Prenatal ultrasound diagnosis of neural tube defects in the era of intrauterine repair - Eleven years' experiences.

OBJECTIVE: To modify the current neural tube defect (NTD) classification for fetal medicine specialists, and to investigate the impact of prenatal ultrasound conus medullaris position screening on the detection rate of closed spinal dysraphism and pregnancy outcomes. MATERIALS AND METHODS: The clinical data of 112 patients prenatally diagnosed with neural tube defects in Taiji clinic from 2008 to 2018 were retrospectively analyzed. All cases were classified following the modified classification. We compared the detection rate before and after introducing the conus medullaris screening and pregnancy outcomes for NTD types. RESULTS: Closed spinal dysraphism type prevailed in our sample (43.8%). The median gestational age at the time of detection for cranial dysraphism was 13.3 weeks, open spinal dysraphism was 22.0 weeks, and closed spinal dysraphism was 22.6 weeks. All cranial dysraphism (n = 43) and open spinal dysraphism cases (n = 20) had pregnancies terminated. For closed spinal dysraphism Class 1, the live-birth rate was 100.0% in the cases without other anomalies and 33.3% in the cases with other anomalies, respectively (X2 = 17.25, p < 0.001). Similarly, for Class 2, pregnancy continuation rate was 50.0% in cases without other anomalies and 20.0% in cases with other anomalies, yet it failed to reach statistical significance (X2 = 0.9, p = 0.524). CONCLUSION: Our case series may help to improve early screening and prenatal diagnosis of NTDs. Modified classification is adjusted for use in ultrasound fetal care facilities, which could be used for predicting pregnancy outcome. We suggest promoting first-trimester anatomical screening in order to make an earlier diagnosis and therefore provide better prenatal care for open spinal dysraphism cases in the era of intrauterine repair. Our findings imply that the use of fetal conus medullaris position as a marker for closed spinal dysraphism improves the detection rate and would unlikely lead to a higher termination rate.

Using deep-learning algorithms to classify fetal brain ultrasound images as normal or abnormal.

OBJECTIVES: To evaluate the feasibility of using deep-learning algorithms to classify as normal or abnormal sonographic images of the fetal brain obtained in standard axial planes. METHODS: We included in the study images retrieved from a large hospital database from 10 251 normal and 2529 abnormal pregnancies. Abnormal cases were confirmed by neonatal ultrasound, follow-up examination or autopsy. After a series of pretraining data processing steps, 15 372 normal and 14 047 abnormal fetal brain images in standard axial planes were obtained. These were divided into training and test datasets (at case level rather than image level), at a ratio of approximately 8:2. The training data were used to train the algorithms for three purposes: performance of image segmentation along the fetal skull, classification of the image as normal or abnormal and localization of the lesion. The accuracy was then tested on the test datasets, with performance of segmentation being assessed using precision, recall and Dice's coefficient (DICE), calculated to measure the extent of overlap between human-labeled and machine-segmented regions. We assessed classification accuracy by calculating the sensitivity and specificity for abnormal images. Additionally, for 2491 abnormal images, we determined how well each lesion had been localized by overlaying heat maps created by an algorithm on the segmented ultrasound images; an expert judged these in terms of how satisfactory was the lesion localization by the algorithm, classifying this as having been done precisely, closely or irrelevantly. RESULTS: Segmentation precision, recall and DICE were 97.9%, 90.9% and 94.1%, respectively. For classification, the overall accuracy was 96.3%. The sensitivity and specificity for identification of abnormal images were 96.9% and 95.9%, respectively, and the area under the receiver-operating-characteristics curve was 0.989 (95% CI, 0.986-0.991). The algorithms located lesions precisely in 61.6% (1535/2491) of the abnormal images, closely in 24.6% (614/2491) and irrelevantly in 13.7% (342/2491). CONCLUSIONS: Deep-learning algorithms can be trained for segmentation and classification of normal and abnormal fetal brain ultrasound images in standard axial planes and can provide heat maps for lesion localization. This study lays the foundation for further research on the differential diagnosis of fetal intracranial abnormalities. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Ecografía en técnicas de Reproducción Asistida / Ultrasound in Assisted Reproductive techniques

La presente revisión de las aplicaciones de la ecografía en las técnicas de reproducción asistida tiene como misión una puesta al día de los últimos datos acerca de su utilidad en el diagnóstico de patologías previas a la realización de la técnica (endometriosis, pólipos endometriales, malformaciones uterinas, miomas, adenomiosis, síndrome de Asherman, ovarios poliquísticos, , hidrosálpinx, etc), la valoración de la reserva ovárica y receptividad endometrial, la diferenciación entre formaciones funcionales que frecuentemente encontramos durante los tratamientos y el uso como guía tanto para controlar el desarrollo multifolicular como la punción ovárica y la transferencia embrionaria. Por último se trata la ayuda que presta la ecografía en el diagnóstico y tratamiento del síndrome de hiperestimulación ovárica y durante el diagnóstico precoz de la gestación normal y patológica, así como su papel en la reducción embrionaria y terminación selectiva de la gestación (AU)

The aim of this review is to present the latest data about the applications of ultrasound in assisted reproductive techniques (ARTs) and their relevance in the diagnosis of pathologies related with infertility (endometriosis, endometrial polyps, uterine malformations, myomas, adenomyosis, Asherman syndrome, polycystic ovaries, hydrosalpinx, etc.). The usefulness of this technique to assess ovarian reserve, to recognize functional ovarian cysts frequently found during treatments, its use as guide for multiple follicular development and its potential to evaluate endometrial receptivity is also updated. Besides, the role of ultrasound during the realization of the oocyte pick up and embryo transfer is also evaluated. Finally, the relevance of ultrasound in other aspects related with reproduction as the diagnosis and treatment of ovarian hyperstimulation syndrome (OHS), the early diagnosis of normal and pathological pregnancy, as well as fetal reduction and selective termination of pregnancies is also covered (AU)

Gestación heterotópica espontánea. Diagnóstico ecográfico precoz y asintomático / Spontaneous heterotopic pregnancy. Early and asymptomatic transvaginal ultrasound diagnosis

El embarazo heterotópico es una situación potencialmente fatal, que es raro que ocurra en una concepción natural, y más raramente todavía se diagnostica en ausencia de síntomas. Además, probablemente debido al bajo índice de sospecha de embarazo heterotópico en las gestaciones no estimuladas, el porcentaje de complicaciones clínicas graves (hemoperitoneo, rotura tubárica, abdomen agudo) es superior en este grupo de pacientes. En nuestro caso se trata de una paciente nulípara de 33 años de edad, con gestación espontánea, que acudió a las 6 semanas y 3 días de amenorrea para su primer control rutinario, en ausencia de síntomas. El estudio ecográfico evidenció una imagen gestacional intraútero y otra junto a ovario derecho. Se realizó una laparoscopia con salpingectomía, incluyendo el embarazo ectópico. A las 38 semanas de gestación dio a luz un recién nacido sano sin complicaciones. Es posible el diagnóstico de un embarazo heterotópico tras concepción natural, incluso en ausencia de síntomas. Es importante realizar una visualización sistema ́tica de los anexos en la primera ecografía, que además de descartar la presencia de enfermedad ovárica, puede diagnosticar la presencia de un embarazo heterotópico, incluso en ausencia de síntomas y complicaciones (AU)

Heterotopic pregnancy is a potentially fatal situation that rarely occurs in a natural conception. Diagnosis in the absence of symptoms is even more exceptional. Furthermore, due to the low index of suspicion of heterotopic pregnancy in natural conceptions, the incidence of serious clinical complications (hemoperitoneum, tubal rupture, acute abdomen) is greater in this group of patients. We report the case of a 33-year-old primigravida with a spontaneous pregnancy who attended her first prenatal visit at 6 weeks and 3 days of amenorrhea. The patient was asymptomatic. Vaginal ultrasound scan showed two gestational sacs, an intrauterine sac and an extrauterine sac next to the right ovary. A laparoscopic right salpingectomy was performed to remove the ectopic pregnancy. A healthy neonate was delivered at 38 weeks’ gestation without complications. Heterotopic pregnancy can be diagnosed after spontaneous conception, even in asymptomatic patients. It is important to carry out routine examination of the adnexae in the first ultrasound scan to exclude ovarian disease and diagnose (or exclude) the presence of asymptomatic heterotopic pregnancy (AU)

Utilisation of obstetric sonography at a peri-urban health centre in Uganda.

BACKGROUND: Maternal mortality is related to obstetric complications in pregnancy some of which could be revealed by obstetric sonography. Obstetric sonography has become part of routine antenatal care in both urban and rural settings. The objective of the study was to assess the utilization of obstetric sonography in a rural hospital of Uganda, including the frequency and appropriateness of its usage as well as determine whether there was any relation between number of obstetric scans, patient management and obstetric outcomes. METHODS: It was a retrospective study in which review of all obstetric charts and obstetric scan requisition forms for all deliveries in Ndejje Health Centre (Uganda) was done. RESULTS: During the study period, there were 105 singleton deliveries, and these mothers underwent a total of 232 obstetric scans. More than half (53.4%) of the scans were classified as inappropriate. There were no significant differences in the number of scans between low- and high-risk pregnancies or between uncomplicated deliveries and those in which induction or instrumental or operative delivery occurred, nor was there any relation between number of scans and obstetric outcome. CONCLUSION: Obstetric sonography has become popular in rural health settings as part of antenatal care. However, it was over-used in the health centre. This overuse was not associated with any identifiable effect on obstetric outcome. Therefore, more appropriate use of obstetric sonography, in accordance with evidence-based guidelines, is recommended.

Fetal echocardiography: z-score reference ranges for a large patient population.

OBJECTIVES: The main goal was to develop new z-score reference ranges for common fetal echocardiographic measurements from a large referral population. METHODS: A retrospective cross-sectional study of 2735 fetuses was performed for standard biometry (biparietal diameter (BPD) and femoral diaphysis length (FDL)) and an assessment of menstrual age (MA). Standardized fetal echocardiographic measurements included aortic valve annulus and pulmonary valve annulus diameters at end-systole, right and left ventricular diameters at end-diastole, and cardiac circumference from a four-chamber view of the heart during end-diastole. Normal z-score ranges were developed for these echocardiographic measurements using MA, BPD and FDL as independent variables. This was accomplished by using first standard regression analysis and then weighted regression of absolute residual values for each parameter in order to adjust for inconstant variance. RESULTS: A simple, linear regression model was the best description of the data in each case and correlations between fetal cardiac measurements and the independent variables were excellent. There was significant heteroscedasticity of standard deviation with increasing gestational age, which also could be modeled with simple linear regression. After this adjustment, the residuals conformed to a normal distribution, validating the calculation and interpretation of z-scores. CONCLUSION: Development of reliable z-scores is possible for common fetal echocardiographic parameters by applying statistical methods that are based on a large sample size and weighted regression of absolute residuals in order to minimize the effect of heteroscedasticity. These normative ranges should be especially useful for the detection and monitoring of suspected fetal cardiac size and growth abnormalities.

[3D and 4D ultrasonography in obstetrics].

The review article analyses the practical application of 3D/4D ultrasound in modern obstetrics. The basic terms applied with this method are introduced including their equivalents in Bulgarian. The main volume rendering modes are described. The advantages of 3D/4D ultrasound in obstetrics are outlined including: 1) improved understanding of normal fetal anatomy and fetal anomalies by the parents; 2) improved maternal-fetal bonding; 3) enhanced diagnosis of fetal anomalies; 4) precise identification of the nature, size and location of certain fetal defects; 5) precise volume measurement of organs with irregular shape; 6) retrospective analysis, data exchange and education. Some specific advantages of 3D/4D sonography are listed regarding its application in the first trimester, for the diagnosis of fetal anomalies and for fetal growth assessment. Some myths about 3D/4D ultrasound popular among patients and medical professionals are discussed. The ethical aspects of 3D/4D ultrasound in obstetrics as well as the future perspectives of the method are also outlined.

Individualized growth charts for ultrasound measurements can significantly improve fetal monitoring.

OBJECTIVE: For monitoring pregnancies it is useful to reduce unnecessary examinations due to wrongfully assumed growth retardation in cases with a small fetal growth potential. It also makes sense to improve the detection of objectively retardated children in order to a disproportionately high growth potential. It was the aim of this study to modify the standard growth charts for ultrasound parameters according to parental influences to better display the individual growth potential. MATERIAL AND METHODS: In a prospective trial 1,390 ultrasound measurements of 174 completed pregnancies were observed. For all patients a standard questionnaire was conducted in which possible predictors for fetal growth were collected. Customizing the growth charts had been achieved by (1) calculating the general impact of parental factors on the ultrasound measurement values, (2) plotting the individual growth charts for each pregnancy and (3) analyzing the difference of every observed measurement from either unchanged normal values or customized growth charts. RESULTS: The obtained biparietal diameter measurements all in all are 291 mm closer to the individualized charts than to the unmodified charts. The total improvement of all thoracal diameter measurements was found to be 294 mm, the summarized advancement of all abdomen circumference values was 1,005 mm and the femur length measurements are 296 mm nearer to customized charts. All results were statistically significant. DISCUSSION: This is the first time the impact of several predictors on ultrasound growth charts had been analyzed. While other working groups have demonstrated the benefit of customizing the fetal weight and length, this concept had never been carried forward onto the growth charts for ultrasound values. The method to adjust the common mean values by so called 'modifiers' is derived from the mathematical concept of the sequential first-trimester screening for Down's syndrome. For customizing growth charts this approach seems to be useful as well. The feasability and the statistical benefit of customizing ultrasound growth charts has been demonstrated in this work. A larger study seems to be promising and should be performed. Further improvements could be obtained by using normal growth charts which were derived from the examined cohort.

Subclassification of indeterminate pelvic ultrasonography: prospective evaluation of the risk of ectopic pregnancy.

STUDY OBJECTIVE: We sought to determine the frequency of ectopic pregnancy among subclasses of indeterminate ultrasonographic examinations. METHODS: A prospective observational study was performed from January 1, 1995, to August 31, 2000, on consecutive emergency department patients in the first trimester of pregnancy with a chief complaint of abdominal pain or vaginal bleeding and who had an indeterminate transvaginal ultrasonographic examination at the time of the ED visit. Patients were excluded if lost to follow-up. Ultrasonographic examinations were subclassified into 5 groups (ie, empty uterus, nonspecific fluid, echogenic material, abnormal sac, normal sac) on the basis of a previously published classification system. Patients were followed up until the diagnosis of ectopic pregnancy was either confirmed or excluded. The frequencies of ectopic pregnancy, along with 95% confidence intervals (CIs), were calculated for each of the subclasses. The relative risk of ectopic pregnancy was calculated when appropriate. RESULTS: Seven hundred eighty patients with indeterminate ultrasonographic examinations were identified. One hundred forty-five were lost to follow-up, and therefore, 635 were enrolled. The frequency of ectopic pregnancy for each subclass is as follows: empty uterus, 36 of 259 (13.9%; 95% CI 10.1% to 18.5%); nonspecific fluid, 6 of 127 (4.7%; 95% CI 1.9% to 9.6%); echogenic material, 4 of 93 (4.3%; 95% CI 1.4% to 10.5%); abnormal sac, 0 of 103 (0%; 95% CI 0.0% to 2.9%); and normal sac, 0 of 53 (0%; 95% CI 0.0% to 5.5%). The relative risk of ectopic pregnancy in patients with an empty uterus versus in those without an empty uterus was 5.2 (95% CI 2.6 to 10.2). CONCLUSION: In our sample, patients with an empty uterus at ultrasonography had the highest frequency of ectopic pregnancy, with a relative risk of ectopic pregnancy 5 times greater than that of the other 4 subclasses.

Adenomatosis quística pulmonar. Revisión bibliográfica / Pulmonay cystic adenomatosis. A literature review

La adenomatosis quística pulmonar es una rara malformación congénita que consiste en un hamartoma torácico generado por un trastorno embrionario que acontece entre la quinta y sexta semana de gestación debido a un cese en la maduración bronquiolar con un excesivo crecimiento del mesénquima pulmonar y cuyo diagnóstico prenatal es hoy día posible debido a las técnicas ultrasonográficas de las que se dispone (AU)

Meningocele dorsal atípico / Atypical dorsal meningocele

No disponible

Are rural general practitioner--obstetricians performing too many prenatal ultrasound examinations? Evidence from western Labrador.

OBJECTIVE: To determine the frequency of prenatal ultrasonography (PNU) in western Labrador in 1994, assess the appropriateness of the ultrasound examinations according to current guidelines and determine whether there was any relation between number of PNU examinations and patient management and obstetric outcomes. DESIGN: Review of all obstetric charts and PNU requisition forms for all deliveries in one hospital in 1994. SETTING: Labrador City and Wabush, Newfoundland. RESULTS: During the study period, there were 103 singleton deliveries, and these mothers underwent a total of 225 PNU studies (mean 2.16 studies per delivery). More than half (53.3%) of the examinations were classified as inappropriate. There were no significant differences in the number of studies between low- and high-risk pregnancies or between uncomplicated deliveries and those in which induction or instrumental or operative delivery occurred, nor was there any relation between number of PNU examinations and maternal or neonatal outcome. CONCLUSION: Compared with PNU use as recommended by the Canadian Task Force on the Periodic Health Examination, this type of examination was overused in Labrador City and Wabush, although the rate of use was comparable to that reported in other Canadian studies. This overuse was not associated with any identifiable effect on maternal or neonatal outcome or on the management of pregnancy and labour. More judicious use of PNU, in accordance with evidence-based guidelines, is recommended.

Interpretation of Doppler blood flow velocity waveforms using neural networks.

Doppler umbilical artery blood flow velocity waveform measurement is used in perinatal surveillance for the evaluation of pregnancy status. There is an ongoing debate on the predictive value of Doppler measurements concerning the critical effect of the selection of parameters for the evaluation of Doppler output. In this paper, we describe how neural network methods can be used both to discover relevant classification features and subsequently to classify patients. Classification accuracy varied from 92-99% correct.