The impact of optimal dating on the assessment of fetal growth

BACKGROUND

The impact of using the Intergrowth (IG) dating formulae in comparison to the commonly used Robinson dating on the evaluation of biometrics and estimated fetal weight (EFW) has not been evaluated.

METHODS

Nationwide cross-sectional study of routine fetal ultrasound biometry in low-risk pregnant women whose gestational age (GA) had been previously assessed by a first trimester CRL measurement. We compared the CRL-based GA according to the Robinson formula and the IG formula. We evaluated the fetal biometric measurements as well as the EFW taken later in pregnancy depending on the dating formula used. Mean and standard deviation of the Z scores as well as the number and percentage of cases classified as <3rd, < 10th, >90th and > 97th percentile were compared.

RESULTS

Three thousand five hundred twenty-two low-risk women with scans carried out after 18 weeks were included. There were differences of zero, one and 2 days in 642 (18.2%), 2700 (76.7%) and 180 (5%) when GA was estimated based on the Robinson or the IG formula, respectively. The biometry Z scores assessed later in pregnancy were all statistically significantly lower when the Intergrowth-based dating formula was used (p < 10- 4). Likewise, the number and percentage of foetuses classified as <3rd, < 10th, >90th and > 97th percentile demonstrated significant differences. As an example, the proportion of SGA foetuses varied from 3.46 to 4.57% (p = 0.02) and that of LGA foetuses from 17.86 to 13.4% (p < 10- 4).

CONCLUSION

The dating formula used has a quite significant impact on the subsequent evaluation of biometry and EFW. We suggest that the combined and homogeneous use of a recent dating standard, together with prescriptive growth standards established on the same low-risk pregnancies, allows an optimal assessment of fetal growth.

Implementing the INTERGROWTH-21st fetal growth standards in France: a 'flash study' of the College Français d'Echographie Foetale (CFEF)

OBJECTIVES

To assess potential differences in fetal size between the French population and the international population from the INTERGROWTH-21^st (IG-21^st ) Project and to measure the impact of switching to the IG-21^st reference standards for fetal size.

METHODS

This was a nationwide cross-sectional study of fetal ultrasound biometry. Low-risk singleton pregnancies were recruited prospectively within the network of the national French College of Fetal Ultrasound, CFEF, over a 6-week period. Further selection was performed based on the criteria of the IG-21^st Project in order to obtain a comparable population. Head circumference (HC) was used as the main fat-free skeletal measure of growth for comparison of French fetal size with that of the IG-21^st population. The impact of switching to the IG-21^st fetal growth standards was quantified by comparing Z-scores calculated using the IG-21^st standards with those calculated using locally derived reference ranges for HC, abdominal circumference (AC) and femur length (FL).

RESULTS

Following selection, 4858 cases were analyzed. The distribution of HC demonstrated clear similarity between our French population and the IG-21^st population: our observed centile curves closely matched those of IG-21^st and the Z-scores were close to 0 across gestational age. The IG-21^st standards performed as well as did locally derived charts in terms of screening for small-for-gestational age by AC, while they identified significantly fewer small FL values than were expected and than did the locally derived charts.

CONCLUSIONS

Under strict selection criteria, fetal size in France is similar to that of the international population used in the IG-21^st Project. The discrepancies in FL are unlikely to impact on prenatal management. Therefore, switching from locally derived reference ranges to the IG-21^st standards appears to be a safe option. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

[Fetal abdominal cysts at the first trimester scan]

OBJECTIVES

Abdominal cysts are seldom detected at the first trimester scan. The aim of this study is to ascertain their outcome, which is currently not established.

METHODS

The French College of Fetal Ultrasound conducted a prospective observational study of 24months, collecting all cases of abdominal cysts discovered during the first trimester ultrasound. Cases of megacystis were excluded from the study. Ultrasound images, prenatal diagnosis expert reports and pregnancy outcomes were collected by sonographers after patient consent.

RESULTS

Ten cases of abdominal cysts were collected. The cysts had a mean diameter of 15mm. They were anechoic in 5 cases, hyperechoic in 2 cases and mixed in 3 cases. In 6 of 10 cases, complete resolution was observed at 18WG with a good post-natal outcome; the five cases with anechoic images were associated with normal pediatric examination at birth and in the case of the resolved hyperechoic image, an isolated imperforate anus was observed. In the four cases of hyperechoic or mixed images that had not resolved, the outcome was poor with four termination of pregnancies, including two cases of cloacal dysgenesis.

CONCLUSIONS

Abdominal cysts are rare at the first trimester scan. They resolve in two thirds of cases and are then associated with good outcome. When they do not resolve or when they are not strictly anechoic, they require a referral ultrasound examination at 18 and 22WG.

[A simple self-assessment tool for the first-trimester ultrasound images]

OBJECTIVES

The objective of this study was to establish a minimum subset of simple criteria for the self-assessment of the quality of first-trimester ultrasound images of nuchal translucency (NT) and crown-rump length (CRL).

METHODS

We designed 162 simplified image-scoring methods (ISM) based on 1, 2, 3 or 4 binary criteria derived from the 8 criteria of the original image scoring method of the French College of Fetal Ultrasound (CFEF). These ISM were assessed on 68,250 consecutive scans of the French national audit conducted by the CFEF on NT and CRL images. The ISM associated with the best precision to identify excellent/reasonable quality scans were selected.

RESULTS

Simplified ISM based on 1, 2, 3 and 4 criteria showed maximum positive predictive values of 95.3% (95.11-95.50) 98.0% (97.87-98.14), 99.3% (99.17-99.35) and 99.7% (99.68-99.79), respectively, to identify excellent/reasonable quality scans. The proportion of excellent/reasonable scans was 2.8 to 16.7% when three criteria among the 8 were insufficient, and 0.17 to 3.95% when four criteria were insufficient.

CONCLUSIONS

The best performing ISM was based on the following four quality criteria: (i) sagittal plane of the NT, (ii) calipers placement for measuring the NT, (iii) image magnification of NT images and (iv) CRL measurement. This score might be the most relevant in clinical practice in the first-trimester screening.

[What's new in fetal medicine?]

One of the major progress in fetal medicine in recent years is the increased sensitivity of sonographic screening for foetal malformations, due to technical improvement but also to a better training of professionals. Screening for chromosomal abnormalities is no longer based on maternal age alone. Second trimester maternal serum screening (MSS) is increasingly used: thus in 1997, 376,798 MSS tests were performed in France, yielding to the prenatal diagnosis of 391 cases of Down's syndrome. First trimester sonographic nuchal translucency measurement (NTM) is an effective screening method when performed under stringent conditions. Quality control however, is more difficult to implement on a large scale for NTM than for MSS. Performing screening tests sequentially carries a danger of generating an unnecessarily high number of amniocentesis, which may be obviated by a rational calculation of an individual's risk to carry an aneuploid baby. First trimester MSS is expected to become standard practice in the next years, probably in combination with NTM. Cytogenetics underwent substantial innovations recently, due to the ever-increasing use of molecular cytogenetics. FISH techniques allow: 1) precise analysis of unexpected structural chromosomal abnormalities diagnosed by routine amniocentesis, 2) rapid screening of the most common aneuploidies by amniocentesis when a fetal structural anomaly is detected by 3rd trimester ultrasound, 3) diagnosis of micro-deletions suspected by fetal ultrasound or post-mortem. Prenatal diagnosis by maternal blood sampling and fetal cells or DNA analysis is now part of routine clinical practice in selected cases, such as fetal sexing in families affected by an X linked disease. Thus one can select those pregnancies eligible to invasive prenatal diagnosis. Pre implantation diagnosis, which has not been legal in France until 1999 is now increasingly used as an alternative to first trimester diagnosis. As for fetal therapy, a major recent breakthrough is the prenatal management of twin to twin transfusion syndrome by either amnioreduction or laser coagulation of inter-twin vascular shunts. In addition, new pathophysiologic concepts involving the renin angiotestin system could lead to further therapeutic innovations. A European randomised trial is now being completed to establish the respective indications of drainage and Laser. All this underscores that fetal medicine is no longer solely a succession of dramatic technical breakthroughs, but is entered an era of large-scale diffusion that requires evidence based evaluation.

Successful intrauterine shunting of a sacrococcygeal teratoma (SCT) causing fetal bladder obstruction

We report a case of a sacrococcygeal teratoma (SCT) diagnosed at 22 weeks with a substantial intrapelvic cystic extension leading to bladder outlet obstruction and hydronephrosis at 27 weeks. Prenatal percutaneous shunting of the cystic teratoma was performed at 28 weeks to avoid prolonged fetal pelvic compression by the tumour that could have adverse effects by stretching the pelvic plexus and sacral nerves. Urinary dilatation resolved completely after shunting and a 3880 g baby girl was delivered at 39 weeks. The potential benefits of in utero shunting to avoid urological complications of SCTs with intrapelvic extension are discussed.

Stilbene content of mature Vitis vinifera berries in response to UV-C elicitation

A method using HPLC analysis has been used to compare the level of resveratrol and its derivatives, piceid, pterostilbene and epsilon-viniferin, in grapevine berries of three Vitis vinifera varieties. The concentration of these compounds has been evaluated in healthy and Botrytis cinerea infected grape clusters, both in natural vineyard conditions and in response to UV elicitation.

Changes in the phytoalexin content of various Vitis spp. in response to ultraviolet C elicitation

The phytoalexin production potential of three American Vitis species and that of three cultivars of Vitis vinifera were evaluated in response to UV-C irradiation. Time course changes in resveratrol, piceid, epsilon-viniferin, and pterostilbene contents were studied within 3 days after a short UV-C irradiation. Results show that the two major stilbenes accumulated as a response to UV-C elicitation are resveratrol and epsilon-viniferin, a resveratrol dehydrodimer, the concentration of both compounds usually reaching quantities >100 microgram/g of fresh weight. In contrast, piceid and pterostilbene were constantly produced in low quantities. Owing to the results obtained, the role of stilbene phytoalexins in the resistance of grapevines to diseases is discussed.

Characterization of a Pterostilbene Dehydrodimer Produced by Laccase of Botrytis cinerea

ABSTRACT In the interaction between grapevines and Botrytis cinerea, one of the main aspects of pathogenicity is fungal ability to degrade phytoalexins synthesized by the plant in response to infection. Laccase-like stilbene oxidase activity in liquid cultures of B. cinerea has been shown to be related to the decrease of phytoalexin concentrations. Recent research and results presented in this paper determined the chemical structure of a pterostilbene metabolite produced by B. cinerea. Study of degradation of pterostilbene that has just one free hydroxy phenyl group function allowed us to determine the oxidative dimerization process undergone by grapevine phytoalexins after B. cinerea infection. The phytopathological significance of this degradation process in the B. cinerea interaction has also been discussed.

Cystic fibrosis screening: a fetus with hyperechogenic bowel may be the index case

BACKGROUND

The potential of hyperechogenic fetal bowel to act as a hallmark for prenatal cystic fibrosis screening in the general population is controversial.

METHODS

Our goal was to evaluate the incidence of cystic fibrosis in 209 fetuses with hyperechogenic bowel diagnosed at routine ultrasonography and with no family history of cystic fibrosis. The diagnosis of cystic fibrosis was based on prenatal screening for the eight mutations most frequently observed in France (deltaF508, deltaI507, 1717-1G-->A, G542X, G551D, R553X, W1282X, N1303K) and at postnatal follow up.

RESULTS

The overall incidence of cystic fibrosis was 7/209 (3.3%) which is 84 times the estimated risk of CF in the general population (112500). Of these seven cases, six were diagnosed prenatally based on DNA analysis (deltaF508/deltaF508, n=5; deltaF508/G542X, n=1). One case in which only one mutation had been recognised was diagnosed clinically after birth (deltaF508/unidentified mutation). Of the seven cases, none was diagnosed at 16-19 weeks, four at 16-24 weeks, and three after this. The incidence of heterozygous fetuses (15/209, 7%) was not significantly higher than the 5% expected in the general population. The mutations involved in these heterozygous cases were deltaF508 (n=13), G542X (n=1), and G551D (n=1).

CONCLUSIONS

Screening for cystic fibrosis should be offered to families in which fetal hyperechogenic bowel is diagnosed at routine ultrasonography. This underlines the need to review genetic counselling in this situation where the fetus is the index case for a genetic disease.

Resveratrol Oxidation in Botrytis cinerea Conidia

ABSTRACT Observations using light microscopy showed that approximately 30% of Botrytis cinerea conidia treated with semi-lethal concentrations (i.e., 60 mug/ml) of the grapevine phytoalexin resveratrol possessed intracellular brown coloration. This coloration was never observed in the absence of resveratrol or in conidia treated with resveratrol together with sulfur dioxide (antioxidant compound) or sodium diethyldithiocarbamate (inhibitor of laccase action), suggesting that discoloration resulted from the laccase-mediated oxidation of resveratrol. Further studies using transmission electron microscopy enabled the observation of particular intravacuolar spherical vesicles and of granular material deposits along the tonoplast. These observations are likely to be related to the oxidation of resveratrol by an intracellular laccase-like stilbene oxidase of B. cinerea.

[Reccurent abortions: unpublished syndrome suggesting the explanation of fetal death]

A report is given of 8 cases of recurrent "idiopathic" abortions sharing in common the following features, unreported so far: (1) high uterine arterial impedance; (2) decrease in endometrial thickness, in spite of normal hormonal and endometrial cycle at biopsy; (3) a history of previous curettages. Such a syndrome could be consistent with the existence of a narrow peripheral symphysis of the uterine cavity, unaffecting its shape at hysterography.

[Value in gynecology of transvaginal pulsed and color Doppler. Study of ovarian vascularization]

Recently, pulsed Doppler has become available on high resolution vaginal ultrasound probes for studying ovarian blood flow. Doppler studies of ovarian blood flow are based on: semiquantitative analysis of Doppler flow waves recorded over the ovarian artery at its entry into the ovary; color Doppler mapping of intraovarian vessels. Semiquantitative analysis of the ovarian artery Doppler flow waves suffers from frequent difficulties at properly identifying the ovarian artery, particularly in multiparous women. Mapping of intraovarian vessels however, appears a most promising feature of vaginal Doppler for studying ovarian blood flow, provided that the proper ultrasound equipment is used. Specifically, transvaginal color Doppler mapping of intraovarian vessels allows for a positive visual detection of the onset of the ovulatory process prior to the actual follicular rupture. Thus, color Doppler mapping of ovarian vessels permits an improved and simplified approach for timing intercourses and inseminations in infertility patients. In controlled ovarian hyperstimulation (COH) used for in vitro fertilization (IVF), mapping of intraovarian vessels by color Doppler offers a fascinating new insight into normal and pathological responses of ovarian follicles to hCG. Finely, color Doppler appears a very promising asset to transvaginal ultrasounds for sorting suspicious ovarian cysts from their benign counter parts. In conclusion, we think that vaginal Doppler should be considered as a marvelous refinement of ultrasounds rather than as a truly new diagnostic tool. Yet vaginal color Doppler carries the potential for markedly improving the sensitivity and the specificity of vaginal ultrasound, particularly for diagnosing benign from potentially malignant ovarian conditions.

[Accidental ultrasonographic disclosure of isolated intra-abdominal fetal hyperechogenicity. Apropos of a series of 87 cases]

Having seen 87 cases we will now attempt to refine the management to be carried out when intra-abdominal hyperechogenic masses are found in the fetus. Before the 20th week of amenorrhoea (47 cases) amniocentesis can be used to study the digestive enzymes to determine the fetal karyotype. The normal results for intestinal enzymes makes it possible to rule out fetal cystic fibrosis. Three karyotype abnormalities were found in this series. After the 20th week (40 cases) intestinal enzymes cannot be interpreted. The diagnosis of cystic fibrosis then must rely on Delta F 508 mutation; but the absence of this mutation does not exclude cystic fibrosis. When ultrasound signs of intra-abdominal hyperechogenicity are found the diagnosis of cystic fibrosis should not be thought of first, because in this series the majority of fetuses who had this sign were born without any malformation. Four cases of cystic fibrosis that were confirmed have been found but equally there were other serious malformations, three chromosome abnormalities, four intestinal atresias, ten unexplained intra-uterine deaths and one case of biliary duct atresia.

Vascular resistance of uterine arteries: physiological effects of estradiol and progesterone

To determine if reproductive hormones played a role at physiological levels on vascular resistance of uterine arteries, we studied young women having inactive ovaries who received exogenous estradiol (E2) and progesterone (P). Six women, ages 27 to 36 with absent or nonfunctioning ovaries, received transdermal E2 and vaginal P after a 28-day replacement regimen duplicating E2 and P levels seen in the menstrual cycle. Vascular resistance of uterine arteries was evaluated before treatment (baseline), on days 13 to 14 and on days 26 to 27, using transvaginal pulsed Doppler combined with real-time imaging. Doppler waveforms were analyzed by the pulsatility index (PI). Baseline evaluation showed narrow systolic Doppler flow waves with a PI of 5.2 +/- 0.4, mean +/- SEM. On cycle day 13, Doppler waveforms showed a marked broadening with uninterrupted diastolic flow indicative of a profound decrease in vascular resistance. This was reflected by a significant decrease in PI to 1.3 +/- 0.3, mean +/- SEM. Doppler measurements made on days 26 to 27 showed no significant change. Our results indicate that at physiological levels, E2 affects vascular resistance of uterine arteries. This represents a new parameter of estrogen action, readily measurable by a noninvasive technique that, in the future, may help for assessing the efficacy of various estrogenic treatments.

[Vaginal echography in ovulation monitoring excluding in vitro fertilization]

Vaginal ultrasonography makes it possible to observe follicles which remain hidden from abdominal ultrasonography, but provides a less accurate measurement of the diameter of large follicles. The vaginal route improves the observations of the endometrium, eliminates certain artifacts in the exploration of ovarian cysts and considerably enhances the accuracy of diagnosis of ectopic pregnancies. The limits of the method must, however, be recognized, and it demands very wide experience on the part of the ultrasonographer.

Transfusion syndrome in a triplet pregnancy

A case is reported of a transfusion syndrome in a triplet pregnancy with intrauterine death of two of the fetuses. This is an exceptional occurrence in a triplet pregnancy and raises the problem of the management of multiple pregnancies associated with the death of one or more of the fetuses. The problem of the method of delivery and the complications arising in triplet dizygotic pregnancies is discussed.

Longitudinal follow-up of 100 patients at risk of intrauterine growth retardation: comparison of diagnosis in two periods

The concept of low birth weight includes two different entities: prematurity and intrauterine growth retardation. Both of them are major public health problems, because they increase perinatal morbidity and mortality Early diagnosis of IUGR leads to adequate decisions, making possible a reduction in perinatal morbidity and mortality. In order to make an early diagnosis of IUGR, clinical methods have proven to be insufficient. Ultrasonography is an important aid to this diagnosis, introducing the measurement of fetal diameters and perimeters. This study, designed to compare both methods, was carried out in at the Antoine Béclère Hospital, Clamart, France. Data processing was done in CLAP-PAHO/WHO. In the first period, retrospective analyses of 116 clinical histories with IUGR were performed. In this study, only fetal diameters were used and the accuracy of clinical and ultrasonographic diagnosis was evaluated. In the second period a prospective longitudinal follow-up study of 100 pregnant women at risk of developing IUGR was carried out. Clinical diagnosis was also evaluated, and compared to the ultrasonographic approach. The parameters used were the fetal diameters and perimeters (head and abdominal perimeters, and their relationship). Sensitivity, specificity and predictive values of the ultrasonic parameters were calculated (table I). The clinical and ultrasonographic diagnosis of both periods were compared with the purpose to analyze the effect of the measurement of fetal perimeters in the diagnostic accuracy. Newborns of the 100 patients in the prospective study were classified into two groups according to birth weight.(ABSTRACT TRUNCATED AT 250 WORDS)

[Antenatal cerebral hemorrhage and fetomaternal platelet incompatibility]

A case of neonatal porencephalia is reported. It was due to antenatal hemorrhage associated with severe thrombocytopenia. Hematologic investigations showed a feto-maternal platelet incompatibility in the PLA1 system.

[Antenatal diagnosis of 2 cases of cytomegalic inclusion disease]

On the occasion of 2 case reports, the authors emphasize the present possibility of evoking cytomegalovirus infection during pregnancy from virologic and serologic data. Such data may lead to change the evolution of such pathologic pregnancies.

[Caffey's disease with antenatal onset]

The authors report one case of Caffey's syndrome with antenatal onset. X-ray of the uterus, that was required because of an hydramnios, led to the diagnosis. Ultrasonography showed the fetal anomalies. Data in the literature concerning case reports of Caffey's syndrome with antenatal onset show a moderate incidence of familial cases.

[Intra-uterine detection of atrio-ventricular block in two children whose mother had Sjögren's syndrome]

A woman with isolated juvenile Sjögren's syndrome gave birth, at 3 years' interval, to two children with complete atrio-ventricular heart block (AVB). This is the first published case of AVB in children of mothers with Sjögren's syndrome without any clinical and laboratory evidence of connective tissue disease, notably lupus. Ultrasonography showed that the AVB was acquired in utero and occurred during the 23rd week of gestation. In both children the AVB was isolated, without any symptom of congenital malformation of the heart; there were no abnormalities of conduction in the mother. Early corticosteroid treatment of the mother's disease had no beneficial effect on AVB in the foetuses. Attempts to reproduce the condition experimentally met with failure.

Monitoring of ovulation induction with human menopausal gonadotropin and human chorionic gonadotropin by ultrasound

Ovarian follicular growth was monitored by ultrasound and plasma estradiol levels in 43 cycles of 27 patients. These women were treated with human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) for anovulation or poor cervical mucus. Ultrasonography can help to prevent multiple pregnancies by allowing the withholding of the ovulatory injection of hCG if the number of mature follicles is too great. Nevertheless, mild to moderate hyperstimulation cannot always be prevented; it is sometimes the price one has to pay to obtain a pregnancy. Giving a direct view of follicular maturation, this method can be helpful in the determination of the best time for the induction of ovulation.

Clinical management of twin pregnancies

Early diagnosis and subsequent management of twin pregnancy resulted in a considerable reduction of preterm deliveries (26% vs 61% for late diagnoses).

[Combined hydramnios with fetal ascites due to intra-uterine meconium peritonitis (authors' transl)]

It is possible with echotomography to make out fetal ascites in the last months of pregnancy. One of the causes of combined fetal ascites and hydramnios among several other possible ones is primary meconium peritonitis, which diagnosis can be confirmed after birth.