It is about time. The advantage of transabdominal cervical length screening.

PURPOSE: Sonographic cervical length (CL) measurement has become a standard practice for identifying women at increased risk for preterm birth. We aimed to assess the time needed for CL measurement during fetal anatomy scan using either transabdominal or transvaginal ultrasound, and to provide a predictive value of the transabdominal CL measurements for reassuring transvaginal CL measurements of more than 25 mm. METHODS: In a prospective study we measured CL transabdominally, and transvaginally in all the anatomy scans performed at 18-25 weeks' gestation, from January 2017 until January 2018. CL and the duration of the examination were compared between the two approaches. Adjustments were made for, body mass index, previous cesarean sections and parity. RESULTS: Four hundred sixty-eight patients participated in the study. The time needed for the transabdominal CL measurement was significantly lower compare with the transvaginal CL measurement (0.46 ± 0.3 min versus 6.9 ± 1.38 min, p < 0.001). The CL measured transabdominally was significantly shorter than the CL measured transvaginally (36.7 ± 6.7 mm versus 41.9 ± 7.3 mm, respectively p < 0.001). All women with transabdominal CL measurements above 36 mm (64.2% of patients) had a transvaginal CL of more than 25 mm. CONCLUSION: Transvaginal measurement of CL is a time-consuming procedure that prolong fetal anomaly scan by 25%. Transabdominal CL measurement of 36 mm is reassuring CL above 25 mm. Transabdominal ultrasound should be used as an initial tool for CL screening. Transvaginal measurements of CL should be reserved for high-risk women, for women with difficulties in demonstrating the cervix abdominally, and for women with transabdominal measurements of less than 36 mm.

Quantification of Fetal Gyrogenesis in the Third Trimester. A Novel Algorithm for Evaluating Fetal Sulci Development.

BACKGROUND AND PURPOSE: The fetal brain changes significantly throughout gestation. From a smooth (lissencephalic) cortex, it transforms into its convolved (gyrencephalic) state. Despite its importance, the diagnosis of delay in brain gyrogenesis is a challenge for many sonographers. This study presents a novel semiautomatic image processing algorithm for simple quantification of sagittal sulci maturation in the third trimester. METHODS: Mid-sagittal fetal brain ultrasound images were obtained during routine third trimester scans. Fetal brain sulci length measurements were performed using a novel semiautomatic image processing algorithm followed by manual measurements. Correlations between the total length of the sulci, gestational age, and fetal biometry were examined. RESULTS: The study included 64 patients. A significant positive linear correlation was found between total sulci length and gestational age (r = .658 for automated measurement, r = .7 for manual measurement, P < .0001). A similar relationship was found comparing total sulci length and fetal head circumference (r = .694 for automated measurement, r = .74 for manual measurement; P < .0001). A significant correlation was observed between automated and manual measurements (r = .947). CONCLUSIONS: We found that fetal gyrogenesis is linear throughout the third trimester of pregnancy. The use of a computer algorithm to measure fetal sulci can be used as a simple prenatal screening test for delayed gyral maturation of the fetal brain.

A Preliminary Study of Three-dimensional Sonographic Measurements of the Fetus.

OBJECTIVES: This study was aimed at establishing an ideal method for performing three-dimensional measurements of the fetus in order to improve the estimation of fetal weight. METHODS: The study consisted of two phases. Phase I was a prospective cross-sectional study performed between 28 and 40 weeks' gestation. The study population (n=110) comprised low-risk singleton pregnancies who underwent a routine third-trimester sonographic estimation of fetal weight. The purpose of this phase was to establish normal values for the fetal abdominal and head volumes throughout the third trimester. Phase II was a prospective study that included patients admitted for an elective cesarean section or for induction of labor between 38 and 41 weeks' gestation (n=91). This phase of the study compared the actual birth weight to two- (2D) and three-dimensional (3D) measurements of the fetus. Conventional 2D ultrasound fetal biometry was performed measuring the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FL). Volume estimates were computed utilizing Virtual Organ Computer-aided AnaLysis (VOCAL), and the correlation between measured volumes and actual neonatal weight was calculated. RESULTS: Overall, this longitudinal study consisted of 110 patients between 28 and 41 weeks' gestation. Normal values were computed for the fetal abdomen and head volume throughout the third trimester. Ultrasound examination was performed within three days prior to delivery on 91 patients. A good correlation was found between birth weight and abdominal volume (r=0.77) and between birth weight and head volume (r=0.5). Correlation between bidimensional measurements and actual fetal weights was found to be comparable with previously published correlations. CONCLUSION: Volume measurements of the fetus may improve the accuracy of estimating fetal size. Additional studies using different volume measurement of the fetus are necessary.

The nuchal translucency examination leading to early diagnosis of structural fetal anomalies.

OBJECTIVE: To evaluate the ability to diagnose structural fetal anomalies during or soon after an extended nuchal translucency (NT) examination. METHODS: The study population included all women who had a routine NT examination in the ultrasound division of one of three centers. Also included in the study were women referred to these centers following an abnormal NT examination. The sonographers were instructed to pay attention to fetal anomalies while performing the NT examination. Each examination was initially attempted transabdominally. Failure to obtain adequate views transabdominally was an indication for a transvaginal examination. When a structural fetal anomaly was detected or suspected, a full fetal anomaly scan was performed. When a diagnosis could not be established, fetal anatomy scan was repeated after 14 weeks of gestation. Fetal cardiac scanning was performed transvaginally, immediately or within 3 days after an increased NT was observed. When fetal anomalies were diagnosed the patients were informed about the possibilities of terminating the pregnancy or continuing the work-up and follow-up. Overall, ascertainment of fetal outcome was available in 85% of the study population. RESULTS: We performed 4467 NT examinations during the study period and additional 123 fetal cardiac scanning following an abnormal NT examination. Overall, we performed 365 fetal cardiac scanning between 11 and 14 weeks of gestation. The fetal anomalies detected included the following: three skeletal anomalies, seven brain anomalies, four urinary system anomalies, four abdominal anomalies, two facial anomalies, and 13 cardiac anomalies. Six of the 13 cardiac anomalies were found in the atrioventricular canal. One third of the patients (11/33) elected to discontinue the pregnancy a short time after the detection of the congenital anomaly (until 14 weeks of gestation) and half of the patients (16\33) asked for termination of pregnancy later. More than 60% of the patients (20/33) with congenital anomalies detected following the NT examination refused to have chorionic villous sampling (CVS) or amniocentesis. CONCLUSION: The opportunity to scan the fetal anatomy in the early stages of pregnancy, when the NT examination is performed, justifies the approach of extended NT examination.

A comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology.

OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal sonography (TVS) compared to hysteroscopy in diagnosing uterine abnormalities. In addition, to determine whether the number of diagnostic hysteroscopies can be reduced and replaced by TVS examinations. STUDY DESIGN: In this retrospective study, we summarized data from 128 patients who underwent TVS examination and hysteroscopy in our ultrasound unit during the last two years. Specimens were obtained and sent for histopathological examination. Sensitivity, specificity, positive and negative predictive values for diagnosing uterine pathology were calculated for each method. RESULTS: Hysteroscopy had a significantly higher sensitivity in diagnosing intra-uterine fibroids while TVS had a significantly higher sensitivity in diagnosing retained products of conception. Although hysteroscopy had better predictive values for diagnosing uterine polyps the difference was not statistically significant. The combination of both TVS and hysteroscopy did not seem to improve the sensitivity and specificity. There were three additional important findings: two cases of uterine hyperplasia and one case of endometrial carcinoma in patients with abnormal uterine bleeding were all diagnosed by hysteroscopy after being suspected on the TVS examination. CONCLUSION: TVS is an excellent tool in evaluating retained products of conception. In other cases of uterine pathology, diagnostic hysteroscopy is needed to improve diagnostic accuracy.

Prenatal diagnosis of scrotal-inguinal hernia: two case reports and review of the English literature.

We present two cases of a prenatal diagnosis of inguinal hernia and the fetal outcome. Initial differential diagnosis included sacrococcygeal teratoma and testicular termatoma, while the final diagnosis was scrotal-inguinal hernia based on sonographic visualization of bowel loop movement in the scrotal mass.

Measurements of the lower uterine segment during gestation.

PURPOSE: To establish normal values for the lower uterine segment (LUS) thickness and to recognize factors that may affect these values. METHODS: In this cross-sectional study, we measured the LUS thickness in women between 11 and 41 weeks gestation. Women with placental abnormalities and fetal anomalies were excluded. Fetal weight, location of placental implantation, and cervical length were estimated. The LUS was examined to identify the thinnest zone and evaluated using the transvaginal approach with an empty urinary bladder. Full LUS thickness was measured with a caliper at the inner surface of the posterior bladder wall and another caliper at the interface between the amniotic fluid and the decidua. The myometrium was measured with the first caliper at the interface between the amniotic fluid and the deciduas and the second between the bladder wall and the myometrium. Normal values for the LUS were established throughout gestation, and correlations between the LUS gestational age, fetal weight, previous cesarean section, and other parameters were examined. RESULTS: Overall, 350 women were included in our study. Median parity was 1 (0-6) and the majority (62%, 218/350) of women have not had a previous cesarean section. The LUS thickness inversely correlated with gestational week (Pearson's r = -0.11, p < 0.03). When stratifying the linear regression model to women with and without a history of a previous cesarean section, it was demonstrated that gestational age was moderately correlated with LUS only in the second group of patients (Pearson's r = -0.16, p = 0.1 and Pearson's r = -0.47, p < 0.0001, respectively). During the post term period, patients who had had a previous cesarean section had significantly thinner LUS compared with patients who had not had a previous cesarean section (46 mm ± 20 versus 59 mm ± 20, p = 0.002, respectively). Neither parity nor the number of previous cesarean sections were found to correlate with the thickness of the LUS (p > 0.05). Multivariate linear regression (R(2) = 0.215, F(2, 63) = 9.021, p < 0.001) demonstrated that both gestational week (ß = -0.13, p < 0.04) and cesarean section (ß = -0.01, p < 0.0001) were independent factors associated with the thickness of the LUS; for every 1 week increase in gestational week, there was a 1.3 mm decrease in the total thickness of the LUS CONCLUSIONS: We have established reference ranges for LUS thickness throughout gestation. The LUS thickness decreases throughout gestation in singleton pregnancies and is significantly thinner in postterm period pregnant women with a previous cesarean section.

Sonographic evaluation of the superior sinus sagittalis.

OBJECTIVE: The aim of this study was to characterize the normal ultrasonographic growth of the fetal superior sinus sagittalis (SSS) throughout gestation. PATIENTS AND METHODS: In a prospective cross-sectional study, measurements of the fetal sinus sagittalis were obtained in patients undergoing elective fetal anatomical surveys or fetal growth scan at between 16.6 and 34.7 weeks of gestation. Special attention was given to the SSS of the fetal brain. On the coronal plane, the SSS may be easily identified immediately below the frontal bone, and anterior to the fetal head parenchyma. RESULTS: 206 fetuses were scanned. A regression line of the SSS was created throughout gestation and a first-degree correlation was found between gestational age (GA) and the SSS height (r = 0.418; p < 0.0001; SSS = -0.015 + 0.0178 × GA). Normal values were established for different gestational weeks. CONCLUSION: We provide ultrasonographic dimensions of the fetal SSS across pregnancy. This data potentially allows for prenatal diagnosis of abnormal appearance of the SSS.

Sonographic study of the relationship between gestational diabetes mellitus and fetal activity.

OBJECTIVE: To evaluate the relationship between gestational diabetes mellitus (GDM) and fetal activity. MATERIALS AND METHODS: We prospectively studied 18 pregnant patients with GDM and 20 pregnant patients with normal glucose screening test. An ultrasound equipment was used to perform a 30 min transabdominal sonographic recording for each patient. Each ultrasound exam was recorded using a DVD recorder. Fetal activity was analyzed using duration and number of episodes of fetal breathing and body movements. The recordings were analyzed using a stopwatch in order to accurately evaluate each recording. The data was statistically analyzed using the parametric and non-parametric t-test. RESULTS: The results of the study indicated that there was a significant correlation (p = 0.007) between the duration of fetal breathing movement and GDM. Fetuses of mothers suffering from GDM had a significantly longer duration of fetal breathing movements compared with fetuses of non diabetic mothers. In addition, the total duration of fetal activity (time of fetal body movements plus fetal breathing movements) was significantly higher (p = 0.005) in GDM compared with non GDM pregnancies. The difference in fetal body movements between GDM and normal pregnancies was not statistically significant. CONCLUSION: The results of this study support the hypothesis that GDM has a direct influence on fetal activity. The significance of this finding should be further evaluated.

Corpus callosum growth in normal and growth-restricted fetuses.

OBJECTIVE: The aim of this study was to characterize the normal ultrasonographic growth of the corpus callosum (CC) in normal and in growth-restricted fetuses throughout gestation. METHODS: This was a prospective cross-sectional study. Consecutive routine biometric measurements and fetal organ scans were obtained in patients undergoing elective fetal anatomical surveys or evaluation of the fetal growth between 16 to 33 weeks. Special attention was given to the CC of the fetal brain. In addition, we evaluated the growth of the CC in growth-restricted fetuses throughout pregnancy. RESULTS: Two hundred and fifty two normal fetuses were scanned between 16 and 36 weeks of gestation. A regression line of the CC was established through gestation and a second-degree correlation was found between gestational age and CC outer margin. Twenty four growth-restricted fetuses were also evaluated in which the growth of the CC was significantly below both the 25(th) and 50(th) percentiles in 77.3% and 95.5%, respectively, for the same gestational age. CONCLUSIONS: We provide nomograms for the ultrasonographic dimensions of the fetal CC that allows for prenatal diagnosis of abnormal dimensions of CC. The significance of abnormal CC growth in growth-restricted fetuses should be further evaluated.

Fetal cardiac scanning performed immediately following an abnormal nuchal translucency examination.

OBJECTIVE: To study the implications of early fetal cardiac scanning immediately following an abnormal nuchal translucency (NT) examination. METHODS: Fetal cardiac scanning was performed immediately after an increased NT was observed. Scans were performed transvaginally at 11 to 14 weeks. Fetal echocardiography was repeated between 14 and 24 weeks in continuing pregnancies, or when the cardiac scanning appeared normal at 11 to 14 weeks. RESULTS: We performed 2513 NT examinations. An abnormal NT was observed in 135 (5.4%) patients. In addition, 65 patients with an abnormal NT were referred to us for fetal cardiac scanning from other offices. Overall, we performed 200 fetal cardiac scans between 11.2 and 13.5 weeks for an abnormal NT examination. Twelve major fetal cardiac anomalies were diagnosed between 12 and 13.5 weeks. Seven patients (58%) terminated pregnancy between 12 and 14 weeks without performing chorionic villous sampling (CVS). Five patients asked for chromosomal analysis before deciding about their pregnancy. Fetal cardiac anomalies were suspected in six additional cases, but only one of them was diagnosed. Another five minor and one major fetal cardiac anomaly were suspected at 11 to 14 weeks but diagnosed later on fetal echocardiography. CONCLUSION: Major fetal cardiac anomalies can be detected immediately following an abnormal NT examination and be useful for the patients' decisions about the management of their pregnancy.

Screening for structural fetal anomalies during the nuchal translucency ultrasound examination.

OBJECTIVE: The purpose of this study was to evaluate the ability to screen for structural fetal anomalies during the nuchal translucency (NT) ultrasound examination, without performing a complete anatomic fetal scan, by using the sagittal views of the fetus. STUDY DESIGN: In a prospective study, we evaluated all the suspected structural findings observed during the NT examinations performed in our Division of Maternal-Fetal Medicine in 2004-2005. The purpose of the examination was to screen for fetal chromosome abnormalities by using the fetal NT measurements. However, the sonographers were instructed to pay attention to any abnormality observed while obtaining the sagittal views of the fetus. Other views were not to be obtained and fetal anatomy scan was performed only if a structural fetal anomaly was suspected when viewing the fetus in sagittal planes. When a structural fetal anomaly was suspected, a fetal anatomy scan was performed, and then a diagnosis was established at 14-16 weeks' gestation or later. RESULTS: We performed 1723 NT examinations during the study period. The sonographers suspected structural fetal anomalies in 22 cases (1.3%), most of them performed between 11.2 and 13 weeks' gestation. Further evaluation of these cases diagnosed 9 fetuses (0.52%) with structural anomalies including: acrania, holoprosencephaly, Dandy-Walker syndrome, cerebellar agenesis, prune belly syndrome, 2 cases of omphalocele, and 2 cases of cleft lip. The NT was abnormal (greater than 3 mm) in only 1 case (omphalocele). None of the additional 8 cases diagnosed with structural anomalies had a positive maternal serum screening result for trisomy 21. Eight of these 9 fetal structural anomalies were sonographically confirmed at 14-16 weeks' gestation and the remaining 1 was confirmed at 20 weeks' gestation. An additional 13 noncardiac structural anomalies were detected in the study group during routine fetal anatomy scan performed at 14-16 or at 18-24 weeks' gestation. Four of these 9 fetal cardiac defects (44%) were diagnosed by an early fetal echocardiography performed for an increased fetal NT. CONCLUSION: In addition to chromosomal anomalies and congenital cardiac defects, the NT examination can provide an opportunity to screen for structural fetal anomalies when viewing within the sagittal planes of the fetus. The NT examination can be used as a screening test for those who require an early fetal anatomy scan without performing an additional early anatomy scan to all patients.

Prenatal diagnosis of fetal chest lymphangioma.

OBJECTIVE: Prenatally diagnosed cystic nuchal hygroma is often associated with chromosomal anomalies and hydrops fetalis. Chest lymphangioma diagnosed later in gestation appears to be a completely different disease, with a low incidence of chromosomal and structural anomalies. METHODS: Two chest cavernous lymphangiomas of the fetus are presented. The sonographic images, chromosomal analyses, and macroscopic and microscopic evaluations are described. RESULTS: Fetal chest cavernous lymphangiomas were identified at 15 and 22 weeks' gestation. In the first case, the couple decided to interrupt gestation. In the second case, prenatal sonography showed a multilocular, cystic lymphangioma external to the chest wall with no flow on Doppler sonography. Follow-up sonography revealed normal fetal growth and slow enlargement of the cystic mass surrounding the left chest cavity. The neonate was delivered without complications and was treated surgically. CONCLUSIONS: The chest lymphangioma appears to be a lesion usually not associated with other congenital abnormalities. The prenatal diagnosis of chest wall lymphangioma is relatively easy sonographically, and the treatment of choice is surgical excision. The outcome is relatively favorable, with a low incidence of chromosomal and structural anomalies.

Nomogram of maxillary bone length in normal pregnancies.

OBJECTIVE: The aim of this study was to define normal ultrasonographic growth of the fetal maxillary bone throughout pregnancy as a basis for further studies and as normative data for assessing deviations in growth. METHODS: A prospective cross-sectional study was performed. Consecutive routine biometric measurements and fetal organ scans were obtained from patients undergoing elective fetal anatomic surveys. Special attention was paid to the profile view of the fetal face, and the maxillary bone was identified and measured. RESULTS: Three hundred twenty-seven fetuses between 13 and 40 weeks' gestation were scanned. The maxillary bone is seen as a rodlike structure; it is a part of the facial skeleton that allows the opening and closing of the pharynx. A linear growth function was observed across gestational age (GA), and first-degree correlation was found to exist between GA and the maxillary bone (r = .645; P < .0001; y = 7.78 + 0.18 x GA). Significant correlation was also found between the maxillary bone and biparietal diameter (BPD) (r = 0.652; P > .0001; y = 8.36 + 0.66 x BPD), head circumference (HC) (r = .645; P < .0001; y = 8.39 + 0.18 x HC), femoral bone length (FBL) (r = .640; P < .0001; y = 9.28 + 0.7 x FBL), and abdominal circumference (AC) (r = .640; P < .0001; y = 8.91 + 0.17 x AC). CONCLUSIONS: Normative data for ultrasonographic measurements of the fetal maxillary bone throughout pregnancy are provided. These data potentially allow the prenatal diagnosis of abnormal maxillary bone length.

Mild cerebral ventriculomegaly in fetuses: characteristics and outcome.

BACKGROUND: A fetal ultrasonographic (US) finding of mild ventriculomegaly (MVM) is not uncommon, but its prognostic significance is not clearly defined. OBJECTIVE: To evaluate the clinical and US characteristics and outcome of fetuses with mild dilatation of the cerebral lateral ventricles. PATIENTS AND METHODS: We reviewed the medical records of 34 consecutive fetuses with US evidence of MVM (atrial width of the lateral ventricles = 10-15 mm) at 18-35 weeks of gestation. RESULTS: Of the 34 fetuses with MVM, 7 underwent karyotype examination and were normal. In 4 of the 34 fetuses the pregnancy was terminated (at autopsy: 1 was normal, 2 had hydrocephalus and for 1 the parents refused autopsy). Eight fetuses that were delivered had congenital malformations; 3 of them died during the early neonatal period. In 6 of the 8 fetuses with malformations, karyotypes were available and 3 had chromosomal aberrations (trisomy 18, 45XO, and triploidy 69XXX). Spontaneous in utero resolution of the MVM occurred in 10/30 (33.3%) of the cases. Of the 26 infants that remained in follow-up, 16 (61.1%) were normal at 1 month and at 2 years of age. CONCLUSIONS: Our data confirm those of previous reports as to the characteristics and outcome of MVM. In the setting of mild fetal ventriculomegaly with a normal karyotype and an absence of malformations, the outcome appears to be favorable.

Congenital cervical teratoma, associated with agenesis of corpus callosum and a subarachnoid cyst.

Cervical teratoma is a neoplasm composed of embryonic tissues with representation of all three germ layers. We report an extremely rare case of fetal cervical teratoma presenting at 24 weeks of gestation. A submaxillary mass and agenesis of corpus callosum were identified on ultrasonography, associated with agenesis of corpus callosum and a subarachnoid cyst.

Hemivertebra: prenatal diagnosis, incidence and characteristics.

OBJECTIVE: Hemivertebra is a rare congenital spinal anomaly where only one side of the vertebral body develops, resulting in deformation of the spine, such as scoliosis, lordosis, or kyphosis. We aimed to determine the incidence and clinical characteristics of hemivertebra. PATIENTS AND METHODS: We present three fetuses with a prenatal ultrasonographic diagnosis of hemivertebra at 15-22 weeks' gestation, and we determine the incidence and clinical characteristics of hemivertebra among 78,500 live-born infants at a tertiary medical center in Israel. RESULTS: There were 26 cases of hemivertebra (0.33/1,000 live-born infants): male/female ratio 1/1, Jewish/Arab ratio 10/16, and ratio of single/multiple type of hemivertebrae 17/9. Twenty-three out of 26 infants (88.5%) with hemivertebra had additional congenital anomalies (cranial, cardiac, renal, intestinal, and skeletal). CONCLUSIONS: Hemivertebra is not an infrequent finding in fetuses and live-born infants. Comprehensive ultrasonographic screening of the fetus allows early prenatal diagnosis of hemivertebra, and provides parents with helpful information for their decision regarding the fate of pregnancy.

[Prenatal diagnosis of fetal neoplasms].

A variety of neoplasms can develop in each fetal organ. Most fetal neoplasms can be detected by ultrasonographic examination. Cancer appearing either at birth or within the first month of life occurs in 36.5 per million liveborn infants. The death rate is 6.24-7.6 per million live births. This article briefly reviews the sonographic findings in the most common fetal neoplasms and presents the authors' experience in the prenatal ultrasonographic diagnosis of fetal neoplasms: intracranial fetus-in-fetu, adrenal neuroblastoma and mesoblastic nephroma.