Mobil Monitoring Doppler Ultrasound (MoMDUS) study: protocol for a prospective, observational study investigating the use of artificial intelligence and low-cost Doppler ultrasound for the automated quantification of hypertension, pre-eclampsia and fetal growth restriction in rural Guatemala.

INTRODUCTION: Undetected high-risk conditions in pregnancy are a leading cause of perinatal mortality in low-income and middle-income countries. A key contributor to adverse perinatal outcomes in these settings is limited access to high-quality screening and timely referral to care. Recently, a low-cost one-dimensional Doppler ultrasound (1-D DUS) device was developed that front-line workers in rural Guatemala used to collect quality maternal and fetal data. Further, we demonstrated with retrospective preliminary data that 1-D DUS signal could be processed using artificial intelligence and deep-learning algorithms to accurately estimate fetal gestational age, intrauterine growth and maternal blood pressure. This protocol describes a prospective observational pregnancy cohort study designed to prospectively evaluate these preliminary findings. METHODS AND ANALYSIS: This is a prospective observational cohort study conducted in rural Guatemala. In this study, we will follow pregnant women (N =700) recruited prior to 18 6/7 weeks gestation until their delivery and early postpartum period. During pregnancy, trained nurses will collect data on prenatal risk factors and obstetrical care. Every 4 weeks, the research team will collect maternal weight, blood pressure and 1-D DUS recordings of fetal heart tones. Additionally, we will conduct three serial obstetric ultrasounds to evaluate for fetal growth restriction (FGR), and one postpartum visit to record maternal blood pressure and neonatal weight and length. We will compare the test characteristics (receiver operator curves) of 1-D DUS algorithms developed by deep-learning methods to two-dimensional fetal ultrasound survey and published clinical pre-eclampsia risk prediction algorithms for predicting FGR and pre-eclampsia, respectively. ETHICS AND DISSEMINATION: Results of this study will be disseminated at scientific conferences and through peer-reviewed articles. Deidentified data sets will be made available through public repositories. The study has been approved by the institutional ethics committees of Maya Health Alliance and Emory University.

Assessing the risks for stillbirth in São Paulo, Brazil: protocol for a multidisciplinary case-control study - FetRisks.

Stillbirth is a fundamental component of childhood mortality, but its causes are still insufficiently understood. This study aims to explore stillbirth risk factors by using a multidisciplinary approach to stimulate public policies and protocols to prevent stillbirth, improve maternal care and support bereaved families. METHODS AND ANALYSIS: In this case-control study with stillbirths and live births in 14 public hospitals in São Paulo, mothers are interviewed at hospitals after delivery, and hospital records and prenatal care registries are reviewed. Maternal and umbilical cord blood samples and placentas are collected to analyse angiogenesis and infection biomarkers, and the placenta's anatomopathological exam. Air pollutant exposure is estimated through the participant's residence and work addresses. Traditional and non-invasive autopsies by image-guided histopathology are conducted in a subset of stillbirths. Subsample mothers of cases are interviewed at home 2 months after delivery on how they were dealing with grief. Information contained in the official prenatal care registries of cases and controls is being compiled. Hospital managers are interviewed about the care offered to stillbirth mothers. Data analysis will identify the main risk factors for stillbirth, investigate their interrelations, and evaluate health services care and support for bereaved families. We hope this project will contribute to the understanding of stillbirth's risk factors and related health services in Brazil, providing new knowledge about this central public health problem, contributing to the improvement of public policies and prenatal and puerperal care, helping to prevent stillbirths and improve the healthcare and support for bereaved families. ETHICS AND DISSEMINATION: This study protocol was approved by the Ethics Committee of the Municipal Health Secretary (process no 16509319.0.3012.5551) and of the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (process no 16509319.0.0000.0068). Results will be communicated to the study participants, policy-makers and the scientific community.

Cumulative sum learning curve for cordocentesis among maternal-fetal medicine fellows in a low-cost simulation model.

OBJECTIVE: To determine the individual learning curves for cordocentesis in a low-cost simulator for maternal-fetal medicine (MFM) fellows. METHODS: This observational, descriptive, educational, and prospective study was performed from July through November 2022. After an introductory course based on a standardized technique for cordocentesis, each second-year MFM fellow who accepted to participate in the study performed this procedure using a low-cost simulation model, and experienced operators supervised the cordocenteses. Learning curves were then created using cumulative sum analysis (CUSUM). RESULTS: Seven second-year MFM fellows with no previous experience in cordocentesis accepted to participate in the study. A total of 2676 procedures were assessed. On average, residents performed 382 ± 70 procedures. The mean number of procedures to achieve proficiency was 369 ± 70, the overall success rate was 84.16%, and the corresponding failure rate was 15.84%. At the end of the study, all fellows were considered competent in cordocentesis. One fellow required 466 attempts to achieve competency, performing a total of 478 procedures, but the resident with the fewest attempts to reach competency required 219 procedures, completing 232 procedures. Some of the most frequent reasons for failed attempts included not reaching the indicated point for vascular access (20.99%) and being unable to retrieve the sample (69.10%). CONCLUSION: CUSUM analysis to assess learning curves, in addition to using low-cost simulation models, helped to appraise individualized learning, allowing an objective demonstration of competency for cordocentesis among MFM fellows.

Society for Maternal-Fetal Medicine Special Statement: Utilizing telemedicine to address disparities in maternal-fetal medicine: a call to policy action.

The combination of deserts in maternal-fetal medicine coverage across the United States and the COVID-19 pandemic accelerated the implementation of telemedicine programs for maternal-fetal medicine care delivery. Although telemedicine-based care has the potential to facilitate timely access to maternal-fetal medicine services, which can improve maternal and neonatal outcomes, telemedicine is a relatively novel healthcare modality that needs to be implemented strategically. As with any medical service, telemedicine care requires rigorous evaluation to assess outcomes and ensure quality. Important health policy considerations, including access to services and insurance coverage, have substantial implications for equity in the implementation of telemedicine, particularly for reproductive healthcare following the 2022 United States Supreme Court decision in Dobbs v Jackson Women's Health Organization that overturned the constitutional right to an abortion. Investing resources and advocating for a rigorous, widely accessible telemedicine infrastructure at this crucial moment will establish an important foundation for more equitable pregnancy care. Key advocacy priorities for maternal-fetal medicine telemedicine include (1) expanding insurance coverage of telemedicine across payers, regardless of geographic location; (2) advocating for interstate licensure parity; (3) increasing access to affordable Internet and digital literacy training; and (4) ensuring access to reproductive healthcare, including abortion care, delivered via telemedicine.

Verma-Naumoff syndrome: a case report / Síndrome de Verma-Naumoff: a propósito de un caso

In skeletal dysplasias, there are short rib polydactyly syndromes, which traditionally differentiate into four lethal types. This report describes a case of Type III, which presented characteristics of Types I and II. A 38-year-old woman presented fetal growth restriction at 17 weeks and 6 days, decreased amniotic fluid, enlarged and hyperechogenic kidneys, and long bones below the 3rd percentile. Three weeks later, she developed anhydramnia. The couple did not consent to the performance of an invasive test for genetic diagnosis and chose to maintain the pregnancy. At 33 weeks, due to premature labor and interactivity, a cesarean section was performed, giving birth to a female baby, who died due to respiratory failure there were no vocal cords and no trachea visible at laryngoscopy. On physical examination, he had the phenotypic characteristics of the syndrome. An X-ray showed short ribs and severe pulmonary hypoplasia. After birth, the parents chose not to carry out a genetic study or an anatomical examination. Researchers have suggested that there is an intersection of the anatomical changes of the types. This case report supports this theory.

En las displasias esqueléticas, existen síndromes de polidactilia de costillas cortas, que tradicionalmente se diferencian en cuatro tipos letales. Este reporte describe un caso del tipo III, que presentó características de los tipos I y II. Mujer de 38 años con restricción del crecimiento fetal a las 17 semanas y 6 días, líquido amniótico disminuido, riñones agrandados e hiperecogénicos y huesos largos por debajo del percentil 3. Tres semanas después, desarrolló anhidramnia. La pareja no consintió en la realización de una prueba invasiva de diagnóstico genético y optó por mantener el embarazo. A las 33 semanas, debido al parto prematuro y la interactividad, se realizó una cesárea, dando a luz a un bebé, que murió debido a una insuficiencia respiratoria: no había cuerdas vocales ni tráquea visible en la laringoscopia. Al examen físico presentaba las características fenotípicas del síndrome. Una radiografía mostró costillas cortas e hipoplasia pulmonar severa. Después del nacimiento, los padres optaron por no realizar un estudio genético ni un examen anatómico. Los investigadores han sugerido que existe una intersección de los cambios anatómicos de los tipos. Este reporte de caso apoya esta teoría.

Maternal and perinatal outcomes in mixed antenatal care modality implementing telemedicine in the southwestern region of Colombia during the COVID-19 pandemic.

INTRODUCTION: Contingency measures due to the COVID-19 pandemic limited access to routine prenatal care for pregnant women, increasing the risk of pregnancy complications due to poor prenatal follow-up, especially in those patients at high obstetric risk. This prompted the implementation and adaptation of telemedicine. OBJECTIVE: We aim to evaluate the maternal and perinatal outcomes of patients who received prenatal care in-person and by telemedicine. METHODS: We conducted a retrospective observational cohort study of pregnant women who received exclusive in-person and alternate (telemedicine and in-person) care from March to December 20,202, determining each group's maternal and neonatal outcomes. RESULTS: A total of 1078 patients were included, 156 in the mixed group and 922 in the in-person group. The patients in the mixed group had a higher number of prenatal controls (8 (6-9) vs 6 (4-8) p < 0.001), with an earlier gestational age at onset (7.1 (6-8.5) vs 9.3 (6.6-20.3), p < 0.001), however, they required a longer hospital stay (26 (16,67%) vs 86 (9,33%), p = 0.002) compared to those attended in-person; there were no significant differences in the development of obstetric emergencies, maternal death or neonatal complications. DISCUSSION: Incorporating telemedicine mixed with in-person care could be considered as an alternative for antenatal follow-up of pregnant women in low- and middle-income countries with barriers to timely and quality health care access.

Multimodal Early Birth Weight Prediction Using Multiple Kernel Learning.

In this work, a novel multimodal learning approach for early prediction of birth weight is presented. Fetal weight is one of the most relevant indicators in the assessment of fetal health status. The aim is to predict early birth weight using multimodal maternal-fetal variables from the first trimester of gestation (Anthropometric data, as well as metrics obtained from Fetal Biometry, Doppler and Maternal Ultrasound). The proposed methodology starts with the optimal selection of a subset of multimodal features using an ensemble-based approach of feature selectors. Subsequently, the selected variables feed the nonparametric Multiple Kernel Learning regression algorithm. At this stage, a set of kernels is selected and weighted to maximize performance in birth weight prediction. The proposed methodology is validated and compared with other computational learning algorithms reported in the state of the art. The obtained results (absolute error of 234 g) suggest that the proposed methodology can be useful as a tool for the early evaluation and monitoring of fetal health status through indicators such as birth weight.

Causal effects on low Apgar at 5-min and stillbirth in a malaria maternal-fetal health outcome investigation: a large perinatal surveillance study in the Brazilian Amazon.

BACKGROUND: Malaria elimination in Brazil poses several challenges, including the control of Plasmodium falciparum foci and the hidden burden of Plasmodium vivax in pregnancy. Maternal malaria and fetal health outcomes were investigated with a perinatal surveillance study in the municipality of Cruzeiro do Sul, Acre state, Brazilian Amazon. The research questions are: what are the causal effects of low birth weight on low Apgar at 5-min and of perinatal anaemia on stillbirth? METHODS: From November 2018 to October 2019, pregnant women of ≥ 22 weeks or puerperal mothers, who delivered at the referral maternity hospital (Juruá Women and Children's Hospital), were recruited to participate in a malaria surveillance study. Clinical information was obtained from a questionnaire and abstracted from medical reports. Haemoglobin level and presence of malarial parasites were tested by haematology counter and light microscopy, respectively. Low Apgar at 5-min and stillbirth were the outcomes analysed in function of clinical data and epidemiologic risk factors for maternal malaria infection using both a model of additive and independent effects and a causal model with control of confounders and use of mediation. RESULTS: In total, 202 (7.2%; N = 2807) women had malaria during pregnancy. Nearly half of malaria infections during pregnancy (n = 94) were P. falciparum. A total of 27 women (1.03%; N = 2632) had perinatal malaria (19 P. vivax and 8 P. falciparum). Perinatal anaemia was demonstrated in 1144 women (41.2%; N = 2779) and low birth weight occurred in 212 newborns (3.1%; N = 2807). A total of 75 newborns (2.7%; N = 2807) had low (< 7) Apgar scores at 5-min., and stillbirth occurred in 23 instances (30.7%; n = 75). Low birth weight resulted in 7.1 higher odds of low Apgar at 5-min (OR = 7.05, 95% CI 3.86-12.88, p < 0.001) modulated by living in rural conditions, malaria during pregnancy, perinatal malaria, and perinatal anaemia. Stillbirth was associated with perinatal anaemia (OR = 2.56, 95% CI 1.02-6.42, p = 0.0444) modulated by living in rural conditions, falciparum malaria during pregnancy, perinatal malaria, and perinatal fever. CONCLUSIONS: While Brazil continues its path towards malaria elimination, the population still faces major structural problems, including substandard living conditions. Here malaria infections on pregnant women were observed having indirect effects on fetal outcomes, contributing to low Apgar at 5-min and stillbirth. Finally, the utility of employing multiple statistical analysis methods to validate consistent trends is vital to ensure optimal public health intervention designs.

Severe fetal anaemia caused by congenital cytomegalovirus infection.

A 22-year-old pregnant woman was referred to our fetal medicine unit due to severe fetal growth restriction at 26 weeks of gestation. An extensive detailed ultrasound revealed signs of bilateral periventricular hyperechogenicity, suggesting fetal infection potentially due to cytomegalovirus (CMV). Doppler ultrasound showed a high peak systolic velocity in the middle cerebral artery. Percutaneous umbilical cord blood sampling confirmed fetal CMV infection and severe fetal anaemia. We present this case to highlight the importance of fetal anaemia, which can be fatal regardless of whether it is associated with generalised oedema or hydrops fetalis.

Prenatal diagnosis of congenital heart defects: experience of the first Fetal Cardiology Unit in Mexico.

OBJECTIVE: The purpose of this article was to describe our experience with the prenatal diagnosis of CHD in patients referred to our Fetal Cardiology Unit. METHODS: Prospective cohort study of consecutive fetuses referred for advanced fetal echocardiography to our Fetal Cardiology Unit during a 3-year period (September 2015-September 2018). RESULTS: Totally 809 fetuses were evaluated, with 1263 fetal advanced echocardiographies performed. Suspected cardiac abnormality was the most common indication for referral (62.2%). Only 7.3% of patients had known morbidities or risk factors for CHD. Mean gestational age at first examination was 25.6 ± 6.4 weeks. A total of 528 (65.3%) fetuses were found to have a cardiac defect: 40.7% had isolated CHD while 24.6% had associated anomalies. The most common defects found were ventricular septal defects (20.3%), followed by conotruncal defects (9.7%), hypoplastic left heart syndrome (9.3%), fetal arrhythmias (8.9%), and venous anomalies (8.7%). 31.6% presented abnormal genetic studies, the most frequent being Down syndrome (23/212, 10.8%), followed by DiGeorge syndrome (11/212, 5.2%). CONCLUSIONS: Prenatal screening and diagnosis of CHD in Mexico are feasible, with suspected cardiac abnormality being the main reason for referral to a specialized Fetal Cardiology Unit. Efforts must be made to make screening available to the general population in the first and second trimesters of pregnancy by fetal medicine or trained specialists, in order to identify fetal CHD and offer advanced echocardiography, genetic studies, timely fetal cardiac intervention in selected cases, and delivery in tertiary centers, to improve overall survival.

Validación de la calculadora de la Fundación de Medicina Fetal para tamiz de preeclampsia adaptada a población mexicana / Validation of the Fetal Medicine Foundation calculator for pre-eclampsia screening test adapted to a Mexican population

Resumen OBJETIVO: Validar el rendimiento de la calculadora de la Fundación de Medicina Fetal 4.0 adaptada a población mexicana. MATERIALES Y MÉTODOS: Estudio de cohorte efectuado en embarazos con feto único, según el modelo de riesgos en competencia para preeclampsia en un centro de medicina fetal de la Ciudad de México. El riesgo a priori se calculó de acuerdo con la historia clínica. La presión arterial media, el índice de pulsatilidad medio de la arteria uterina y la proteína plasmática A asociada al embarazo se midieron a las 11 a 14 semanas de gestación con metodología estandarizada. El valor de cada marcador se transformó en múltiplos de la mediana adaptados a la población local. Se aplicaron la distribución normal multivariante y el teorema de Bayes para obtener las probabilidades posprueba individuales, que se utilizaron como clasificadores para el área bajo la curva de característica receptor-operador. RESULTADOS: La incidencia de preeclampsia fue del 5.0% (54/1078). El área bajo la curva de característica receptor-operador fue de 0.784 (0.712; 0.856) para preeclampsia a menos de 37 semanas y de 0.807 (0.762; 0.852) para preeclampsia global. CONCLUSIONES: La calculadora FMF 4.0 adaptada a población mexicana resultó válida. Si bien tuvo menor rendimiento al esperado para preeclampsia a menos de 37 semanas, el rendimiento para preeclampsia global fue satisfactorio. Se justifica desarrollar la calculadora local.

Abstract OBJECTIVE: To validate the performance of the Fetal Medicine Foundation 4.0 calculator adapted to the Mexican population. MATERIALS AND METHODS: Cohort study performed in singleton pregnancies, according to the competing risk model for preeclampsia in a fetal medicine center in Mexico City. The a priori risk was calculated according to the clinical history. Mean arterial pressure, mean uterine artery pulsatility index and pregnancy-associated plasma protein A were measured at 11 to 14 weeks of gestation with standardized methodology. The value of each marker was transformed into multiples of the median adapted to the local population. Multivariate normal distribution and Bayes' theorem were applied to obtain individual posttest probabilities, which were used as classifiers for the area under the receiver-operator characteristic curve. RESULTS: The incidence of preeclampsia was 5.0% (54/1078). The area under the receiver-operator characteristic curve was 0.784 (0.712; 0.856) for preeclampsia at less than 37 weeks and 0.807 (0.762; 0.852) for global preeclampsia. CONCLUSIONS: The FMF 4.0 calculator adapted to Mexican population proved valid. Although it had lower performance than expected for preeclampsia at less than 37 weeks, the performance for global preeclampsia was satisfactory. The development of the local calculator is justified.

Use of infectious disease surveillance reports to monitor the Zika virus epidemic in Latin America and the Caribbean from 2015 to 2017: strengths and deficiencies.

OBJECTIVES: To summarise the occurrence of congenital Zika syndrome (CZS) in Latin America and the Caribbean from 2015 to 2017 using two outcome measures derived from infectious disease surveillance reports and to assess the completeness of these reports. DESIGN: Surveillance study. SETTING: Pan American Health Organization (PAHO)/WHO epidemiology reports on confirmed and suspected Zika virus infection and cases of CZS. PARTICIPANTS: Populations of 47 countries in the South and Central Americas, Mexico and the Caribbean. PRIMARY AND SECONDARY OUTCOME MEASURES: The number of CZS cases per 1000 births (using 2016-2017 births as a denominator) and the number of CZS cases per 1000 births in women with Zika virus infection during pregnancy. RESULTS: By 4 January 2018, 548623 suspected and 239063 confirmed Zika virus infections had been reported to PAHO/WHO from 47 countries. In 25 countries, over 80% of infections were reported as suspected. There were 3617 confirmed CZS cases in 25 countries; 2952 (82%) had occurred in Brazil. The number of CZS cases per 1000 births varied considerably with Brazil and several Caribbean island communities (Puerto Rico, St Martin, Martinique, Guadeloupe and Grenada) having the highest CZS prevalence above 0.5 per 1000 births. Analysing the number of CZS cases per 1000 births in women infected with Zika virus during their pregnancy highlighted the inaccuracies of the data, with Venezuela likely to have had severe under-reporting of CZS. CONCLUSIONS: Expressing data on CZS in relation to total births, rather than as absolute numbers, better illustrates the burden of disease, providing that under-reporting of CZS is not too severe. Data on infections in pregnant women enable potential under-reporting of CZS to be identified. Both measures are recommended for future PAHO/WHO publications. Evidence of severe under-reporting of Zika virus infections and CZS makes interpretation of the data and comparisons between countries challenging.

Preventive measures to avoid vertical transmission in untreated pregnant women with HIV/AIDS.

The HIV/AIDS during pregnancy has high morbidity and mortality, without optimal prevention and treatment. The advanced stage cases are found in developing countries due to late detection, but, also in developed countries due to immigration; therefore, the professionals should know the management steps for these patients. The implementation of specific interventions can reduce vertical transmission incidence until 1%-8%. It is presented a case of a pregnant woman with AIDS detected during first hospitalisation, due to a ventilatory failure by opportunistic germs; at the delivery the specific interventions were implemented, being able to eliminate vertical transmission to the newborn. This article explains the four main aspects to be considered for reducing vertical transmission (detection of HIV, viral load levels-CD4 lymphocyte count, way and moment of childbirth and antiretroviral therapy) and shares experiences of the management of an advanced case, in order to help professionals to handle these cases and its complications.

Validation of Fetal Medicine Foundation algorithm for prediction of pre-eclampsia in the first trimester in an unselected Brazilian population.

OBJECTIVE: The objective of this study is to evaluate the predictive performance of the Fetal Medicine Foundation (FMF) algorithm for prediction of preeclampsia (PE) between 11 and 14 weeks of gestation in an unselected Brazilian population. METHODS: We conducted a prospective cohort study with 617 singleton pregnancies of unselected risk. Biophysical markers (mean pulsatility index, mean arterial pressure) and biochemical markers (placental growth factor (PLGF) and PAPP-A) were inserted into the FMF software and converted into multiples of the median (MoM). The subjects were divided into five groups: early-onset PE, parturition <34 weeks' gestation; preterm PE, parturition <37 weeks; PE, parturition at any gestational age; gestational hypertension (GH); and control group. Areas under the receiver operating characteristics curve (AUC) were calculated for the outcomes. RESULTS: Among 617 patients, seven developed early-onset PE, 18 developed preterm PE (seven early PE plus 11 delivered between 34 and 36 + 6 weeks gestation), 34 developed PE (18 preterm PE plus 16 delivered after 37-week gestation), 12 pregnant women developed GH, and 517 women comprised the control group. The best predictive performance using the FMF algorithm occurred in the early-onset PE group, with AUC = 0.946 (95% CI 0.919-0.973) and the detection rate of 28.6% and 85.7% for 5% and 10% false-positive (FP), respectively. CONCLUSIONS: The FMF algorithm to predict PE was effective in a Brazilian population, mainly in the early-onset form of the disease at 10% FP.

Seroreactivity to Anisakis spp. in the perinatal period.

BACKGROUND: This study had sought to assess the seroreactivity to the fish nematode Anisakis spp. in a puerperal population, as well as to ascertain whether a correlation exists between maternal and cord blood levels. METHODS: Blood samples were obtained from puerperal women and cord blood to measure specific anti-Anisakis antigen IgG and IgE by ELISA. Non-parametric tests were used to compare two or more independent and related samples. RESULTS: Of the 99 maternal serum samples assessed, 21 were positive on ELISA (21.2%). There were no significant differences in the mean ranks of IgG optical density levels between women who ate fish and those who did not (p = 0.456), those who ate raw fish and those who did not (p = 0.479), or between those who had allergic complaints and those who did not (p = 0.431). CONCLUSION: Transplacental passage of antibodies occurred, leading to moderate correlation between maternal and cord blood serum levels.

Revealed versus concealed criteria for placental insufficiency in an unselected obstetric population in late pregnancy (RATIO37): randomised controlled trial study protocol.

INTRODUCTION: Fetal growth restriction (FGR) affects 5%-10% of all pregnancies, contributing to 30%-50% of stillbirths. Unfortunately, growth restriction often is not detected antenatally. The last weeks of pregnancy are critical for preventing stillbirth among babies with FGR because there is a pronounced increase in stillbirths among growth-restricted fetuses after 37 weeks of pregnancy. Here we present a protocol (V.1, 23 May 2016) for the RATIO37 trial, which evaluates an integrated strategy for accurately selecting at-risk fetuses for delivery at term. The protocol is based on the combination of fetal biometry and cerebroplacental ratio (CPR). The primary objective is to reduce stillbirth rates. The secondary aims are to detect low birth weights and adverse perinatal outcomes. METHODS AND ANALYSIS: The study is designed as multicentre (Spain, Chile, Mexico,Czech Republic and Israel), open-label, randomised trial with parallel groups. Singleton pregnancies will be invited to participate after routine second-trimester ultrasound scan (19+0-22+6 weeks of gestation), and participants will be randomly allocated to receive revealed or concealed CPR evaluation. Then, a routine ultrasound and Doppler scan will be performed at 36+0-37+6 weeks. Sociodemographic and clinical data will be collected at enrolment. Ultrasound and Doppler variables will be recorded at 36+0-37+6 weeks of pregnancy. Perinatal outcomes will be recorded after delivery. Univariate (with estimated effect size and its 95% CI) and multivariate (mixed-effects logistic regression) comparisons between groups will be performed. ETHICS AND DISSEMINATION: The study will be conducted in accordance with the principles of Good Clinical Practice. This study was accepted by the Clinical Research Ethics Committee of Hospital Clinic Barcelona on 23May 2016. Subsequent approval by individual ethical committees and competent authorities was granted. The study results will be published in peer-reviewed journals and disseminated at international conferences. TRIAL REGISTRATION NUMBER: NCT02907242; pre-results.

Applicability of three-dimensional imaging techniques in fetal medicine.

OBJECTIVE: To generate physical models of fetuses from images obtained with three-dimensional ultrasound (3D-US), magnetic resonance imaging (MRI), and, occasionally, computed tomography (CT), in order to guide additive manufacturing technology. MATERIALS AND METHODS: We used 3D-US images of 31 pregnant women, including 5 who were carrying twins. If abnormalities were detected by 3D-US, both MRI and in some cases CT scans were then immediately performed. The images were then exported to a workstation in DICOM format. A single observer performed slice-by-slice manual segmentation using a digital high resolution screen. Virtual 3D models were obtained from software that converts medical images into numerical models. Those models were then generated in physical form through the use of additive manufacturing techniques. RESULTS: Physical models based upon 3D-US, MRI, and CT images were successfully generated. The postnatal appearance of either the aborted fetus or the neonate closely resembled the physical models, particularly in cases of malformations. CONCLUSION: The combined use of 3D-US, MRI, and CT could help improve our understanding of fetal anatomy. These three screening modalities can be used for educational purposes and as tools to enable parents to visualize their unborn baby. The images can be segmented and then applied, separately or jointly, in order to construct virtual and physical 3D models.

OBJETIVO: Gerar modelos físicos de fetos utilizando imagens obtidas por ultrassonografia tridimensional (US3D), ressonância magnética (RM) e, em alguns casos, tomografia computadorizada (TC), para orientar a técnica de adição de camadas. MATERIAIS E MÉTODOS: Foram usadas imagens obtidas de 31 gestantes, incluindo 5 casos de gestação gemelar. Os exames foram realizados usando US3D, RM e em alguns casos TC, e os arquivos foram exportados para uma estação de trabalho em formato DICOM. Um único observador realizou o processo de segmentação manual usando tela de alta resolução. Um software que converte imagens médicas em modelos numéricos foi utilizado para construir modelos virtuais 3D, que foram fisicamente materializados. RESULTADOS: Os modelos virtuais e físicos baseados na US3D, RM e TC realizados separadamente ou em conjunto foram concluídos com sucesso. A aparência pós-natal do feto abortado ou do recém-nascido se assemelhou muito com os modelos físicos, particularmente nos casos de malformações. CONCLUSÃO: O uso da US3D, RM e TC pode ajudar para melhor compreensão das características físicas do feto. Essas técnicas podem ser usadas com fins didáticos para auxiliar na abordagem multidisciplinar e na melhor compreensão dos pais. As imagens podem ser segmentadas e aplicadas separadamente ou combinadas para construir modelos virtuais 3D e físicos.

Applicability of three-dimensional imaging techniques in fetal medicine / Aplicabilidade da tecnologia tridimensional na medicina fetal

Abstract Objective: To generate physical models of fetuses from images obtained with three-dimensional ultrasound (3D-US), magnetic resonance imaging (MRI), and, occasionally, computed tomography (CT), in order to guide additive manufacturing technology. Materials and Methods: We used 3D-US images of 31 pregnant women, including 5 who were carrying twins. If abnormalities were detected by 3D-US, both MRI and in some cases CT scans were then immediately performed. The images were then exported to a workstation in DICOM format. A single observer performed slice-by-slice manual segmentation using a digital high resolution screen. Virtual 3D models were obtained from software that converts medical images into numerical models. Those models were then generated in physical form through the use of additive manufacturing techniques. Results: Physical models based upon 3D-US, MRI, and CT images were successfully generated. The postnatal appearance of either the aborted fetus or the neonate closely resembled the physical models, particularly in cases of malformations. Conclusion: The combined use of 3D-US, MRI, and CT could help improve our understanding of fetal anatomy. These three screening modalities can be used for educational purposes and as tools to enable parents to visualize their unborn baby. The images can be segmented and then applied, separately or jointly, in order to construct virtual and physical 3D models.

Resumo Objetivo: Gerar modelos físicos de fetos utilizando imagens obtidas por ultrassonografia tridimensional (US3D), ressonância magnética (RM) e, em alguns casos, tomografia computadorizada (TC), para orientar a técnica de adição de camadas. Materiais e Métodos: Foram usadas imagens obtidas de 31 gestantes, incluindo 5 casos de gestação gemelar. Os exames foram realizados usando US3D, RM e em alguns casos TC, e os arquivos foram exportados para uma estação de trabalho em formato DICOM. Um único observador realizou o processo de segmentação manual usando tela de alta resolução. Um software que converte imagens médicas em modelos numéricos foi utilizado para construir modelos virtuais 3D, que foram fisicamente materializados. Resultados: Os modelos virtuais e físicos baseados na US3D, RM e TC realizados separadamente ou em conjunto foram concluídos com sucesso. A aparência pós-natal do feto abortado ou do recém-nascido se assemelhou muito com os modelos físicos, particularmente nos casos de malformações. Conclusão: O uso da US3D, RM e TC pode ajudar para melhor compreensão das características físicas do feto. Essas técnicas podem ser usadas com fins didáticos para auxiliar na abordagem multidisciplinar e na melhor compreensão dos pais. As imagens podem ser segmentadas e aplicadas separadamente ou combinadas para construir modelos virtuais 3D e físicos.

Medicina Fetal: actualidad / Fetal medicine at present

En las últimas décadas existe especial interés en el feto, lo que ha originado un gran avance en la investigación por distintas especialidades de la medicina, sustentado en gran medida por el desarrollo de las aplicaciones fetales de la ecografía, que permiten obtener evidencias claras del diagnóstico de complicaciones. Adicionalmente, hay un avance tecnológico importante en el estudio del material genético del feto en muestras fetales directas u obtenidas de la circulación materna, y se han desarrollado intervenciones que están mejorando el pronóstico pre y posnatal. Estos avances configuran una nueva especialidad médica multidisciplinaria que considera al feto como un paciente individual y en relación con su madre, estableciéndose tratamientos profilácticos, terapéutica médica directa o través de la madre, intervenciones guiadas por ecografía, cirugías abiertas (limitada) y fetoscópicas, con ventajas a los tratamientos convencionales. Esta realidad obliga a revisar aspectos éticos y legales relacionados al no nacido, a cambios tanto en la organización de los servicios de salud, como en la currícula del pre y post grado de los nuevos profesionales.

In recent decades there has been a special interest in studying the fetus, which has originated important progress in research for different medical specialties, based mainly on the development of fetal ultrasound application in diagnosis of fetal complications. In addition, there has been progress in technology for fetal genetic study from material directly obtained from the fetus or from maternal circulation, and interventions that improve pre- and post-natal prognosis. This progress encompasses a new multidisciplinary medical specialty that considers the fetus as an individual patient in the context of the mother-fetus relationship, establishing prophylactic treatments, medical therapies directly applied to the fetus or through the mother, interventions guided by ultrasonography, (limited) open surgery and fetoscopy, with reasonable advantages compared to conventional treatments. This reality compels to revise ethical and legal aspects related to the not-yet born, and implementation of modifications in health care offer and pre- and post-graduate curricula.