunized gestations, none of 8 cases with advanced gestational-maternal age, and none of 6 immune thrombocytopenia cases. This suggests that rapid karyotype should be obtained in all cases of fetal structural malformations, intrauterine growth retardation, and nonimmune fetal hydrops, and may be obtained incidentally in isoimmunized pregnancies and discordant twins to assist in clinical management.

Fetal skeletal anomalies

Skeletal dysplasias are a heterogeneous group of disorders of bone growth resulting in abnormal shape and size of the skeleton. The prenatal diagnosis of these disorders is a particularly challenging task. This article reviews the birth prevalence and classification of skeletal dysplasias and provides an approach to the diagnosis of conditions identifiable at birth.

Fetal and funicular vascular anomalies: identification with prenatal US

Vascular anomalies of the umbilical cord and fetus were evaluated with ultrasound in 11 fetuses. The anomalies included true knot of the cord (n = 1), umbilical vein varix (n = 1), persistent right umbilical vein (n = 1), and unilateral hypertrophy of the iliac artery in cases of a single umbilical artery (n = 8). One fetus with a single umbilical artery had a meningocele, hydrocephalus, and polyhydramnios; another had mitral atresia. The other fetuses were healthy except for the vascular abnormalities. A previously unreported finding in the identification of a single umbilical artery is described.

Diagnosis of trisomy 18 in monozygotic twins by cordocentesis

The incidence of monozygotic twins with trisomy 18 is 1 in 1,000,000 births. We report a case diagnosed prenatally with lymphocyte culture from fetal blood samples obtained by cordocentesis. Fetal growth lag and structural malformations detected by ultrasonography indicated chromosomal abnormality. A saline solution infusion technique ensured that cordocentesis obtained a sample from each twin.

Elevated alpha-fetoprotein and a normal fetal sonogram: association with placental abnormalities

This report documents the outcome of 25 pregnancies with elevated serum alpha-fetoprotein levels on two separate samplings despite normal anatomic appearance of the fetus on a detailed "consultative" sonographic examination. Six of these also had elevated amniotic fluid alpha-fetoprotein. All fetuses in this series were anatomically normal at time of delivery; one aborted fetus was triploid. Of the 25 pregnancies, 16 had sonographically demonstrable placental hemorrhage, eight retroplacental and eight subchorionic. One had hydropic changes in the placenta associated with triploidy. Of the subgroup of six pregnancies in which both serum and amniotic fluid values were elevated, one had a retroplacental hemorrhage, one had a subchorionic hemorrhage, and one had diffuse hydropic changes in the placenta. A control group of 112 patients with normal alpha-fetoprotein levels yielded four with small (less than 2 cm3) subchorionic hemorrhage. The occurrence rate of placental hemorrhage in women with elevated alpha-fetoprotein and normal fetus was 64%, whereas the control group of patients with normal alpha-fetoprotein had a 3.6% occurrence rate of placental hemorrhage. Sonographically detectable placental abnormalities may be associated with elevated alpha-fetoprotein in serum and/or amniotic fluid samples. Such abnormalities may occur because of fetomaternal admixture associated with placental hemorrhage and/or intraamniotic bleeding resulting from subchorionic hemorrhage.

The value of adnexal sonographic findings in the diagnosis of ectopic pregnancy

A prospective study of 383 patients with suspected ectopic pregnancy was carried out at Yale-New Haven Hospital to determine the value of adnexal sonographic findings in the diagnosis of ectopic pregnancy. In patients with adnexal sonographic results and human chorionic gonadotropin titers less than 6000 mIU/ml (n = 220), the presence of a noncystic mass had a positive predictive value of 83%, and the presence of a cystic mass had a positive predictive value of 35%. The combination of a noncystic mass and fluid in the cul-de-sac (found in 22% of all patients with ectopic gestations) was the best predictor of an ectopic pregnancy with a 94% positive predictive value. It is suggested that the demonstration of a non-cystic mass, alone or in the presence of fluid in the cul-de-sac, be used as an indication for diagnostic laparoscopy.

A prospective study of the accuracy of ultrasound in predicting fetal microcephaly

A prospective study of the diagnostic accuracy of ultrasound in the prediction of fetal microcephaly was performed on a study population of 24 patients. An occipitofrontal diameter larger than the predicted mean -2 standard deviations (SD), a head perimeter larger than the predicted mean -2 SD, and a head perimeter/abdominal perimeter larger than the predicted mean -1 SD were found to exclude fetal microcephaly. An occipitofrontal diameter smaller than the predicted mean -4 SD, a head perimeter smaller than the predicted mean -5 SD, a head perimeter/abdominal perimeter smaller than the predicted mean -3 SD, and a femur length/head perimeter larger than the predicted mean +3 SD were found to cause no errors in the diagnosis of microcephaly. If neither of these two groups of tests is satisfied, fetal microcephaly cannot be reliably diagnosed or excluded on the basis of a single ultrasound examination.

Ultrasound investigation of the posterior fossa in the fetus

One hundred and thirty normal pregnancies, ranging in gestational age from 15 to 40 weeks, were investigated to evaluate the capability of ultrasound to demonstrate the anatomy of the fetal posterior fossa. The cerebellum, including the cerebellar hemispheres, the superior and inferior vermis, the fourth ventricle, and the cisterna magna could be demonstrated easily. The ultrasound interpretation of the brain structures was verified by the anatomic dissection of the brains of 10 stillborn premature infants. A systematic approach to the prenatal ultrasound examination of the posterior fossa is described.

Criteria for the prenatal diagnosis of holoprosencephaly

Holoprosencephaly is a congenital anomaly of the central nervous system whose prenatal sonographic appearance may to similar to that of ventriculomegaly. A clear differential diagnosis is extremely important because the two conditions have different prognoses and therefore require different obstetric management. Eight cases of prenatally recognized holoprosencephaly are analyzed and criteria for a specific diagnosis proposed. The specificity and limitations of ultrasound findings, such as identification of a holoventricle, presence of a dorsal sac, and facial anomalies are discussed.

Antenatal diagnosis and obstetric management of Dandy-Walker syndrome

Real-time ultrasound equipment has the potential for investigating the fetal neural axis and allows the diagnosis of many anomalies arising from this area. Five cases of Dandy-Walker syndrome, one of the major causes of congenital hydrocephalus, were diagnosed antenatally. In all cases ultrasound allowed specific recognition of the defect in the cerebellar vermis. This defect connected the fourth ventricle to a posterior fossa cyst in four cases and to an occipital meningocele in one case. In three cases the diagnosis was made prior to viability, and the parents elected termination of pregnancy. In two cases recognized in the third trimester, neurosurgical care was provided soon after delivery.

Perineal scanning

Although various techniques have been described to aid in the ultrasound diagnosis of placenta previa and incompetent cervix, these maneuvers depend on the precise identification of the internal cervical os, a feat which is notoriously difficult to accomplish consistently. In an attempt to get a closer view of the cervix we tried another approach. This simple technique of perineal scanning has the potential to help considerably with these problems.

Ultrasound cystourethrography by perineal scanning for the assessment of female stress urinary incontinence

Perineal scanning using linear array ultrasound was used as an alternative to radiologic cystourethrography in the investigation of female urinary incontinence. The technique provides similar information to that obtained by fluoroscopy without exposing the patient and the physician to radiation. The bladder neck and urethra as well as the urodynamic catheter are readily visualized. Familiarity with the unusual configuration of the sonogram needs to be attained.

The value of serial human chorionic gonadotropin testing as a diagnostic tool in ectopic pregnancy

This study examines the sensitivity of serial human chorionic gonadotropin determinations in the detection of ectopic pregnancy for patients who present with human chorionic gonadotropin titers less than 6500 mIU/ml. A log human chorionic gonadotropin time curve was used to calculate the slope of change. A slope below 0.11 (85% confidence limit for intrauterine gestations) is used as the cutoff value. Of 50 patients with serial titers at sampling intervals of 2 to 5 days, 26 (49%) had falling values and 22 had subnormal slopes. Only five had initially normal slopes and two of these patients eventually had falling titers. The sensitivity of an abnormal slope (below 0.11) in the detection of ectopic pregnancy was 90%. A 12.5% false positive rate was found in a group of 24 intrauterine pregnancies.

The prenatal diagnosis of Robin anomalad

The Robin anomalad was diagnosed by the sonographic detection of polyhydramnios and fetal micrognathia in a patient at risk because of a previously affected child. Ultrasound in the second trimester failed to demonstrate any facial anomaly, but mandibular hypoplasia was clearly documented in the third trimester. The antenatal diagnosis allowed immediate neonatal assistance to prevent glossoptosis-induced respiratory failure.

Antenatal diagnosis of renal anomalies with ultrasound. IV. Bilateral multicystic kidney disease

Bilateral multicystic kidney disease is a congenital disorder that is fatal in the newborn period. A series of nine cases of bilateral multicystic kidney disease diagnosed prenatally by ultrasound is presented. Ultrasound criteria necessary for the diagnosis are bilateral multicystic kidneys, loss of renal architecture, nonvisualization of the fetal bladder, and absence of amniotic fluid. Seven of the nine cases had autopsy confirmation of the diagnosis. Three cases had other associated congenital anomalies. Precise prenatal diagnosis may allow patients the option of elective abortion or may prevent unnecessary obstetric intervention. We propose that a reliable diagnosis can be made with prenatal ultrasound.

Pathological pregnancies. Results of amniotic fluid studies and fetal outcome

Late amniocenteses (greater than 20 weeks' gestation) were performed in 114 pregnancies with no a priori genetic risk, but referred because of abnormal clinical and/or ultrasound findings suggesting fetal malformations. Reasons for referral included polyhydramnios (51 cases), oligohydramnios (15 cases), fetal growth retardation (FGR) (16 cases) and abnormal fetal ultrasound findings excluding anencephaly (32 cases). In 42 of these cases, referral was motivated by a combination of the above abnormal findings. When polyhydramnios was the sole anomaly (25 cases), 5 fetuses were malformed (20%), abnormal fetal karyotype and/or elevated amniotic fluid alphafetoprotein (AFP) were demonstrated in 2 cases. Oligohydramnios was the sole anomaly in one case; the infant died of prematurity. Fetal growth retardation was the sole anomaly in 14 cases, 11 otherwise normal newborns were small for date, 2 died at birth and 1 was malformed (1/14, 7%). In this group all fetal karyotypes were normal and in 2 cases amniotic fluid AFP were increased. In the 32 pregnancies without abnormal amniotic fluid volume and/or FGR and with fetal malformation(s) suggested by ultrasound, all malformations except one (ovarian cyst possibly ruptured during birth) were confirmed at birth, amniotic fluid AFP was elevated, and/or karyotype was abnormal in 6 cases. In 42 pregnancies where more than one alarm sign was present, abnormal karyotype and/or elevated amniotic fluid AFP level were recorded in 21 of the 39 cases where amniocentesis was performed, 33 fetuses were malformed (79%) and 13 died in the perinatal period (31%). The high incidence of abnormal results of amniocentesis found in this survey of pathological pregnancies, particularly in those with multiple alarm signs, emphasizes the need for amniocentesis in these situations.

The effect of different human chorionic gonadotropin assay sensitivity on screening for ectopic pregnancy

The distribution of human chorionic gonadotropin levels in 184 patients with ectopic pregnancy is examined. The impact of changing the sensitivity of human chorionic gonadotropin testing on the incidence of false negative results is discussed. Pregnancy blood tests with a detection threshold of 200 mIU/ml were associated with an 11.9% incidence of false negative results.

Diagnosis of ectopic pregnancy: value of the discriminatory human chorionic gonadotropin zone

A prospective study was conducted to test the hypothesis that the absence of an intrauterine gestational sac when the serum level of human chorionic gonadotropin (hCG) is above 6500 mIU/mL is indicative of ectopic pregnancy. A total of 383 patients who were clinically suspected to have ectopic pregnancies had pelvic ultrasound examinations with serum hCG determinations on the day of the scan. There were 217 (57%) intrauterine gestations, 104 (27%) ectopic pregnancies, and 62 (16%) spontaneous abortions. Forty-one percent of patients had an hCG level above 6500 mIU/mL. The absence of an intrauterine gestational sac at an hCG concentration above this level had a sensitivity of 100%, a specificity of 96%, a positive predictive value of 86%, a negative predictive value of 100%, and was 98% efficient, based on a 19.4% prevalence of ectopic pregnancies among this group.

Value of culdocentesis in the diagnosis of ectopic pregnancy

The diagnostic value of culdocentesis was examined in all patients admitted with hemoperitoneum during a three-year period. There was a total of 158 women with positive culdocentesis, of whom 132 (83.5%) had tubal ectopic pregnancies and 26 had other diagnoses. Of the 132 patients with ectopic gestations, the majority (62%) had unruptured tubes. A nondiagnostic culdocentesis should not be used either to raise or to lower the clinician's suspicion of ectopic pregnancy as 16% of patients with an ectopic pregnancy had a nondiagnostic culdocentesis, of which one-quarter were ruptured and three-quarters had hemoperitoneum diagnosed at the time of surgery. A positive culdocentesis along with a positive serum human chorionic assay was associated with an ectopic pregnancy in 99.2% of cases. This procedure should not be limited to the evaluation of patients with classic peritoneal signs, as 45% of the authors' patients with a positive culdocentesis did not have such findings.

The interhemispheric fissure: a commonly mislabeled cranial landmark

The bright midline echo observed in fetal cranial sonography has been termed by many authors the "falx cerebri." Anatomic, embryologic, and sonographic evidence presented here suggests that this terminology is incorrect and that use of the term "interhemispheric fissure" is more appropriate.

Sonographically monitored amniocentesis to decrease intraoperative complications

The rates of intraoperative complications (dry and bloody taps) of two amniocentesis techniques were compared in 1300 patients undergoing second trimester procedures for genetic indications. The sonographically guided technique consisted of the selection of a site for needle insertion with ultrasound, removal of the transducer, and immediate amniocentesis. The sonographically monitored technique consisted of the continuous visualization of the needle during the entire procedure. Six hundred twelve amniocenteses were performed with the sonographically guided technique and 688 with the sonographically monitored technique. There was a statistically significant decrease in the incidence of bloody and dry taps of the first needle insertion (relative risk = 38%, P less than .0001) and also in the number of patients that required multiple needle insertions (relative risk = 42%, P less than .0001) with the sonographically monitored technique.

Sonographic monitoring to guide the performance of postabortal uterine curettage

This communication describes a technique of sonographically monitored uterine curettage. This method is of particular value in the management of postabortal endomyometritis associated with retained products of conception or in any situation in which anatomic variation (for instance, retroversion) makes curette insertion difficult.

Antenatal diagnosis of renal anomalies with ultrasound. III. Bilateral renal agenesis

Bilateral renal agenesis is a lethal congenital anomaly. A reliable prenatal diagnosis is extremely important, since it may offer options for pregnancy termination or may change obstetric management in the third trimester. This study examined the accuracy of ultrasound in making an antenatal diagnosis of bilateral renal agenesis in three different populations: (1) patients with a family history of bilateral renal agenesis, (2) patients diagnosed during the course of a routine scan, and (3) patients referred because of a previous suspicious ultrasound examination in a level I ultrasound facility. In group A there were three true positive, 13 true negative, no false negative, and no false positive diagnoses. In group B there were three true positive and no false positive diagnoses. In group C there were 12 true positive, 17 true negative, one false negative, and no false positive diagnoses. The value and potential pitfall of the different diagnostic criteria are discussed. We conclude that ultrasound is a valuable tool in the detection of intrauterine renal failure, although there are limitations to a specific diagnosis of bilateral renal agenesis.

The diagnosis of congenital renal anomalies with ultrasound. II. Infantile polycystic kidney disease

Infantile polycystic kidney disease in an autosomal recessive disorder which in its severe form is characterized by bilateral renal enlargement and renal failure. The present study was undertaken to assess the diagnostic accuracy of antenatal sonography in a population at risk. Nineteen patients with fetuses at risk for infantile polycystic kidney disease were referred for ultrasound examination to the Perinatal Unit at Yale-New Haven Hospital. Ten infants had infantile polycystic kidney disease (53%). A positive antenatal sonographic diagnosis was made by the presence of oligohydramnios, an absent urinary bladder, bilateral renal enlargement as measured by the kidney circumference-to-abdominal circumference ratio, and the typical hyperechogenic appearance of the kidneys in the disease. A correct antenatal diagnosis was made in nine of the 10 affected infants. There were no false positive diagnoses. A false negative diagnosis occurred in an infant with a less severe form of the disease. Ultrasound is a valuable tool in the antenatal diagnosis of infantile polycystic kidney disease.

Fetal cardiac dimensions: a potential tool for the diagnosis of congenital heart defects

This study proposes normal values for fetal heart dimensions. They include the transverse and longitudinal diameters of the heart, as well as an estimate of the cardiac volume. The resulting nomograms were useful in the diagnosis of various congenital anomalies, as is demonstrated in three case reports. Although the nomograms are not intended to compete with more elaborate techniques of investigation of the fetal heart, such as M-mode echocardiography or Doppler studies, they are much easier to use and could be used as a complementary method to identify possible fetal cardiac anomalies.

Fetal pericardial fluid: a normal finding of the second half of gestation

In a series of 104 consecutive pregnancies ranging from 20 to 40 weeks' gestation which were examined with real-time ultrasound, we observed 46 fetuses with pericardial fluid. High resolution makes the detection of normal pericardial fluid now feasible.

The diagnosis of fetal microcephaly

Of 16 fetuses in whom microcephaly was suspected, nine (56.2%) were affected with microcephaly, and seven (43.8%) were unaffected. Subsequently, nomograms with mean and SDs for biparietal diameter, occipitofrontal diameter, head perimeter: bdominal perimeter, biparietal diameter:femur length, and femur length:head perimeter we derived. With the use of the data from 27 sonograms of the 16 fetuses, different thresholds of abnormality were tested. Three standard deviations from the mean for biparietal diameter, occipitofrontal diameter, head perimeter, and femur length:head perimeter were sensitive thresholds for the diagnosis of fetal microcephaly with no false negative diagnoses. Four standard deviations from the mean for occipitofrontal diameter, head perimeter:abdominal perimeter, and femur length:head perimeter were specific tests with no false positive diagnoses. The use of multiple diagnostic tests was necessary to improve accuracy in the diagnosis of fetal microcephaly. Further clinical studies are needed to delineate more clearly optimal tests and thresholds of abnormality.

Pergolide therapy in Parkinson's disease

A total of 26 patients were treated with pergolide mesylate, a semi-synthetic ergot derivative with the property of direct dopamine activity. Of these patients, 18 suffered from late failure of L-dopa, while the remaining 8 had never before been treated with L-dopa. The aim of the trial was to study the activity of pergolide, either by giving it to untreated patients or by reducing as much as possible the L-dopa given in patients with parkinsonism. Adverse effects and failure rate were reduced by slowly increasing the daily dosage, by giving considerable dose flexibility whenever side-effects were manifest, and by the use of relatively low doses (mean of 3.8 mg in the L-dopa-group and 2.9 in the other group). At present, from 26 patients, 13 (50%) still remain in the study for an average treatment period of 16 months (3 weeks to 25 months for the group as a whole). All patients experienced a beneficial effect from pergolide, especially during the first months of treatment, in selfcare, rigidity, gait and automatic movements. Slight or no improvement was seen in tremor, speech and posture. The most frequent side-effects were nausea and vomiting (in the initial phase of the treatment), insomnia and psychotoxic reactions (mostly periods of confusion accompanied by visual hallucinations and paranoid illusions). The study indicated that pergolide mesylate is a useful additive for treatment of parkinsonism, but special attention should be paid to the important psychotoxic adverse effects that may appear, even at a low dose.

A longitudinal study of fetal weight growth

In a longitudinal study of fetal growth, the authors attempted to provide normal values for estimating fetal weights at various gestational ages.

The binocular distance: a new way to estimate fetal age

Fetal ocular biometry has been previously established and reported. The purpose of this communication is to report an equation to predict fetal age from the binocular distance. The error of the estimation is also reported. The potential value of this measurement is illustrated in a case of thanatophoric dysplasia.

Vascular anatomy of the fetus

Real-time ultrasonography is utilized in this study to demonstrate most of the large vessels in fetuses from 22 weeks on. Images of the aorta, the coronary ostium, the vessels of the aortic arch, the carotids, the ductus arteriosus, the superior mesenteric artery, the celiac axis, the common iliac artery, the external iliac artery, and the femoral artery are demonstrated. Additionally, images of the subclavian vein, the superior mesenteric veins, the splenic vein, the portal vein, the hepatic veins, the ductus venosus, the renal veins, the iliac veins, and the inferior vena cava, as well as the pulmonary artery and veins and the azygos vein, are presented.

Estimation of gestational age from measurements of fetal long bones

The general practice of using fetal long bone growth charts to derive gestational age does not yield mathematically valid results. The authors tried to calculate gestational age from the lengths of long bones (femur, humerus, tibia, ulna) from 12 to 40 weeks of gestation. The combined use of the four bones allows a good estimation of gestational age that may be useful should the biparietal diameter measurement be unreliable, unobtainable, or abnormal.