Prediction of Lung Maturity in Fetuses with Growth Restriction through Quantitative Ultrasound Analysis.

The present study aimed to evaluate the performance of QuantusFLM software, which performs quantitative analysis of lung tissue texture through ultrasound images, in predicting lung maturity in fetal growth restriction (FGR). We included patients with singleton gestations between 34 and 38 6/7 wk and divided them into two groups: FGR and control (appropriate for gestational age [AGA]). The images were captured by ultrasound according to a specific protocol up to 48 h before delivery and analyzed with QuantusFLM software. The main clinical outcome evaluated was lung maturity (i.e., the absence of neonatal respiratory morbidity). We included 111 patients; one was excluded because of low image quality, leaving 55 patients in each group. The FGR group had a lower birth weight (2207 g vs. 2891 g, p < 0.001) and a longer stay in the neonatal intensive care unit (NICU) (10 d vs. 5 d, p = 0.043). QuantusFLM software was able to predict lung maturity in FGR with accuracy, sensitivity, specificity and positive and negative predictive values of 94.5%, 96.2%, 50%, 98.1% and 33.3%, respectively. QuantusFLM had good accuracy in predicting lung maturity in FGR with reliability in identifying pulmonary maturity.

Fetal growth restriction: current knowledge.

BACKGROUND: Fetal growth restriction (FGR) is a condition that affects 5-10% of pregnancies and is the second most common cause of perinatal mortality. This review presents the most recent knowledge on FGR and focuses on the etiology, classification, prediction, diagnosis, and management of the condition, as well as on its neurological complications. METHODS: The Pubmed, SCOPUS, and Embase databases were searched using the term "fetal growth restriction". RESULTS: Fetal growth restriction (FGR) may be classified as early or late depending on the time of diagnosis. Early FGR (<32 weeks) is associated with substantial alterations in placental implantation with elevated hypoxia, which requires cardiovascular adaptation. Perinatal morbidity and mortality rates are high. Late FGR (≥32 weeks) presents with slight deficiencies in placentation, which leads to mild hypoxia and requires little cardiovascular adaptation. Perinatal morbidity and mortality rates are lower. The diagnosis of FGR may be clinical; however, an arterial and venous Doppler ultrasound examination is essential for diagnosis and follow-up. There are currently no treatments to control FGR; the time at which pregnancy is interrupted is of vital importance for protecting both the mother and fetus. CONCLUSION: Early diagnosis of FGR is very important, because it enables the identification of the etiology of the condition and adequate monitoring of the fetal status, thereby minimizing risks of premature birth and intrauterine hypoxia.

Assessment of Intracranial Structure Volumes in Fetuses With Growth Restriction by 3-Dimensional Sonography Using the Extended Imaging Virtual Organ Computer-Aided Analysis Method.

OBJECTIVES: To assess intracranial structure volumes by 3-dimensional (3D) sonography in fetuses with growth restriction. METHODS: We conducted a prospective cross-sectional case-control study involving 59 fetuses with growth restriction (38 fetuses with estimated weight <3rd percentile and 21 fetuses with estimated weight between 3rd and 10th percentiles, according to Hadlock et al [Radiology 1984; 150:535-540]) and 54 controls between 24 and 34 weeks' gestation. The following fetal intracranial structure volumes were assessed: cerebellum, brain, and frontal region. The volume was assessed by 3D sonography using the extended imaging virtual organ computer-aided analysis method with 10 sequential planes. Analysis of variance was used to compare fetal groups. The intraclass correlation coefficient was used to assess intraobserver and interobserver reproducibility. RESULTS: Statistical significance between the brain, frontal region, and cerebellar volumes and a relationship between the frontal region and the brain in fetuses with estimated weights below the 3rd percentile and controls were observed (P < .001; P < .001; and P = .002; and P = .008, respectively). Good intraobserver and interobserver reproducibility was observed for the fetal brain, frontal region, and cerebellar volumes, with intraclass correlation coefficients of 0.998, 0.997, 0.997, 0.999, 0.997, and 0.998, respectively. CONCLUSIONS: The intracranial structure volumes assessed by 3D sonography using the extended imaging virtual organ computer-aided analysis method were reduced in fetuses with growth restriction (estimated weight <3rd percentile).

Assessment of maternal Doppler parameters of ophthalmic artery in fetuses with growth restriction in the third trimester of pregnancy: A case-control study.

AIM: The aim of this study was to assess the Doppler parameters of the ophthalmic artery of pregnant women carrying fetuses with growth restriction (FGR) compared with normal fetuses. MATERIAL AND METHODS: A prospective cross-sectional study was conducted with 120 pregnant women (60 FGR and 60 normal fetuses) between 32 and 40 weeks of gestation. FGR diagnosis was based on an estimated fetal weight below the 10th percentile of the Hadlock curve. Ophthalmic artery Doppler images were obtained with a linear transducer, with color Doppler examination of the region medial to the optic nerve. The following indices were obtained: pulsatility index, resistance index, peak systolic velocity, second peak velocity (P2), end diastolic velocity, and P2 / peak systolic velocity ratio. The Mann-Whitney U-test and Student's t-test were used to compare the groups with regard to quantitative variables, and the χ(2) -test was used for categorical variables. RESULTS: Pulsatility index and resistance index were significantly lower in pregnant women with FGR than in those with normal fetuses, with P < 0.001 in both indices. P2 and end diastolic velocity were significantly higher in pregnant women with FGR than in those with normal fetuses (P = 0.002 and P = 0.004, respectively). The P2 / peak systolic velocity ratio was significantly higher in the FGR group than in the control group (P < 0.001). In FGR subgroups, with (17 fetuses) and without (43 fetuses) uterine artery Doppler abnormalities, no significant changes were observed between the groups. CONCLUSION: In the third trimester of pregnancy, we observed significant differences in the ophthalmic artery Doppler parameters of pregnant women with FGR compared with those with normal fetuses.

Fetal thigh and upper-arm volumes by three-dimensional ultrasound to predict low postnatal body mass index.

OBJECTIVE: To assess the usefulness of estimating fetal upper arm and thigh volumes as predictors of low postnatal body mass index (BMI) using three-dimensional ultrasonography (3DUS) with extended imaging virtual organ computer-aided analysis (XI VOCAL). METHODS: This prospective cross-sectional study analyzed 300 singleton pregnancies between 33 and 41 weeks of gestation. The Hadlock 4 formula was used to estimate fetal weight. The XI VOCAL 10 planes method was used to assess fetal upper arm and thigh volumes. After delivery, the newborns' BMI was evaluated and considered low (≤10th percentile) or normal (>10th percentile). We determined receiver operating characteristics (ROC) curves and respective areas under the curves for the percentiles of fetal weight and fetal thigh and upper arm volumes. RESULTS: Of the 300 newborns, BMI was ≤10th percentile for 21 and >10th percentile for 279 newborns. The area under the ROC curve for fetal weight, obtained using the Hadlock formula, and fetal upper arm and thigh volumes, obtained by 3DUS, were 0.801, 0.930 and 0.924, respectively. We determined the sensitivity and specificity of the three parameters for predicting low postnatal BMI and found values of 85.70% and 65.60%, respectively, for fetal weight, 90.48% and 88.17%, respectively, for fetal thigh volume, and 76.19% and 92.47%, respectively, for fetal upper arm volume. CONCLUSION: Fetal upper arm and thigh volumes estimated using 3DUS with XI VOCAL were effective predictors of low postnatal BMI.

Evaluation of passage of fetal erythrocytes into maternal circulation after invasive obstetric procedures.

AIM: The aim of this study was to evaluate the passage of fetal erythrocytes into the maternal circulation after invasive obstetric procedures, using the Kleihauer-Betke test, flow cytometry and α-fetoprotein concentration in maternal blood. MATERIAL AND METHODS: This was a prospective descriptive study on patients who underwent: amniocentesis, cordocentesis, chorionic villus sample, amniotic infusion, bladder drainage and ventricular-amniotic shunt to investigate the karyotype; treatment for hydrocephalus, oligohydramnios, obstructive uropathy and polyhydramnios; and investigation of lung maturity. Maternal blood samples were collected before and 60 min after the invasive obstetric procedure in order to evaluate the passage of fetal erythrocytes using the Kleihauer-Betke test, flow cytometry and α-fetoprotein concentration. RESULTS: In total, 43 invasive obstetric procedures were performed. The procedures performed were: 27 cases of amniocentesis (62.7%), seven cases of cordocentesis (16.2%), four chorionic villus samples (9.4%), two amniotic infusions (4.7%), two ventricular-amniotic shunts and one bladder drainage (2.3%). After one case of cordocentesis with two puncture attempts via the placenta, a significant increase in fetal erythrocytes was detected using the three methods. After another cordocentesis with one puncture via the placenta, a significant increase in fetal erythrocytes was detected using flow cytometry and α-fetoprotein concentration, but not through the Kleihauer-Betke test. The other 41 samples did not show any significant increase in fetal erythrocytes in the maternal blood. CONCLUSION: Invasive obstetric procedures performed during prenatal care are safe when performed by experienced professionals with the proper technique, with minimal chance of passage of fetal erythrocytes into the maternal compartment.

Prenatal diagnosis and postnatal ultrasound findings of cloacal anomaly: a case report.

Cloacal malformation is an extremely rare fetal pathological condition that presents as a variety of defects. It predominantly affects females, with prevalence of 1 in 50,000 births. Prenatal ultrasonography on a 20-year-old caucasian woman (G4P1A2) at 33 weeks of pregnancy showed the fetus having a large cystic mass in the lower abdomen with a single septum, bilateral hydronephrosis, ambiguous genitalia, and a single umbilical artery. The pregnancy developed accentuated oligohydramnios, and presence of a fetal brain-sparing effect was diagnosed using arterial Doppler velocimetry. The newborn showed abdominal distension, ambiguous genitalia, and rectal atresia, with a single perineal opening. Pelvic ultrasound done on the first day after delivery revealed the presence of a large retrovesical septated cystic mass of dense content in the fetal abdomen, and bilateral hydronephrosis. Hysterotomy was performed, and 70 mL of dense liquid was drained through an abdominal colostomy. The infant died on the 27th day of life as a result of infectious complications. Prenatal diagnosing of female urogenital anomalies is usually difficult because of their rarity, different types of manifestation, and lack of characteristic ultrasound signs. Presence of a septated cyst with dense content in the fetal abdomen confirms the finding of hydrometrocolpos, thus raising clinical suspicion of a cloacal anomaly.

Prenatal and Postnatal Schizencephaly Findings by 2D and 3D Ultrasound: Pictorial Essay.

Schizencephaly is a brain-destructive lesion relating to clefts in the fetal brain that usually communicate with the ventricular system, subarachnoid space, or both. It presents as two types: Type I (closed) and Type II (open). During pregnancy, it may be suspected in the course of ultrasonography, which highlights ventricular dilatation and brain abnormalities. Usually, the diagnosis is confirmed postnatally using trans-fontanel ultrasonography. The etiology of schizencephaly is still unknown, but it may be derived from a primary disorder of brain development or from bilateral middle cerebral artery occlusion. Many causative agents including vascular insult, infections, toxins, and medications have been associated with this malformation. We present a pictorial essay of six cases of schizencephaly that were suspected on prenatal ultrasound scans and confirmed postnatally by trans-fontanel, two-dimensional and three-dimensional ultrasonography.

prenatal diagnosis of amniotic band syndrome in the third trimester of pregnancy using 3D ultrasound.

Amniotic band syndrome is characterized by a build-up of bands and strings of fibrous tissue that adhere to the fetus and can compress parts of the fetus, thus causing malformations and even limb amputation while the fetus is still in the uterus. The clinical manifestations are extremely variable and their extent may range from a single abnormality, like a constriction ring, to multiple abnormalities. Such abnormalities are generally diagnosed at the end of the first or the beginning of the second trimester using two-dimensional ultrasonography (2DUS). Three-dimensional ultrasonography (3DUS) in rendering mode allows spatial analysis of the fetus and amniotic band, thus enabling better comprehension of this pathological condition and better counseling for the parents. There has not previously been any evidence to show that 3DUS would be useful in cases of late diagnosis (third trimester) of amniotic band syndrome. In the present case, a primigravid woman underwent her second obstetric ultrasound scan in the 34(th) week, from which we observed two bands in contact with the right forearm, but with normal movement of this limb and its fingers. 3DUS made it possible to see the spatial relationship of these bands to the fetal body, thereby confirming their adherence to the limb. After the birth, the prenatal diagnosis of amniotic band syndrome without limb constriction was confirmed. A surgical procedure was carried out on the third day after birth to excise the bands, and the newborn was then discharged in a good general condition.

Fetal growth restriction: current knowledge to the general Obs/Gyn.

BACKGROUND: Fetal growth restriction (FGR) is a condition that affects 5-10 % of gestations, and it is the second primary cause of perinatal mortality. In this review the most recent knowledge about FGR is presented focusing on its concept, etiology, classification, diagnosis, management, and prognosis. METHODS: Searches were conducted in Pubmed, Embase and Lilacs database using the term fetal growth restriction. RESULTS: FGR is classified as type I (symmetric), manifested early, in which there is a proportional reduction of all fetal parts, generally associated with chromosome abnormalities; type II (asymmetric), with late onset, in which there is a more accentuated reduction of the abdomen, generally related to placental insufficiency; and type III (mixed), with early manifestation, resulting from infections or exposure to toxic agents. Diagnosis may be clinical, although ultrasound associated with arterial and venous Doppler is essential for diagnosis and follow-up. Currently there is no treatment capable of controlling FGR, and the moment of interruption of pregnancy is of vital importance in order to protect maternal and fetal interests. CONCLUSION: Early diagnosis of FGR is very important, because it permits the etiological identification and adequate monitoring of fetal vitality, minimizing the risks related to prematurity and intrauterine hypoxia.

Como deve ser o rastreamento e o diagnóstico do diabetes mellitus gestacional? / What should be the screening and diagnostic strategies for gestational diabetes?

O diabetes mellitus gestacional (DMG) é uma das patologias mais comuns na gravidez. Quando não diagnosticado e não tratado, pode determinar sérias complicações durante a gravidez e parto com aumento da morbidade e mortalidade perinatal, além de ser marcador de risco de complicações tanto para a mãe como para a criança e de desenvolverem doenças no futuro. Apesar disso, não há consenso sobre a melhor forma de rastrear e diagnosticar essa doença na gravidez. Esta revisão teve como objetivo demonstrar quais os métodos descritos na literatura recente e nos consensos de especialistas para esse rastreamento, além de mostrar o esforço que tem sido feito para sistematizar e unificar o rastreamento e o diagnóstico do DMG.

Gestational diabetes (GD) is one of the most prevalent clinical disorders in pregnancy. When it is not diagnosed and treated, it can lead to serious complications during pregnancy and at delivery, as well as increase perinatal morbidity and mortality, besides being a condition that predisposes the mother and the child to future complicatons. Nevertheless, there is no consensus as to the best way of screening and diagnosing this disorder in pregnancy. This review presents the methods recently described in the literature and the consensus of specialists on screening, as well as the efforts to standardize and unify GD screening and dignosis.

A ultrassonografia rotineira em pré-natal de baixo risco colabora com a diminuição das mortalidades maternas e neonatais / Does routine ultrasound in low risk pregnancy collaborate with the reduction of maternal and neonatal mortality

Esta revisão sistemática teve como objetivo avaliar se a realização da ultrassonografia (US) de rotina em gestações de baixo risco colabora com a diminuição da mortalidade materna e neonatal. Foi realizada uma revisão criteriosa da literatura dos últimos 20 anos, analisamos 121 estudos e deu-se preferência às revisões e aos ensaios clínicos randomizados, sendo esses estudos classificados segundo os níveis de evidência da Associação Médica Brasileira. Resultados: A US precoce possibilita melhor datação da gestação, evitando pós-datismo e induções desnecessárias, diagnostica gestações múltiplas com estabelecimento da corionicidade, e em lugares e casos em que a interrupção da gestação é permitida, diminui a mortalidade perinatal. A US morfológica do primeiro e segundo trimestres tem boa sensibilidade para detectar anomalias fetais, e o morfológico de segundo trimestre mostrou-se com razoável relação custo-benefício. A US após 24 semanas não demonstrou nenhum benefício claro para a mãe ou para o feto, a exceção da avaliação da maturidade placentária que parece reduzir a mortalidade perinatal. Conclusões: O tema continua controverso, necessitando de mais estudos que avaliem seu benefício em longo prazo. Como os estudos demonstram maior benefício antes de 24 semanas, algumas sociedades recomendam a realização de 2 exames: um ao redor de 12 semanas e o morfológico de segundo trimestre.

This systematic review aimed to assess whether the implementation of ultrasound (US) in routine low-risk pregnancies collaborates with decreasing maternal and neonatal mortality. We conducted a careful review of the literature of the last 20 years and analyzed 121 studies, and preference was given to the reviews and randomized clinical trials. These studies were classified according to the levels of evidence from the Brazilian Medical Association. Results: The early US allows: early dating of pregnancy avoiding post-term pregnancy and unnecessary inductions, diagnosis of multiple pregnancies and the establishment of chorionicity and reduce perinatal mortality in places and circumstances in which termination of pregnancy is allowed. The first and second trimester US screening have good sensitivity for detecting fetal abnormalities, and the second trimester US proved to be a reasonable cost-benefit analysis. The US after 24 weeks showed no clear benefit to the mother or the fetus, except for the evaluation of placental maturity that seems to reduce perinatal mortality. Conclusions: The issue remains controversial, requiring further studies to evaluate its long-term benefit. As the studies show more benefit before 24 weeks, some guidelines recommend performing 2 tests: 1 around 12 weeks and the second trimester screening.