To determine if there is evidence of levator ani atrophy in primiparous women.

This is a prospective observational cohort study on 202 primiparous women recruited between November 2006 and March 2008. Translabial ultrasound volumes were obtained at 36-38 weeks’ gestation and at a mean of 4.5 months postpartum. Peripartum changes in bladder neck elevation and reduction of anteroposterior hiatal diameter on pelvic floor muscle contraction (PFMC) and changes in muscle thickness were analysed.

Of the 202 participants enlisted, 158 (78%) completed the study. There was a significant reduction in both tested ultrasound measures of levator function (P = 0.001 and P = 0.03) when comparing antenatal and postnatal results, and this was significantly associated with delivery mode for reduction of hiatal diameter on PFMC (P = 0.013). No significant changes were detected in muscle thickness (P = 0.76).

There is a reduction in sonographic measures of pelvic floor function after childbirth, but muscle atrophy is unlikely to be a significant factor.

To review the available literature on outcome of pregnancy when an isolated Single Umbilical Artery (iSUA) is diagnosed at the time of the mid-trimester anomaly scan.

We searched MEDLINE (1951-2012), Embase (1980-2012) and the Cochrane Library (until 2012) for relevant citations reporting on outcome of pregnancies with an iSUA seen on ultrasound. Data were extracted by two reviewers. Where appropriate, we pooled odds-ratios (OR) for the dichotomous outcome measures: small for gestational age (SGA), perinatal mortality and aneuploidy. For birth weight we determined the mean difference with 95% confidence interval (CI).

We identified three cohort studies and four case-control studies reporting on 928 pregnancies with iSUA. There was significant heterogeneity between cohort and case-control studies. Compared to fetuses with a three vessel cord (TVC), fetuses with an iSUA were more likely to be SGA (OR 1.6, 95%CI 0.97-2.6, n = 489) or suffer perinatal mortality (OR 2.0, 95% CI 0.95-4.2, n = 686), although for neither of the outcomes statistical significance was reached. The difference in mean birth weight was 49 grams (3105 versus 3158 grams; 95% CI -154.7 to 52.6, n = 407). We found no evidence that iSUA fetuses have an increased risk for aneuploidy.

In view of the non-significant association between iSUA and fetal growth and perinatal mortality, and in view of the heterogeneity in studies on aneuploidy, we feel that large-scale, prospective cohort-studies are needed for definite conclusions on the appropriate work-up in iSUA pregnancies. At present, targeted growth assessment after diagnosis of an iSUA should not be routine practice.

To investigate the effect of endometrial injury on reproductive outcomes, pain and ultrasound markers of endometrial receptivity, when performed during oral contraceptive pills (OCP) pre-treatment, in unselected women undergoing assisted reproductive techniques (ART)

Women undergoing ART were randomly allocated to perform either endometrial injury with a pipelle de Cornier or a sham procedure, 7–14 days before starting controlled ovarian stimulation (COS). We evaluated clinical pregnancy, live birth, implantation rate, miscarriage, and multiple pregnancy. Pain during procedure was evaluated using a 10 cm visual analogue scale. Endometrial thickness and volume, and the three-dimensional power Doppler (3DPD) indices (VI, FI and VFI) was assessed during COS when at least one follicle was ≥17 mm.

158 women were included. Endometrial injury was associated with higher live birth (41.8% vs. 22.8%, injury vs. control respectively; P = 0.01), clinical pregnancy (49.4% vs. 29.1%; P = 0.01), pain (6.42 ± 2.35 cm vs. 1.82 ± 1.52 cm; P < 0.001), endometrial VI (3.71 ± 1.77 vs. 2.95 ± 1.56; P < 0.01), and VFI (0.97 ± 0.51 vs. 0.76 ± 0.40; P < 0.01). No significant effect was observed on miscarriage (15.4% vs. 21.7%, P = 0.53) and multiple pregnancy (22.5% vs. 25.0%, P = 0.79), endometrial thickness (10.12 ± 1.55 mm vs. 9.98 ± 1.62 mm; P = 0.59), volume (6.18 ± 1.63 cm³ vs. 6.01 ± 1.48 cm³; P = 0.51), and FI (26.12 ± 2.82 vs. 25.91 ± 2.72; P = 0.65).

Endometrial injury performed only once, under OCP pre-treatment, 7–14 days before starting COS, increases live birth and clinical pregnancy, but might cause a considerable pain.

We aimed to document the normal measurements (length, width, antero-posterior diameter) and proportions of the uterus according to age and gravidity. We hypothesized that the proportions of the uterus conformed to the classical Golden Ratio (1.618).

The ultrasonographic measurements of 5466 uteri were retrospectively reviewed for length, width and antero-posterior dimensions. Age and gravidity were used as explanatory variables.

The mean length of the uterus increases to 72 mm at the age of forty and declines to 42 mm at the age of 80 years. Gravidity increases uterine length, width and antero-posterio diameter. The mean ratio of the length / width of the uterus is 1.857 at birth and decreases to 1.452 at the age of 91 years. At the age of 21 the ratio equals 1.618, also known as the Golden Ratio. The ratio also decreases with increasing gravidity.

Uterine size varies in relation to age and gravidity. We observed that the proportions of the uterus conformed to the Golden Ratio at the age of 21, which coincides with peak fertility.

Surgery for deep infiltrating endometriosis (DIE) of the rectum may be performed using segmental bowel resection or a more conservative approach such as shaving or discoid resection. The aim of this study was to evaluate the diagnostic accuracy of rectal endoscopic sonography (RES) in the prediction of the infiltration depth of rectal endometriosis and to ascertain whether RES could be used to choose between bowel resection and a conservative approach.

In this retrospective study, 38 consecutive patients with symptomatic DIE who underwent laparoscopic colorectal resection were included. The RES results for the infiltration depth of rectal endometriosis were compared to the results of the pathological examination. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LHRs) and test accuracy were calculated for the presence of infiltration of the muscularis layers and submucosal/mucosal layers as demonstrated by RES and confirmed by histopathological analysis.

The PPV of RES for muscularis layer infiltration was 100%, whereas the sensitivity, specificity, PPV, NPV, test accuracy and positive and negative LHRs for submucosal/mucosal layer involvement were 89%, 26%, 55%, 71%, 55%, 1.21 and 0.40, respectively.

RES is a valuable tool for detecting rectal endometriosis. Muscularis layer endometriotic infiltration can be accurately predicted, whereas RES is less valuable for the detection of submucosal/mucosal layer involvement and cannot be used to choose between bowel resection and a more conservative approach.

Assess the effectiveness of first trimester integrated screening of early and late small for gestational age (SGA) newborns.

A prospective cohort of singleton pregnancies underwent routine first-trimester screening between 2009 and 2011 (n = 4,970). A logistic regression-based predictive model for SGA (birth weight <10th percentile) divided in early or late-onset based on gestational age at delivery below/above 34 weeks, was constructed. The model included maternal baseline characteristics; serum levels of pregnancy associated plasma protein-A and fβ-human chorionic gonadotropin at 8–12 weeks; blood pressure and uterine artery Doppler at 11 + 0-13 + 6 weeks.

The prevalence of early and late SGA was 0.6% and 7.9%, respectively. Association with preeclampsia (PE) was 67% and 8% respectively. At a false positive rate (FPR) of 15%, the detection rate (DR) for early SGA was 73%, however it differed substantially for cases with and without PE (90% vs 40%). For late SGA, at FPRs of 15% and 50%, DRs were 32% and 70% respectively, which did not substantially differ between cases with and without PE.

First-trimester integrated screening predicts early SGA mainly due to its strong association with preeclampsia. Although prediction of late SGA was poorer, at a high FPR it might be considered as part of first trimester strategies to select women requiring ultrasound in the third trimester.

To evaluate the usefulness of first trimester crown-rump length (CRL) discordance in predicting adverse outcome in twin pregnancies.

This retrospective study included a large cohort retrieved from local ultrasound databases at 14 obstetric departments in Denmark, comprising all twin pregnancies with two live fetuses scanned between 11 and 14 weeks' gestation in the period 1 January 2004 to 31 December 2006. The association between a CRL discordance ≥10 % and adverse outcome was evaluated.

Among 1993 twin pregnancies, 1733 were dichorionic (156 (9%) discordant, 1577 (91%) concordant) and 260 were monochorionic (32 (12%) discordant, 228 (88%) concordant). In dichorionic twin pregnancies we found an association between CRL discordance ≥10% and preterm delivery before 34 weeks (p = 0.007), birth weight discordance (p = 0.001) and mean birth weight (p = 0.033). In monochorionic twin pregnancies we found an association between CRL discordance ≥10 % and birth weight discordance (p = 0.02) and mean birth weight (p = 0.03). To evaluate CRL discordance as a predictor of fetal loss and preterm delivery before 34 weeks, receiver operating characteristics (ROC) curves were created for each outcome. For CRL discordance ≥10 % as a predictor of fetal loss and preterm delivery in dichorionic twin pregnancies, sensitivity was 0.17 (95% CI 0.06-0.28) and 0.14 (95% CI 0.10-0.18), respectively, and in monochorionic twin pregnancies 0.10 (95% CI 0.03-0.22) and 0.16 (95% CI 0.06-0.26), respectively.

CRL discordance in twin pregnancies is associated with, but not a strong predictor of, adverse outcome.

To improve the accuracy of three-dimensional ultrasound (3D US) with respect to magnetic resonance imaging (MRI) in the assessment of cervix and vagina in uterine malformations (UM) and compared to physical examination.

Prospective study of 16 patients diagnosed of UM with cervix involvement, using 3D US. The acquisition of cervix volume was trans-vaginal (4 cases repeated in the peri-ovulation period) while that of the vagina was trans-perineal following filling with gel. MRI was performed in 13 patients using endo-vaginal gel. All cases had bimanual gynecological examination and speculoscopy performed. The diagnostic concordance was calculated.

Cervix 3D US findings: 12 duplicated cervices, 2 complete and 2 incomplete septate. The cervical canal image in the peri-ovulation period was subjectively better, but did not change any of our diagnoses.

Vagina 3D US findings: 4 dividing-walls and 2 blind hemi-vaginas.

The clinical examination diagnoses coincided in all cases of cervix anomalies, but 2 vaginal dividing-walls were not diagnosed with 3D US.

MRI diagnosed 9 duplicate cervices, 3 complete septate, 1 incomplete septate, 5 vaginal dividing-walls and 2 blind hemi-vaginas. A complete septate uterus was a duplicate cervix with 3D US and clinical examination.

Both techniques were highly efficient in the diagnosis of anomalies of the cervix and the vagina compared to physical examination. The overall diagnostic concordance of the 3D US with physical examination (Kappa 0.84; 95%CI: 0.62-1) was slightly inferior to that observed when comparing MRI (Kappa 0,9; 95%CI: 0,72-1), differences not being statistically significant.

The acquisition of isolated cervix volume defines the extent of the ecto-cervix and the limits of the cervical canal in UM. The use of endo-vaginal gel makes possible the diagnosis of associated vaginal anomalies with 3D US.

Studies have demonstrated an association between congenital heart disease (CHD) and neurodevelopmental delay. Neuroimaging studies have also demonstrated a high incidence of preoperative brain abnormalities. The aim of this study was to perform a systematic review in order to quantify the non-surgical risk of brain abnormalities and of neurodevelopmental delay in cases with CHD.

MEDLINE, EMBASE and The Cochrane Library, without language restrictions were searched electronically, utilising combinations of the terms congenital heart, cardiac, neurologic, neurodevelopment, MRI, ultrasound, neuroimaging, autopsy, preoperative and outcome. Reference lists of relevant articles and reviews were hand searched for additional reports. Cohort and case–control studies were included. Studies reporting neurodevelopmental outcomes and/or brain lesions on neuroimaging in infants with CHD before heart surgery were included. Cases of chromosomal or genetic abnormalities, case reports and editorials were excluded. Between-study heterogeneity was assessed using the I² statistic.

The search yielded 9,129 citations. Full manuscripts were retrieved for 119 and the following were included in the review; 13 studies (n=425 cases) reporting on brain abnormalities either preoperatively or in those who did not undergo congenital cardiac surgery and 9 (n=512 cases) reporting preoperative data on neurodevelopmental assessment. The prevalence of brain lesions on neuroimaging was 34% (95% CI 24-46%, I² = 0%) in transposition of the great arteries, 66%, (95% CI 53-79%, I² = 0%) in left-sided heart lesions and 46% (95% CI 40-52%, I² = 18.1%) in mixed/unspecified cardiac lesions, while the prevalence of neurodevelopmental delay was 42% (95% CI 34-51%, I²=68.9%).

In the absence of chromosomal or genetic abnormalities, infants with CHD are at increased risk of brain lesions on neuroimaging and neurodevelopmental delay. These findings are independent of the surgical risk, but it is unclear whether the time of onset is fetal or post-natal.

To examine the feasibility and accuracy of nasal bone (NB) assessment in the retronasal triangle (RNT) view for aneuploidy screening in the first trimester of pregnancy.

Consecutive women with singleton pregnancies undergoing sonographic screening at 11–13 weeks of gestation were prospectively evaluated. In all cases, assessment of the NB by using the RNT view was attempted and classified as present (if one or both of the NBs were clearly seen) or absent/hypoplastic (if the NB was not visualized or small and less echogenic than the surrounding bones). The detection rate of fetal karyotypic abnormalities by the assessment of the NB in the RNT view was calculated.

A total of 1977 women were scanned. The RNT was successfully examined in all but 7 fetuses (99.6%). Fetal outcome was available in 1767 (89.7%) of evaluated cases and 39 (2.2%) cases of aneuploidy were documented (trisomy 21, n=17; trisomy 18, n=8; trisomy 13, n=5; Turner syndrome, n=5; and triploidy, n=4). The prevalence of absent/hypoplastic NB was 12/1728 (0.7%) in chromosomally normal fetuses and 12/17 (70.6%) in trisomy 21 fetuses. Sensitivity, specificity, and positive and negative predictive values of absent/hypoplastic NB for trisomy 21 were 70.6%, 99.3%, 50.0%, and 99.7%, respectively. The positive and negative likelihood ratios of NB assessment were 101 (95% confidence intervals= 53–193) and 0.3 (95% confidence intervals= 0.14–0.62), respectively.

The RNT view is a useful technique for assessing the NB during the first trimester. With this new approach, performance of absent/hypoplastic NB as a marker of aneuploidy, mainly trisomy 21, appears to be similar to that previously reported by using the midsagittal plane.

To determine the clinical significance of a chorionic bump diagnosed by ultrasound in women attending a teaching hospital early pregnancy unit (EPU).

This was a retrospective case control study over an eight-year period 2003–2010. Cases were identified by searching our early pregnancy database and were matched to controls in a ratio of 1:3. The primary outcome measure was miscarriage vs. on-going pregnancy. Secondary outcomes were gestation at delivery and the presence or absence of fetal abnormality.

37 798 pregnancies were examined over the study period and 57 pregnancies with a chorionic bump were identified, giving an estimated prevalence of 1.5 per 1000 pregnancies (0.15% (95% CI 0.01-0.73%)). Of the 52 women with follow up data, 20 (38.5% (95% CI 26.4-52.1)) miscarried vs. 31/151 (20.5% (95% 14.8-27.70)) in the control group (p=0.01). There were four second trimester miscarriages in the study group and none in the controls (p<0.01). 32/52 (62% 95% CI (47.9-73.6)) patients had a live birth in the study group vs. 118/151 (79% 95% (70.9 to 84.0)) in the control group (p=0.02). There were no differences in preterm delivery rates or fetal anomalies. No significant relationship was found between the size of the bump or its location in relation to the umbilical cord insertion, and the risk of miscarriage.

Women presenting to EPU who were found to have a chorionic bump on their first trimester ultrasound scan had approximately double the risk of miscarriage compared with matched controls, due to increased losses during the second trimester of pregnancy.

To evaluate in a cohort of 248 fetuses seen at a tertiary referral center, the frequency of isolated ventricular septal defects (VSD) among all congenital heart defects (CHD), the association with chromosomal and post-natal anomalies, and the rate of spontaneous closure.

A 6-year study on 10800 patients referred for a cardiac scan, with 995 confirmed congenital heart diseases (CHD). The prevalence and characteristics of VSDs were analyzed, including follow-up until one year of age. A multivariate binary logistic regression was performed to test the independent contribution of the VSD/Aorta ratio (<0.5 and ≥0.5) and location of VSD (perimembranous and muscular) in the prediction of spontaneous closure before one year of life.

248 (24.9% of all CHD) VSDs were diagnosed, 216 (87.1%) muscular and 32 (12.9%) perimembranous. Median GA at diagnosis was 30.4 (range 17–41) weeks and mean size 2.6 (SD, 0.77) mm. Serious chromosomal anomalies were found in 1 (3.1%) perimembranous VSD compared to none of 216 muscular defect (p=0.12). Post-natal malformations were diagnosed in 8 cases (3.8%). Spontaneous closure occurred in 13 fetuses (5.32%) and 151 infants (76.3%), and it was predicted by VSD/Aorta ratio (OR 0.445; 95% CI 0.216-0.914, p<0.03) and location (OR 0.385, 95% CI 0.160-0.926, p<0.0.03).

In a fetal cardiology unit, isolated muscular VSD is today the most prevalent CHD. Contrary to post-natal series muscular VSD were the most common. Perimembranous VSD was associated with a higher risk of chromosomal anomalies. Muscular VSD had similar risks to normal pregnancies. Spontaneous closure was frequent and occurred in most cases postnatally.

To evaluate the reliability of measuring the levator hiatus and levator-urethra gap (LUG) using three-/four-dimensional (3D/4D) transperineal ultrasound in women during first pregnancy and six months postpartum, and to assess the learning curve for these measurements.

An inexperienced observer was taught to measure the hiatus and LUG by an experienced observer. After training, 3D/4D image sets of 40 women in first trimester were analyzed by the two observers. Then, another training session took place and both observers repeated the analyses of the same image sets. Finally, analyses of 40 image sets of the women six months postpartum were performed by both observers. Intra- and interobserver reliability were determined by Intraclass Correlation Coefficients (ICC) with 95% Confidence Intervals (CI).

Levator hiatus measurements

In pregnant women interobserver reliability was substantial to almost perfect after both the first and second training (ICC 0.62-0.83 and ICC 0.71-0.89). In parous women interobserver reliability was moderate to almost perfect. Intraobserver reliability was substantial to almost perfect for both observers.

LUG measurements

In pregnant women interobserver reliability was slight to moderate after the first training (ICC 0.14-0.54), but improved after the second training (ICC 0.38-0.71). In parous women interobserver reliability was fair to moderate. Intraobserver reliability was moderate to substantial for the experienced observer and slight to moderate for the inexperienced observer.

The levator hiatus and LUG can be reliably measured using 3D/4D ultrasound in primigravid and primiparous women. The technique to measure hiatal distances requires limited teaching, but LUG measurements are more difficult and require more extensive training.

We performed a meta-analysis to examine the performance of second trimester (14-24 weeks gestation) isolated fetal pyelectasis as a marker for trisomy 21, and to calculate its associated weighted pooled likelihood ratios.

PubMed, Ovid MEDLINE, and Cochrane databases were searched using the terms “pyelectasis” and “pelviectasis.” Studies were included if fetuses with isolated pyelectasis were reported separately from fetuses with other soft markers of aneuploidy and/or structural anomalies and if knowledge of the fetal karyotype was unknown at the time of the ultrasound.

Individual study statistics were pooled as weighted positive and negative likelihood ratios with 95% confidence intervals using a random-effects model. Ten observational studies were included (2,148 cases of isolated pyelectasis). Isolated fetal pyelectasis was defined in 7 out of 10 studies as a renal pelvis AP diameter ≥4mm. Isolated fetal pyelectasis was associated with pooled positive and negative likelihood ratios of 2.78 (95% CI 1.75-4.43) and 0.99 (95% CI 0.98-1.00), respectively.

The detection of isolated fetal pyelectasis on mid-trimester ultrasound is associated with an increased likelihood of trisomy 21; if the finding of isolated fetal pyelectasis is used to adjust the trisomy 21 risk from maternal serum screening tests, a positive likelihood ratio of 2.78 should be used in the calculation.

To report 3 different antenatal therapeutic approaches for fetal lung masses associated with hydrops.

Three prospectively followed cases are described and all 17 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed.

Three hydropic fetuses with large intra-thoracic lung masses presented at 17, 21 and 24 weeks gestation, respectively. An aortic feeding vessel was identified in each case and thus a broncho-pulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with: (1) interstitial laser; (2) thrombogenic coil embolisation and (3) radio-frequency ablation (RFA). Complete (1&3) or partial (2) resolution of the lung mass and hydrops was observed in all cases. An healthy infant was born at term after laser therapy (1), and the involved lung lobe was resected at day on day 2 of life.

Despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolisation.

In case 3, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labour at 33 weeks.

The natural history of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolisation led to procedure related complications and need further evaluation.

The association between pre-eclampsia and the delivery of a large for gestational age (LGA) neonate remains unclear. In this study we compared the role of two nomograms to classify LGA neonates delivered to women with pre-eclampsia, and determined the frequency of placental vascular lesions according to the timing of delivery.

This cohort study included 118 consecutive women with pre-eclampsia delivering between 23-41 weeks’ gestation. The frequencies of LGA neonates according to customized growth curves and a national birthweight (BW) chart were compared. Similarly, the frequencies of LGA neonates and histological placental vascular lesions were compared between preeclamptic women delivering at < 34 weeks (n = 40) and those delivering later (n = 78).

1) Customized growth curves classified a higher proportion of LGA neonates than BW curves [18.6% (22/118) vs. 10.2% (12/118); p = 0.002]; 2) Among preeclamptic women delivering at ≥ 34 weeks, but not earlier, the proportion of neonates classified as LGA by customized growth curves was higher than BW curves [26.9% (21/78) vs. 15.4% (12/78); p = 0.004]; and 3) Placental vascular lesions were less frequent in preeclamptic women delivering at ≥ 34 weeks than those delivering earlier [41% (32/78) vs. 62.5% (25/40); p = 0.03]

1) Customized growth curves classify a higher proportion of LGA neonates than population birthweight curves among women with pre-eclampsia delivering at ≥ 34 weeks; 2) Preeclamptic women delivering at ≥ 34 weeks have fewer placental vascular lesions than those delivering earlier.

to compare the echocardiographic findings at <15 weeks gestation with a later follow-up scan, and determine both the accuracy of early diagnosis and the frequency of findings that change.

In the period 2002 to end 2009, all patients with a detailed fetal echocardiogram at less than 15 completed weeks of gestation and a repeat scan at least 6 weeks later were sought from our database.

Of 1200 patients fulfilling our selection criteria, the cardiac findings were normal at both scans in 1069. In 46 cases, there was the same cardiac abnormality at both scans. There was a false positive diagnosis in 7 cases. In 50 cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 29 fetuses, there was discordance between the early and later morphological diagnosis, 15/29 being considered significant differences, with 10/15 representing a true progression of findings between the early and the later scans, rather than missed or incorrect diagnoses.

A high degree of accuracy in the identification of CHD can be achieved in early fetal echocardiography (sensitivity 84.8% (75.0-91.9%), specificity 95.3% (93.9-96.4%)). The identification of every case of tetralogy of Fallot and small atrioventricular septal defects presented particular diagnostic challenges in early fetal echocardiography. A small but significant group showed progression of findings during this stage of rapid fetal heart growth, particularly in obstructive lesions.

Sono-elastography is an imaging technique added to sonography, measuring tissue strain. The aim of this article is to systematically define specific sono-elastographic characteristics of the myometrium, fibroids and adenomyosis and evaluate the feasibility of sonoelastography in patients suspected of gynecological pathology and to compare it with histology-based and MRI-based diagnoses.

We performed a prospective observational cohort study from 2009 to 2011 using a Samsung Medison Accuvix V10 machine. Women included underwent routine transvaginal ultrasound and additional real-time sonographic elastography. The acquirements of elastographic images were standardized. We analyzed elastographic characteristics of myometrium, fibroids and adenomyosis. An independent observer, unaware of clinical, histological or MRI findings evaluated the recorded elastographic images and cine loops. These elastographic-based diagnoses were compared with histology and/or MRI diagnosis.

With elastography the uterus is well delineated from the surrounding bowels. The myometrium was uniform in color in 49% of the cases, with a main color of purple or dark blue. Both fibroids and adenomyosis have different elastographic characteristics with different color patterns. In general fibroids were darker and adenomyosis brighter then adjacent myometrium. The agreement between elastography based diagnosis of fibroids and adenomyosis with MRI were excellent, and with histology it was also excellent for fibroids, but less optimal for adenomyosis.

Elastography is able to identify clear discriminating characteristics of the uterus, fibroids and adenomyosis and the elastographic based diagnosis are in excellent agreement with MRI. Agreement between the elastography image of adenomyosis and histology was less optimal.

The aim of this study was to examine the feasibility of reconstructing three-dimensional echocardiographic views in fetuses with double outlet right ventricle, which might enhance prognostication with respect to the postnatal surgical approach.

Retrospective blinded observational study. Our database was reviewed from January 2007 to June 2011 to identify fetuses with usual atrial arrangement, concordant atrioventricular connections, double outlet right ventricle and relatively balanced left and right ventricular size. Six fetuses, where there was an intention to treat, were included.

In all six cases, important features were identified including the location of ventricular septal defect and its relation to the atrioventricular valves and great arteries. The postnatal surgical approach was predicted accurately in each case.

In a group of fetuses with double outlet right ventricle, detailed evaluation by 3D fetal echocardiography enhanced visualization of the anatomy, leading to accurate prediction of the type of surgical repair. Prospective validation in a large cohort of fetuses is warranted.

To examine the inter- and intra-operator repeatability of manual placement of callipers in the assessment of basic biometric measurements and to compare the results to an automated calliper placement system.

Stored ultrasound images of 95 normal fetuses between 19 and 25 weeks’ gestation were used. Five operators (two experts, one resident and two students) were asked to measure the BPD, OFD and FL two times manually and automatically. For each operator, intra-operator repeatability of the manual and automated measurements was assessed by within operator standard deviation. For the assessment of the interoperator repeatability, the mean of the four manual measurements by the two experts was used as the gold standard.The relative bias of the manual measurement of the three non-expert operators and the operator-independent automated measurement were compared with the gold standard measurement by means and 95% confidence interval.

In 88.4% of the 95 cases, the automated measurement algorithm was able to obtain appropriate measurements of the BPD, OFD, AC and FL. Within operator standard deviations of the manual measurements ranged between 0.15 and 1.56, irrespective of the experience of the operator.Using the automated biometric measurement system, there was no difference between the measurements of each operator. As far as the inter-operator repeatability is concerned, the difference between the manual measurements of the two students, the resident, and the gold standard was between −0.10 and 2.53 mm. The automated measurements tended to be closer to the gold standard but did not reach statistical significance.

In about 90% of the cases, it was possible to obtain basic biometric measurements with an automated system. The use of automated measurements resulted in a significant improvement of the intra-operator but not of the inter-operator repeatability.

To help elucidating the mechanism of action of the Arabin cervical pessary in pregnancies at high risk of premature delivery.

Informed consent was obtained for this ethics committee-approved study. In 198 fetuses undergoing clinical fetal MR imaging, without risk for and without factual preterm birth, cervical length and utero-cervical angle versus gestational age was established. In 73 patients at high-risk for premature birth an Arabin cervical pessary was placed at 14–33 weeks of gestation. We performed MRI of the cervix immediately before and after placement and monthly follow-up until pessary removal. Success of pessary placement was assessed. In a subgroup of 54 singleton pregnancies with short cervix and pessary placement at 17–31 weeks of gestation, the utero-cervical angle and the cervical length was measured at MRI at follow-up and compared with the pre-pessary value using a Wilcoxon signed-rank test.

In fetuses without risk for premature birth, the utero-cervical angle did not vary however, the cervical length decreased significantly with gestational age (r = 0.15, p < 0.05). The cervical pessary could be successfully placed at first attempt in 60(82.2%) and at second attempt in 66(90.4%) out of 73 patients and remained in good position until removal. In 5 patients we failed to place the pessary after 2 attempts, in 1 patient the pessary dislodged during follow-up and in 1 case the pessary was partly placed in the external cervical canal and triggered labor the next day. Among the subgroup of 54 singleton patients, 46(85.2%) delivered at 34 weeks or more. The median utero-cervical angle immediately after pessary placement was significantly more acute as compared to the value prior to placement (146 vs.132 degrees,p<0.01). For the remaining 8 patients that delivered before 34 weeks of gestation, the median utero-cervical angle before and immediately after pessary placement remained unchanged (152 vs.143 degrees,p=NS).

In patients at high risk of premature delivery, correct placement of the Arabin cervical pessary should be immediately controlled, which can be easy and fast done with MRI. Our study provides some evidence that in singleton pregnancies with short cervix, cervical pessary delays birth by a mechanical effect on the utero-cervical angle.

The size of the posterior fossa (PF) is a significant parameter in diagnosing PF malformations. In this study nomograms of PF dimensions in normal foetuses, assessed in the median plane in the second and third trimesters, were constructed. Fetuses diagnosed with PF abnormalities were studied concerning the created tables of normal PF development.

A prospective cross-sectional study of 378 healthy foetuses of low-risk singleton pregnancies between 15 and 35 weeks was performed. The PF size was evaluated in the median head plane using 3D-MPR display. All sonographic volumes were obtained by sagittal acquisition using a transabdominal or transvaginal probe.

The borders of the PF were defined from the clivus to the tentorium and from the occipital bone to the level of the upper mesencephalic edge. The measured PF parameters included the Posterior Fossa Area (PFA), the Posterior Fossa Perimeter (PFP), the Tecto-Occipital Distance (TOD), and the Clivo-Tentorial Distance (CTD). The measurements were plotted on growth tables according to the gestational age. Thirty-nine foetuses diagnosed with PF malformations were analyzed by calculating the z-scores of the PFA, PFP, TOD, and CTD using the developed nomograms.

Of the 378 initially included examinations, 281 were selected due to adequate visualization of the PF borders, resulting in an overall feasibility rate of 74.3% for PF median plane morphometry. A linear growth pattern with Pearson's correlation coefficient of 0.97, 0.97, 0.96, and 0.95 was found for PFA, PFP, TOD, and CTD, respectively (P<0.001 for each). Chiari II malformation (CM-II) and Dandy-Walker malformation (DWM) showed the most prominent impact on the PF size. PFA z-scores exceeded 2.6 in all five DWM cases and were below −2.66 in all eleven CM-II cases.

Sonographic evaluation of the foetal PF size in the median plane is feasible. The constructed nomograms provide reference data that may be helpful, when evaluating PF congenital malformations.

To assess the presence and degree of indirect signs of corpus callosum agenesis (ACC) by time of gestation. The endpoint is to define in which percentage each sign is already present in a gestational age < 24 weeks.

Fifty-four cases of ACC undergoing three-dimensional neurosonology at our unit from January 2005 to December 2012 were analysed. A single examination was available in 48 cases, while 6 cases were followed up longitudinally for a total of 69 examinations. The following variables were retrospectively assessed: indication for referral, width of the atrium, colpocephaly, visualization/non-visualization of the cavum septi pellucidi, presence of dorsal cyst, additional CNS and non-CNS anomalies, karyotype.

Overall, there were 31 cases of cACC (44 examinations) and 23 cases of pACC (25 examinations). Mean gestational age was lower in the cases referred because of anomalies other than ACC than in those referred because of ventriculomegaly and/or suspicion of ACC (p < 0.05). Atrial width showed a positive linear correlation with advancing gestational age (p < 0.0001); it was < 10.0 mm in 25/34 (73.5%) < 24 gestational weeks and in 9/35 (25.7%) cases beyond 23 weeks (P < 0.001). Colpocephaly was present in 20.6% (7/34) of cases < 24 weeks of gestation and in 68.6% (24/35) of cases after 23 weeks (P < 0.05). The cavum septi pellucidi was present at least in part and visible in 17/25 (68%) of pACC cases. In 9/25 (36.0%) cases of pACC, there was nor ventriculomegaly nor absence of the cavum septi pellucidi. Associated anomalies were present in 25/54 (46.3%) cases, and in 11 cases these included or consisted of CNS abnormalities. Karyotype was abnormal in 7/40 (17.5%) cases in which it was available.

Most of the indirect signs of ACC are either absent or barely visible at the time of the midtrimester screening ultrasound in a significant proportion of cases. Therefore, ACC may escape diagnosis at midtrimester screening ultrasound. In particular, pACC may not show any abnormality of the trans-ventricular screening view < 24 gestational weeks in 43.5% of cases. The medico-legal implications of such findings are important and should be considered.

we present two successful cases of fetoscopic release of amniotic bands with umbilical cord involvement, and provide a review of the literature on fetal intervention for Amniotic Band Syndrome (ABS).

Our two case reviews, as well as a review of the literature were performed. A total of 14 patients with an amniotic band syndrome underwent fetoscopic intervention between 1965 and 2012. Two of the authors, independently completed literature searches in PubMed, Ovid and MEDLINE for articles related to amniotic band syndrome. STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines were followed.

Among fourteen published cases of ABS, 57% and 7% of cases were complicated by PPROM and spontaneous preterm birth (SPTB), respectively. Over all, the procedure resulted in a functional limb in 50% (7/14) of cases. There were 3 cases with intra-operative complications including intra-amniotic bleeding, uterine wall bleeding, and inability to complete the cases due to ineffective equipment.

Fetoscopic release of amniotic bands with minimally invasive surgery may allow for preservation of life and/or limb function, in cases of amniotic band syndrome. The acceptable functional outcome in 50% of the cases is reassuring, although more experience and further studies are needed in order to hone in on the appropriate selection criteria that will justify the risk of this invasive in-utero therapy for ABS.

The objective of this study is to establish reference ranges of quantitative characteristics of the corpus callosum allowing the accurate diagnosis of corpus callosum pathologies such as hypogenesis, dysgenesis and thick corpus callosum.

For the present study a total number of 604 pregnant women referred for sonographic examination to the DEGUM level III Centre for Prenatal Diagnosis and Therapy, Hospital Nordwest, Frankfurt/Main, were recruited to undergo specific sonographic examination from 18-41 weeks of gestation. . 466 three-dimensional sonographic volumes of normal fetal brains were acquired transabdominally (n = 170) as well as transvaginally (n = 296) and analyzed offline using dedicated computer software (4D View, GE, Austria, Zipf). Measurements of the corpus callosum included both the length and the height (= thickness) of the rostrum, genu, body and splenium. Three different measurements of the length of these structures were performed.

Using 3-D ultrasound we were able to visualize the corpus callosum as a hypoechoic structure starting at 18 weeks of gestationGrowth charts and tables were established for the following parameters: curved corpus callosum length (CCL-C), inner-inner corpus callosum length (CCL-II), outer-outer corpus callosum length (CCL-OO), rostrum height (rostrum-H), genu height (genu-H), body height (body-H), splenium height (splenium-H). We observed a non-linear growth and an approximately four-fold increase in all corpus callosum lengths; a three-fold increase in the rostrum height (= thickness); a four-fold increase in the genu height; a two-fold increase in the body height (= thickness) and a three-fold increase in the splenium height (= thickness). The growth patterns of the rostrum and the body height appear to be similar. They show a rapid development until 24, respectively 22 weeks of gestation, to be followed by stagnation after this period. The growth patterns of the genu and the splenium are also similar. They are characterized by progressive growth throughout gestation.

3-D neurosonography serves as an excellent tool to detect and measure the fetal corpus callosum. Knowledge of the normal growth pattern may be useful for the differentiation of normal and abnormal corpus callosum development.

The aims of this study were to ascertain the outcome of twin reversed arterial perfusion (TRAP) sequence cases managed in our unit and to systematically review the cases reported in the literature treated using intrafetal laser therapy.

This was a retrospective cohort study of all TRAP sequence cases identified from 2000 to 2012. Pregnancy management and outcomes were ascertained from maternal and neonatal records. We also performed a meta-analysis of the literature on the use of intrafetal laser therapy in TRAP. Adverse pregnancy outcome was defined as a composite of intrauterine death (IUD) and preterm birth <37 weeks’ gestation.

23 cases of TRAP were identified during the study period. Six were managed conservatively and 17 were treated with laser therapy. All cases managed conservatively were complicated by IUD at a median GA of 14⁺⁴ (IQR, 12⁺⁴-16⁺⁵) week. Among the treated cases, fourteen (82%) delivered a healthy twin at a median GA of 37⁺¹ (IQR, 34⁺⁰-38⁺³) weeks. Ten studies were reviewed in detail and the data was combined with that from the current study. The overall neonatal survival was 80%. Adverse pregnancy outcome was significantly lower when the treatment was performed before 16 weeks’ gestation (19% vs 66%, p=0.0025).

The study data demonstrates a high risk of early pregnancy spontaneous fetal demise, lack of accurate prognostic markers and improved pregnancy outcomes with laser therapy. In these cases we recommend elective treatment with intrafetal laser therapy between 13 and 16 weeks’ gestation.

To illustrate the significance of distortion of the interhemispheric fissure (DIHF) associated with impacted medial borders of the frontal lobes and discuss the relevance of DIHF in prenatal diagnosis.

A retrospective observational study of 13 foetuses, in which DIHF was identified on prenatal imaging, was conducted to investigate associated biological and anatomical anomalies.

Anatomical anomalies associated with DIHF were identified in 10 cases including mainly midline anomalies (syntelencephaly [n=2], lobar holoprosencephaly [n=1], Aicardi syndrome [n=2],), but also schizencephaly (n=1), cortical dysplasia (n=1) and more complex cerebral malformations [n=3], including neural tube defect in 2 cases. Chromosomal anomaly was identified in 2 cases, including 6p deletion in a case without associated CNS anomalies and a complex mosaicism in a case with synthelencephaly. In two prenatal cases, the finding was isolated based on both pre and post-natal imaging resulting in healthy individuals.

Presence of DIHF on prenatal imaging may provide a clue for diagnosis of cerebral anomalies, especially those involving the midline. If DIHF is "isolated" based on prenatal ultrasound, MRI is recommended for careful analysis of gyration and midline, especially optic and olfactory structures. Karyotyping is also recommended to look for chromosomal anomalies.

To compare the diagnostic accuracy of subjective ultrasound assessment to objective measurement techniques in the evaluation of myometrial and cervical invasion in women with endometrial cancer.

Prospective multicenter study including 144 women with endometrial cancer undergoing transvaginal ultrasound. Myometrial and cervical invasion was subjectively evaluated, and objectively measured in different ways: ;endometrial thickness, tumor/uterine anterio-posterior (AP) ratio, minimal tumor free margin, minimal tumor free margin/uterine AP diameter ratio, tumor volume (3D), tumor /uterine volume (3D) ratio, distance from outer cervical os to the lower margin of tumor (Dist-OCO). Histological assessment from hysterectomy was golden standard.

The sensitivity (79%) and specificity (76%) of tumor/uterine AP diameter (at cut-off 0.53) was not significantly different from subjective evaluation (sensitivity 77%, p = 0.44, specificity 81%, p = 0.32), all other objective measurement techniques had either a significantly lower sensitivity or a lower specificity. Fixing sensitivity at the same level as subjective evaluation all objective measurement techniques, except minimal tumor free margin/uterine AP diameter ratio, had a significantly lower specificity. Dist-OCO was the only parameter that might have potential to predict cervical invasion, it had a non-significantly higher sensitivity than subjective evaluation (vs. 73%, vs. 54% p = 0.06), but a significantly lower specificity (63% vs. 93% p < 0.001).

Subjective assessment of cervical and myometrial invasion is as good as or better than any objective measurement technique. The tumor/uterine AP ratio and minimal tumor free margin/uterine AP diameter ratio seem to be the best objective measurement techniques to predict deep myometrial invasion. It remains to be shown if objective measurements are useful to predict cervical invasion.

The aim of this study was to examine the association between maternal age and a wide range of adverse pregnancy outcomes after adjustment for confounding factors in obstetric history and maternal characteristics.

This was a retrospective study in women with singleton pregnancies attending the first routine hospital visit at 11⁺⁰-13⁺⁶ weeks of gestation. Data on maternal characteristics, medical and obstetric history were collected and pregnancy outcomes ascertained. Maternal age was studied, both as a continuous and as a categorical variable. Regression analysis was performed to examine the association between maternal age and adverse pregnancy outcomes including preeclampsia (PE), gestational hypertension (GH), gestational diabetes mellitus (GDM), preterm delivery (PTD), small for gestational age (SGA), large for gestational age (LGA), miscarriage, stillbirth, elective and emergency cesarean section (CS).

The study population included 76,158 singleton pregnancies with a live fetus at 11⁺⁰-13⁺⁶ weeks. After adjusting for maternal and pregnancy potential confounding variables, advanced maternal age (defined as ≥40 years) was associated with increased risk of miscarriage [OR (95% CI): 2.32 (1.83-2.93), p < 0.001], PE [1.49 (1.22-1.82), p < 0.001], GDM [1.88 (1.55-2.29) p < 0.001], SGA [1.46 (1.27-1.69) p < 0.001] and CS [1.95 (1.77-2.14) p < 0.001], but not for stillbirth, GH, spontaneous PTD or LGA.

Maternal age should be combined with other maternal characteristics and obstetric history when calculating an individualised adjusted risk for adverse pregnancy complications. Advanced maternal age is a risk factor for miscarriage, PE, SGA, GDM and CS, but not for stillbirth, GH, spontaneous PTD or LGA.

To document perinatal outcomes following the “Solomon technique” in the selective photocoagulation of placental anastomoses for severe twin-twin transfusion syndrome (TTTS).

Between January 2010 and July 2012, data were collected from 102 consecutive monochorionic twin pregnancies complicated by severe TTTS that underwent fetoscopic laser ablation. We compared outcomes between subjects who underwent selective laser coagulation with the “Solomon technique” (cases) versus those who had selective laser coagulation without this procedure (controls).

Of the 102 cases examined, 26 (25%) had the “Solomon technique” and 76 (75%) did not. Of the 204 newborns, 139 (68.1%) survived up to 30 days of life. At least one twin survived in 82 (80.4%) pregnancies and both twins survived in 57 (55.9%) pregnancies. When compared with the control group, the “Solomon technique” group had a significantly higher survival rate for two twins (84.6% vs. 46.1%, p<0.01) and a higher overall neonatal survival rate (45/52 (86.5%) vs. 94/152 (61.8%), p<0.01). The “Solomon technique” remained independently associated with dual twin surviving (aOR, 11.35, 95% CI=3.11-53.14, p=0.0007) and overall neonatal survival rate (aOR=4.65; 95% CI=1.59-13.62, p=0.005) after multivariate analysis. There were no cases of recurrent TTTS or twin anemia-polycythemia sequence (TAPS) in the “Solomon technique” group.

The use of “Solomon technique” following selective laser coagulation of placental anastomoses appears to improve twin survival, and may reduce the risk of recurrent TTTS and TAPS.

Despite fetoscopic laser surgery (FLS) having emerged as an effective treatment for twin-twin transfusion syndrome (TTTS), major post-intervention challenges such as iatrogenic preterm premature rupture of membranes (iPPROM) remain. Chorioamnion plug (CAP) placement with absorbable gelatin sponge has been used to seal the entry site in the amniochorion layers to promote healing and prevent iPPROM yet results have been equivocal. Our objective was to test the hypothesis that CAP with an absorbable gelatin sponge at FLS for TTTS may prevent iPPROM.

A retrospective cohort study was performed on a prospectively collected data from consecutive 134 patients who underwent FLS for TTTS. The decision for CAP was left to the discretion of the physician. Pre-operative, operative and post-operative variables were collected and analyzed. The primary outcome was the incidence of iPPROM, and the secondary outcomes were procedure-to-delivery interval and gestational age at delivery. Comparative statistics were performed as appropriate (statistical significance p < 0.05).

CAP was placed in 72 (54%) patients and was not placed in 62 (46%) patients. The factors that were significantly associated with CAP placement were anterior placentation (p=0.04), general endotracheal intubation (p=0.02), and cannula diameter of 12Fr (p=0.003). There were no differences in the rate of iPPROM (39% vs. 32%: CAP vs. no CAP group, respectively; p=0.42) or procedure-to-delivery interval (65.3 ± 34.7 vs. 58.2 ± 30.8 days: CAP vs. no CAP group, respectively; p=0.42) However, CAP increased the risk for iPPROM to occur in the period of 2 – 4 weeks after the procedure. The gestational age at delivery was later in the CAP group compared to no CAP (30.7 ± 4.5 weeks vs. 28.9 ± 3.9 weeks; p=0.02).

CAP did not reduce the overall risk for PPROM and did increase the risk immediately after laser surgery. CAP did not increase the procedure-to-delivery interval. Further research is needed to identify other methods to prevent iPPROM and prolong pregnancy after laser therapy.

To pool published data regarding the sensitivity and specificity of nuchal translucency (NT) in the diagnosis of major congenital heart defects (CHD) in fetuses with normal karyotype.

MEDLINE and SCOPUS searches using combinations of the terms ‘nuchal’ AND ‘cardiac*’ were complemented by perusal of the references of the retrieved articles and an additional automated search using the ‘search for related articles’ PubMed function. Only children with a normal karyotype and major CHDs were analyzed. Weighted estimates and summary receiver operating characteristic curves were calculated

The analysis included 20 studies (205232 fetuses, 537 cases with major CHDs. The pooled sensitivity and specificity of NT>95^th centile was 44.4% (95% CI 39.5-49.5) and 94.5% (95% CI 94.4-94.6), respectively. The pooled sensitivity and specificity of NT>99^th centile was 19.5% (95% CI 15.9-23.5) and 99.1% (95% CI 99.1-99.2), respectively. For the subgroup of studies in which the NT was measured by Fetal Medicine Foundation-certified operators, the pooled sensitivity and specificity of NT>95^th centile was 45.6% (95% CI 39.6-51.7) and 94.7% (95% CI 94.6-94.9), respectively. The corresponding estimates for NT>99^th centile were 21.0% (95%CI 16.5-26.1) and 99.2% (95% CI 99.2-99.3). The pooled positive likelihood ratio for NT>99^th centile was 30.5 (95% CI 24.3-38.6). There was high across-studies heterogeneity for most estimates.

Approximately 44% of CHDs in chromosomally normal fetuses have NT>95^th centile and 20% have NT>99^th centile. However, there is increased heterogeneity across studies, which largely remains even in subgroup analyses of studies of apparently similar design, potentially indicating the presence of some residual unidentified bias.

To assess the potential of first-trimester sonography in the detection of fetal abnormalities using an extended protocol that was achievable with reasonable resources of time, personnel and ultrasound equipment.

This was a prospective two-center 2-year study of 5472 consecutive unselected pregnant women examined at 12 to 13+6 gestational weeks. Women were examined using an extended morphogenetic ultrasound protocol that, in addition to the basic evaluation, involved a color Doppler cardiac sweep and identification of early contingent markers for major abnormalities.

The prevalence of lethal and severe malformations was 1.39%. The first-trimester scan identified 40% of the cases detected overall and 76.3% of major structural defects. The first-trimester detection rate (DR) for major congenital heart disease (either isolated or associated with extracardiac abnormalities) was 90% and that for major central nervous system anomalies was 69.5%. In fetuses with increased nuchal translucency (NT), the first-trimester DR for major anomalies was 96%, and in fetuses with normal NT it was 66.6%. Most (67.1%) cases with major abnormalities presented with normal NT.

A detailed first-trimester anomaly scan using an extended protocol is an efficient screening method to detect major fetal structural abnormalities in low-risk pregnancies. It is feasible at 12 to 13+6 weeks with ultrasound equipment and personnel already used for routine first-trimester screening. Rate of detection of severe malformations is greater in early- than in mid-pregnancy and on postnatal evaluation. Early heart investigation could be improved by an extended protocol involving use of color Doppler.

Maternal administration of 17-alpha-hydroxyprogesterone caproate (17OHPC) is increasingly utilized to prevent preterm birth, but fetal safety of 17OHPC is still a matter of concern. This study aimed to assess whether exposure to 17OHPC during the second and third trimesters of pregnancy affects fetal biometry in twin gestations.

We studied a subset of women with a multiple pregnancy who had been previously included in a randomized clinical trial comparing the effectiveness of 17OHPC and placebo on neonatal outcomes and preterm birth rates. We now compare the individual growth patterns of femur length (FL), head circumference (HC) and abdominal circumference (AC) between fetuses of women who had been randomized to receive either weekly injections of 17OHPC (n=52 women) or placebo (n=58 women) between 16-20 and 36 weeks’ gestation.

The three biometric variables (FL, HC, AC) developed similarly in fetuses of the 17OHPC-exposed and placebo groups during the second half of pregnancy. Birth weight adjusted for parity and fetal sex was also comparable between both groups.

The use of 17OHPC has no adverse effect on fetal biometry and birth weight in twins.

To determine the diagnostic performance of simple rules for discriminating between benign and malignant adnexal masses.

A prospective study was performed between January 2011 and June 2012. Eligible patients were all women diagnosed as having a persistent adnexal mass. Four trainees evaluated the adnexal mass by transvaginal ultrasound under the supervision of an expert examiner. The trainee had to analyze the mass according to IOTA simple rules providing a diagnosis of malignant, benign or inconclusive. All women ultimately included underwent surgery and tumor removal in the center of recruitment. Diagnostic performance was assessed by calculating the sensitivity and specificity as well as positive (LR+) and negative (LR-) likelihood ratios.

340 women were included (patients’ mean age: 42.1 years, range: 13 to 79). Fifty-five (16.2%) tumors were malignant and 285 (83.8%) were benign. Simple rules could be applied in 270 (79.4%). Sensitivity, specificity, LR+ and LR- in those 270 cases in which the rules could be applied were 87.9% (95%CI 72.4% to 95.2%), 97.5% (95%CI 94.6% to 98.8%), 34.7 (95%CI 15.6 to 77.3) and 0.12 (95%CI 0.05 to 0.31), respectively.

Simple rules perform acceptably well in terms of specificity in hands of non-expert examiners. However, non-experts examiners had a 12% false-negative rate, which is relatively high.

To determine the prevalence of obstetric anal sphincter injuries (OASIS) in a cohort of primiparous women and to evaluate its association with demographic, obstetric and ultrasound parameters.

A retrospective analysis of the ultrasound volume datasets of 320 primiparous women, acquired at 5 months postpartum. Tomographic ultrasound imaging (TUI) was used to evaluate the external anal sphincter (EAS). A significant EAS defect was diagnosed if a defect of >30^o was seen in ≥4 of 6 TUI slices bracketing the EAS.

Significant EAS defects were found in 69 women (28% of those delivered vaginally). In 9 of those a 3^rd degree tear was diagnosed intrapartum and was sutured. In 60 women with significant defects there was no documentation of sphincter damage at birth, implying unidentified or occult defects (60/69, 87%). Among them, 29 had had a 2^nd degree tear, two a 1^st degree tear and three an intact perineum. In 31 cases an episiotomy had been performed, with five extensions to a 3^rd degree tear. On multivariate analysis only forceps was significantly associated with OASIS.

In this cohort of primiparous women we found OASIS in 28% of vaginally parous women, and most had not been diagnosed in Delivery Suite. There seems to be a need for better education of Labour Ward staff in the recognition of OASIS. On the other hand, it is conceivable that some defects may be masked by intact tissue. The significance of such defects remains doubtful. Forceps was the only identifiable risk factor.

Single fetal demise in monochorionic twin gestations represents a significant risk for co-twin demise and neurodevelopmental morbidity. Indirect observations have led to a theory of acute exsanguination of the normal twin into the dying twin as the proposed mechanism.

A 22-year-old G3P2 (2002) female with Quintero Stage IV twin-twin transfusion was referred for evaluation. During the course of the examination, bradycardia with impending fetal demise was noted in the recipient twin. Sudden and rapid development of tachycardia and elevation of the peak systolic velocity of the middle cerebral artery in the donor twin were witnessed. The demise of the donor twin was detected 24 hours later. Placental examination revealed one AV and two VA anastomoses.

These observations support the “vascular sink” hypothesis for co-twin demise and neurodevelopmental abnormalities following single fetal demise in monochorionic twins. Rapid fetal exsanguination can occur even in the presence of a minimal number of placental vascular anastomoses.

Previous studies have recommended to repeat nuchal translucency (NT) measurements several times in order to optimize the sensitivity of the screening process. However, truncation is applied within the risk calculation for small NT measurements, therefore repeating NT measurements in the lower range might be useless and time consuming. We aimed to estimate the optimal number of NT measurements that should be performed.

We simulated the expected distribution of repeat NT measurements and their corresponding LR (like hood ratio) for a variety of NT and crown-rump-length (CRL) values at 11–14 weeks based on the published mixture-model for first trimester NT measurement and on published data on NT variability. The ratio between LR obtained from the highest and the lowest repeat measurements were computed and a ratio of 1 indicates that it is useless to repeat the measurements. Last, we tested this approach on a dataset in real–life 1st trimester screening.

LR ratio was computed for various initial NT measurements and for simulated repeat-measurements. These indicated that repeating NT measurements when the first one is between 0.9 and 1.6mm for CRL of 45-84mm respectively is not useful and therefore, time consuming. Based on a real life dataset, our approach would have allowed avoiding repeating measurements in 47 out of 165 cases (28%).

Although there is some variability in NT measurements repeat assessment is not useful for optimal screening performance for smallest NT measurements due to lower truncation limits when applied to risk calculation. Our study provides NT cut-off values for different CRL below which there might be no need to repeat measurement once a good quality image has been obtained.

To evaluate the accuracy of antenatal sonographical measurement of the lower uterine segment (LUS) thickness in the prediction of the risk of uterine rupture during a trial of labour (TOL) in women with a previous Caesarean section (CS).

Pubmed and EMBASE were searched to identify articles published on the subject of sonographic LUS measurement and the occurrence of a uterine defect after delivery. Four independent researchers performed identification of papers and data extraction. The selected studies were scored on methodological quality, sensitivity and specificity of measurement of LUS thickness in the prediction of a uterine defect were calculated. We performed bivariate meta-analysis to estimate summary Receiver Operating Characteristic (sROC) curves.

We included 21 studies with a total of 2,239 analysed patients. The quality of the included studies was good, although comparison was difficult because of heterogeneity.

The estimated sROC curves showed that measurement of LUS thickness seems promising in the prediction of the occurrence of uterine defects (dehiscence and rupture) in the uterine wall. The pooled sensitivity and specificity of myometrial LUS thickness for cut-offs between 0.6-2.0 mm was 0.76 (95% CI: 0.60 to 0.87) and 0.92 (95% CI: 0.82 to 0.97), cut-offs between 2.1-4.0 reached a sensitivity and specificity of 0.94 (95% CI: 0.81 to 0.98) and 0.64 (95% CI: 0.26 to 0.90). The pooled sensitivity and specificity of full LUS thickness for cut-offs between 2.0-3.0 mm was 0.61 (95% CI: 0.42 to 0.77) and 0.91 (95% CI: 0.80 to 0.96), cut-offs between 3.1-5.1 reached a sensitivity and specificity of 0.96 (95% CI: 0.89 to 0.98) and 0.63 (95% CI: 0.30 to 0.87).

The meta-analysis gives support to the use of the antenatal LUS measurements in the prediction of a uterine defect during trial of labour. Clinical applicability should be assessed in prospective observational studies using a standardized method of measurement.

This study aimed to document the changes in the normal embryonic/fetal cardiac axis in the late first and early second trimester of pregnancy.

Images from 188 fetal echocardiograms performed prospectively between 8 and 15 weeks gestation in 166 healthy pregnancies and in 10 with severe fetal heart disease were reviewed. For each echocardiogram, three measurements of the cardiac axis were taken in the axial plane at the level of the four chamber view. One-way analysis of variance followed by Tukey's multiple comparison test were used to compare differences in mean embryonic/fetal cardiac axis at different gestational ages in the healthy pregnancies. For paired results, the embryonic/fetal cardiac axis change was compared using Wilcoxon signed-rank testing

The mean embryonic/fetal cardiac axis was 25.5 ±11.5^O from 8-9⁺⁶ weeks (Group 1), 40.4 ±9.2^O from 10-11⁺⁶ weeks (Group 2), 49.2 ±7.4^O from 12-12⁺⁶ weeks (Group 3), 50.6 ± 5.7^O from 13-13⁺⁶ weeks (Group 4) and 48.6 ± 7.3^O from 14-14⁺⁶ weeks (Group 5). Groups 1 and 2 were significantly different to each other and all other groups (p < 0.05). The results for 22 cases with repeated measures from 8-11⁺⁶ and 12-14⁺⁶ weeks, confirmed that the embryonic/fetal cardiac axis increased significantly (p < 0.001). The cardiac axis was >90^th centile in 4 and <10^th centile in 2 cases with severe congenital heart disease.

The embryonic cardiac axis is relatively midline at 8 weeks and then levorotates in the late first trimester. By 12 weeks gestation, the normal leftward fetal cardiac axis is established and then remains stable until at least 14⁺⁶ weeks. An abnormal cardiac axis observed in some cases of severe congenital heart disease prior to 15 weeks gestation may assist in their prenatal detection

Fetuses with pulmonary outflow tract obstruction (POTO) have altered blood flow to the pulmonary vasculature. We sought to determine whether pulmonary vascular impedance, as assessed via the pulsatility index (PI), is different in fetuses with POTO compared to normal controls.

Branch pulmonary artery PI was evaluated in age-matched normal control fetuses (n=22) and POTO fetuses (pulmonary stenosis (PS) = 15, pulmonary atresia (PA) = 5). Pulsed wave Doppler was performed in the proximal (PA1), mid (PA2) and distal (PA3) branch pulmonary artery. Direction of flow in the ductus arteriosus (DA) was noted. The study and control groups were compared via Student t tests and ANOVA. A linear mixed model evaluated the relationship between PI and DA flow patterns.

There was no difference in PI between control, PS and PA subjects in PA1 and PA2; however, there was a significant difference in PA3. Subjects with PA had a lower PI at PA3 compared to controls (p= 0.003) and PS subjects (p= 0.003). Subjects with retrograde flow in the DA had lower PI’s in PA2 and PA3 as compared to those with antegrade flow (p= 0.01 and 0.005). The PI in PA3 was lower among fetuses that required prostaglandin postnatally as compared to those that did not (p= 0.008).

Fetuses with PA or severe PS with retrograde flow in the DA have decreased PI in the distal pulmonary vasculature. Our findings indicate the capacity of the fetal pulmonary vasculature to vasodilate in response to anatomical obstruction of flow.

We performed a systematic review and meta-analysis to assess the predictive capacity of transvaginal sonographic assessment of the cervix for the outcome of induction of labor.

We searched Medline, Embase and the Cochrane Library, and manually searched reference lists of review articles and eligible primary articles. Studies in all languages were eligible if published in full. Two reviewers independently selected studies and extracted data on study characteristics, quality and test accuracy. We then calculated pooled sensitivities and specificities (95% CI) and summary receiver operating characteristic (sROC) curves.

Outcome measures were test accuracy of sonographically measured cervical length and cervical wedging for Cesarean section, not achieving vaginal delivery within 24 hours and not achieving active labor.

We included 31 studies reporting both on cervical length and the outcome of delivery. The quality of the included studies was mediocre. Sensitivity of cervical length in the prediction of Cesarean delivery ranged from 0.35 to 0.92 and specificity ranged from 0.35 to 1. The estimated summary ROC curve for cervical length indicated a limited predictive capacity in the prediction of Cesarean delivery. Summary estimates of sensitivity/specificity combinations of cervical length at different cut-offs for Cesarean delivery were 0.82/0.34, 0.64/0.74 and 0.13/0.95 for 20, 30 and 40 mm, respectively.

For cervical wedging in the prediction of failed labor induction summary point estimates of sensitivity/specificity were 0.37/0.80.

Cervical length and cervical wedging as measured sonographically at or near term have moderate capacity to predict the outcome of delivery after induction of labor.

To evaluate the role of cervical length (CL) and uterine artery Doppler (UtAD) at 11⁺⁰ to 13⁺⁶ weeks as a predictor of spontaneous preterm delivery (sPTD) in a Chilean population.

This is a prospective study involving 3,480 asymptomatic women with singleton pregnancies attending for a nuchal translucency scan at 11⁺⁰-13⁺⁶ weeks gestation who underwent a transvaginal scan for evaluation of CL and UtAD. After excluding iatrogenic deliveries <34 weeks, 3,310 pregnant women were finally studied. Maternal characteristics and ultrasound variables, adjusted and expressed as the multiple of median (MoM) of the unaffected group, were studied using a logistic regression analysis.

The rate of sPTD <34 weeks was 0.9% (n=31). Previous PTD was present in 7.4% of multiparous women. Patients who subsequently had sPTD were characterized by a significantly higher prevalence of previous PTD (12.9 vs. 3.7%, p< 0.05) than the controls. No significant difference was found in the CL and UtAD between the two groups. The logistic regression analysis showed that a smoking habit and previous PTD were significantly associated with sPTD <34 weeks. The combination of these two findings provided a detection rate of 26% with an 8% FPR.

Neither UtAD nor CL during the first trimester was shown to be a useful predictor of early sPTD. However, a combined model that includes a smoking habit and previous PTD might predict approximately one-third of the women destined to deliver <34 weeks with an 8% FPR.

To evaluate the accuracy of gestation-adjusted birth weight estimation using a 3D fractional thigh volume (TVol) method in pregnant women with gestational diabetes mellitus (GDM), and to compare it with a conventional 2D method (Hadlock).

Pregnant women with GDM were referred at 34-36⁺⁶ weeks for ultrasound examination. Estimated fetal weight (EFW) was obtained using both the Hadlock and the TVol methods. Using a gestation-adjusted projection method, predicted birth weight was compared to actual birth weight at delivery.

Based on 125 pregnancies, the TVol method with gestation-adjusted projection had a mean percentage error in estimating birth weight of −0.01 ± 5% (95% CI −0.96 to 0.98%) while Hadlock with gestation-adjusted projection had an error of 1.28 ± 9.1% (95% CI −0.33 to 2.87%). The mean percentage error of the two methods was significantly different (p=0.039), while the systematic error was not (p=1). For the prediction of macrosomia, sensitivity was 84% and 63% for TVol and Hadlock, respectively (p=0.22, 95% CI −0.02-0.44), specificity was 96% and 89% for TVol and Hadlock, respectively (p=0.01, 95% CI 0.05-0.09).

In women with GDM, a new method of estimating birth weight based on three-dimensional (3D) fractional thigh volume (TVol) measurements performed at 34⁺⁰-36⁺⁶ weeks’ gestation and gestation-adjusted projection of estimated fetal weight, is more accurate than a standard method based on Hadlock's formula in predicting actual birth weight. The TVol method has comparable sensitivity but higher specificity than the Hadlock method in predicting neonatal macrosomia.

To evaluate the intra and interobserver agreement in the first trimester (FT) fetal cardiac structural assessment, using 2D ultrasound (2DUS) and 4D ultrasound (4DUS) (spatiotemporal image correlation STIC technology). Also to compare the methods and to assess the advantages of adding color Doppler in each technique.

Digital videoclips (B-mode and color Doppler) and 4D-STIC volumes (grey scale and color Doppler) from 632 pregnancies with normal hearts fetuses were acquired and stored at FT detailed anomaly scan. Later analysis on a randomized sample of 100 cases was performed. 11 cardiac features were targeted. The agreement of qualitative variables was evaluated using Cohen's kappa. McNemar test for paired proportions was used for the visualization comparison of fetal heart structures between 2DUS/4DUS and grey-scale/color Doppler scan. P<0.05 was considered statistically significant. Statistical analysis was performed using IBM SPSS Statistic 19.

STIC volumes were considered satisfactory (minimum 8/11 parameters) in 78% cases and 2D acquisitions in 89% of the cases. The intra- and interobserver agreement was good for 2D and 4D methods (kappa>0.6), and the proportion of overall agreement was very high using both methods (>0.95). The 2DUS and 4DUS identification of the fetal cardiac structures did not differ significantly. The differences between grey-scale and color Doppler scan were statistically significant in identifying key cardiac features in both methods: 2DUS and 4DUS (p<0.05).

The intra- and interobserver agreement was very good for both methods in assessing FT heart structures. Color Doppler added valuable information in 2DUS and 4DUS.

The aim of this study was to assess the inter- and intraobserver reliability for diagnosing pubovisceral muscle avulsions and measurements of the levator hiatus on magnetic resonance (MR) imaging. Women with recurrent POP or in whom there was a discrepancy between clinical signs and symptoms of pelvic floor dysfunction were potentially eligible to participate.

Magnetic resonance imaging datasets of the pelvic floor of 262 women were obtained and scored by two observers. A random sample of 100 patients was reviewed a second time by one of the observers. Intraclass correlation coefficient with 95% confidence interval (ICC 95%CI) of all measurements were calculated. Furthermore, mean differences with accompanying limits of agreement were calculated to estimate agreement between two measurements and to detect possible systematic biases.

Good interobserver reliability for pubovisceral muscle avulsions was found (ICC 0.76 – 0.79) and excellent agreement for measurements of the levator hiatus (ICC 0.85 – 0.89). The intraobserver reliability for pubovisceral muscle avulsions and other levator hiatus measurements also showed to be excellent (ICC 0.80 – 0.97). A significant systematic bias was observed in the mean difference of levator hiatus transverse diameter when measured by both observers, however, narrow limits of agreement were observed.

Pubovisceral muscle avulsions and levator hiatus measurements can be assessed with good to excellent reliability.

to evaluate the contribution of the examination of specific anatomical hallmarks of the fetal posterior brain on the mid-sagittal 1^st trimester scan to the early detection of open spina bifida (SB).

Four independent observers reviewed a series of 260 mid-sagittal 1^st trimester scan images comprising 52 cases of SB and 208 normal fetuses. The following analysis was performed for each mid-sagittal 1^st trimester scan by all reviewers: Herman Score calculation, CFEF-IT Score calculation, intracranial translucency (IT) present or absent, caudal displacement of the brainstem (BS), cisterna magna (CM) absent of present. Both the sensitivity and the false positive rate for SB detection were calculated for each of these three hallmarks. A secondary analysis was performed on a subset of images achieving a Herman score ≥ 7.

The higher detection rate was achieved by the non visualisation of the CM with an associated sensitivity of 50-73% and 39-76% for the whole images and the subset of images achieving a Herman score≥ 7 respectively. The posterior shift of the BS achieved the highest detection rate (86%) for reviewer 1 only. The inter-observer discrepancy was also the largest for this sign. Absence of IT was associated with a lower detection for all observers. Overall, an abnormal posterior brain presenting at least one of these three hallmarks was associated with a detection ranged from 50 to 90%.

Non visualisation of the CM achieved the best screening performance. Both non-visualisation of IT and posterior shift of the BS were associated with acceptable but lower detection rates. A prospective evaluation of the changes in posterior brain is needed to allow assessment of the most pertinent criteria for 1^st trimester screening for SB.

To assess the detection rate of triploidy at first-trimester screening for trisomy 21 and evaluate outcome in triploid pregnancies.

From 2008–2011, 198,427 patients women with singleton pregnancies underwent first-trimester screening (FTS) at 11+2 – 14+0 weeks of gestation. FTS included: Nuchal translucency (NT), maternal serum free β-human chorionic gonadotrophin (β-hCG) and pregnancy associated plasma protein-A (PAPP-A). In all triploid fetuses FTS parameters were re-evaluated. Karyotypes were established by invasive testing (CVS or AC) or post abortem and obtained from the Danish Cytogenetic Central Register and the Danish Fetal Medicine Database.

A total of 30 triploid fetuses attended FTS. Twenty-five triploid fetuses were diagnosed as a result of abnormal FTS, a detection rate of 83%.Twenty-three fetuses were identified due to a high risk of trisomy 13, 18 or 21 and two fetuses due to structural abnormalities at FTS. The incidence of triploidy at FTS was 1:6614. A smaller CRL than estimated by last menstrual period was found in 95 % of the fetuses with the data available for evaluation. Eight fetuses had larger BPD than expected by gestational age.

69, XXX fetuses had significantly lower β-hCG MoM and PAPP-A MoM than 69, XXY fetuses (p=0.045 and p=0.02).

No infants with triploidy were born in the study period. Among the triploid gestations, 80% of the women chose termination of pregnancy, 16 % had spontaneous miscarriages, and one was stillborn.

First trimester screening for trisomy 21 also provides a high detection rate for triploidy

To explore factors affecting 2 reflex pelvic floor muscle contraction (PFMC) patterns in women with pelvic floor disorders.

A retrospective analysis of pelvic floor ultrasonography and urodynamic data was performed for 667 symptomatic women with pelvic floor disorders. Two reflex PFMC patterns were identified on ultrasonography as an anorectal lift (ARL) and inward clitoral motion (ICM) preceding or occurring during coughing. Possible factors affecting reflex PFMC reactivity included patient demographics, pelvic organ prolapse stages, ultrasonography findings, and urodynamic data. Univariate and multivariate logistic regression models with odds ratios (OR) and 95% confidence intervals (CI) were used to assess the associations between the factors and reflex PFMC patterns, with P < 0.05 considered statistically significant.

Of 667 women, 560 (84.0%) and 536 (80.4%) clearly demonstrated reflex ARL and ICM, respectively. Significant differences were noted in age (P = 0.000), parity (P = 0.033), and menopause (P = 0.005) between women with and without reflex ICM during coughs. The multivariate logistic regression model showed that age was the only independent factor affecting reflex ICM reactivity (OR 0.93, 95% CI 0.88–0.99, P = 0.017). In contrast, no significant differences were noted between women with or without reflex ARL.

Aging has a negative effect on the reactivity of reflex ICM during coughs.

Neoadjuvant chemotherapy (NACT) is frequently used in the management of patients with locally advanced cervical cancer. Tailoring subsequent surgical treatment requires accurate preoperative assessment. The aim of our work was to assess the accuracy of magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) in the evaluation of tumor size and in the detection of residual tumor following NACT.

The prospective study involved 42 women with locally advanced histologically confirmed cervical cancer referred to NACT. Clinical examination, TRUS and MRI were performed before and after NACT and the tumour size was measured by imaging methods in three standardized diameters (anteroposterior, laterolateral and craniocaudal). Thereafter patients underwent surgical treatment and tumour was measured by pathologist on a fixed surgical specimen in the same dimensions. Tumour volumes were calculated (diameter A x B x C x Π/6) and data obtained by both imaging methods was compared with pathological results as the gold standard.

Progression of the disease during NACT occurred in 6 patients (14%), who were referred for primary radiotherapy. For various reasons, MRI could not be performed in 6 women. These 12 cases were excluded from the study and data from 30 remaining patients were finally analysed. On average, tumour volume decreased after NACT by 85.7% and 85.4% as measured by MRI and TRUS. The agreement between measurements obtained by MRI and histology did not reach significance and interclass correlation was low (inter-class correlation = 0.344, 95% CI = − 0.013 - 0.610, P=0.059), while the agreement between TRUS and histology was statistically significant and interclass correlation was high (inter-class correlation = 0.795, 95% CI = 0.569 - 0.902, P ˂0.0001).

The accuracy of residual tumour detection (for non-microscopic tumour of >5 mm³ in volume) reached 87% for MRI, and 80% for TRUS. Similarly, the sensitivity of TRUS was lower than that of MRI (85 % vs. 96 %). The positive predictive values were the same for both methods.

TRUS should be considered as an accurate diagnostic method in the evaluation of tumour volume after neoadjuvant chemotherapy in patients with cervical cancer. There was a lower correlation with pathological tumour volumometry observed for MRI in comparison with TRUS in our study. However, the overal accuracy and sensitivity in the detection of zero residual disease were higher in MRI than in TRUS, while positive predictive values were equal. TRUS may constitute a reliable alternative imaging method to MRI.

Placental invasion can lead to a potentially life-threatening situation in the third stage of labor. Early prenatal differentiation between the three degrees of placental invasion (placenta accreta, increta, or percreta) would be desirable because it would enable the creation of a precise individual treatment plan. We intended to evaluate whether the maximum degree of placental invasion was predictable with ultrasound imaging, using criteria that were developed at our department.

In a retrospective study, all 232 patients at risk for placental invasion, who were part of a routine screening program for placental invasion from January 2001 – January 2011, were included. The whole placenta was scanned in a systematic fashion using both grey-scale ultrasound and color-flow mapping. Sonographic findings were compared with the clinical outcome during and after delivery and the histomorphologic examination of the placenta.

Placental invasion was suspected by ultrasound in 40 patients (17.2%) and clinically/histopathologically confirmed in 35 patients (15.1%). Sensitivity, specificity, and positive and negative predictive values were 91.4% (95% CI 77.6 – 97.0), 95.9% (95% CI 92.2 – 97.9%), 80.0% (95% CI 65.2 – 89.5%), and 98.4% (95% CI 95.5 - 99.5%), respectively. No case of placenta increta or percreta was diagnosed as normal placentation or placenta accreta (overall accuracy 100%).

Our data suggest that prediction of the degree of placental invasion is possible using antenatal ultrasound, with a high overall accuracy.

Decreased middle cerebral artery (MCA) pulsatility index (PI) is a marker of fetal brain-sparing in placental insufficiency, and it is also found in fetuses with severe congenital heart disease. This study sought to explore the impact of anatomic subtypes in fetal heart disease on MCA-PI and head growth.

We retrospectively reviewed fetal echocardiograms of pregnancies complicated by fetal hypoplastic left heart syndrome (HLHS, n=42) with (n=28) and without (n=10) anatomic coarctation, isolated severe aortic coarctation (n=21), transposition of the great arteries (TGA, n=11) and severe pulmonary outflow tract obstruction (POTO, n=15) comparing observations with gestation-matched controls (n=89). No fetus had major extracardiac pathology or aneuploidy. MCA and umbilical artery (UA) PI, the cerebral placental ratio (CPR=MCA-PI/UA-PI) and neonatal head circumference were obtained and expressed as z-scores.

Lower MCA-PI, higher UA-PI and lower CPR were observed in fetal HLHS and isolated coarctation with reversed arch flow (n=6) (p<0.001) but not TGA, POTO or isolated coarctation with antegrade arch flow (n=15) compared to controls. No difference was found between HLHS with anatomical coarctation and those without, however MCA-PI correlated positively with neonatal head circumference in HLHS with reversed distal arch flow (r=0.33, p<0.05).

Severe left heart obstruction with reversed aortic arch flow is associated with altered fetal cerebral blood flow, and in these conditions, MCA-PI positively correlates with head growth. Anatomical arch obstruction itself may not be a contributing factor to altered MCA flow in fetal HLHS.

Transvaginal scanning is core to any ovarian cancer (OC) screening strategy. General population screening involves older postmenopausal women in whom ovarian visualisation is difficult due to decreasing ovarian size and lack of follicular activity. We report on factors affecting visualisation of postmenopausal ovaries in the multicentre United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).

UKCTOCS is a randomised controlled trial of 202,638 postmenopausal women with 50,639 women in the ultrasound scan arm. Transvaginal scan (TVS) is the primary screening modality in the ultrasound scan arm. Age, education, ethnicity, BMI, previous pelvic surgery, lifestyle and reproductive factors, personal/family history of cancer were assessed for their effects on ovarian visualisation at the initial TVS.

Between 11^th June 2001 and 18^thAugust 2007, 43867 women underwent initial TVS. Median age and BMI of the women were 60.6(IQR 9.9) and 25.7(IQR 5.8) respectively. The right ovary was visualised in 29297(66.8%) and the left ovary in 28726(65.5%). Visualisation of ovaries decreased with previous hysterectomy (OR 0.534, 95% CI 0.504-0.567), previous tubal ligation (OR 0.895, CI 0.852 -0.940), increasing age (OR 0.953, 95% CI 0.950-0.956), unilateral oophorectomy (OR 0.224, 95% CI 0.186 -0.269), and rising BMI (overweight: OR 0.918, 95% CI 0.876 - 0.962; obese: OR 0.715, 95% CI 0.677 - 0.755). Increased visualisation was observed with history of infertility(OR 1.134, 95% CI 1.005-1.279) and increasing age (in years) at menopause(OR 1.005, 95% CI 1.001-1.009).

Several factors affect visualisation of postmenopausal ovaries. Their impact needs to be taken into consideration when developing quality assurance for ovarian ultrasound scanning or comparing study results as their prevalence may differ between populations.

To report the neonatal morbidity in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic endoluminal tracheal occlusion (FETO) and compare it with historical controls with less severe forms that were managed expectantly.

This is a prospective multicenter study on neonatal outcomes and prenatal predictors in 90 FETO survivors (78 left, 12 right) and 41 controls from the antenatal CDH registry with either severe or moderate hypoplasia who were managed expectantly. We also investigated early neonatal morbidity indicators, including need for patch repair, duration of mechanical ventilation and supplemental oxygen, age at full enteral feeding and incidence of pulmonary hypertension.

Gestational age at delivery was predictive of duration of assisted ventilation (p=0.046), days on supplemental oxygen (p=0.019) and age at full enteral feeding (p=0.020). When delivery took place after 34 weeks, neonatal morbidity of FETO cases was comparable to that of expectantly managed cases with moderate hypoplasia.

Fetal intervention for severe CDH is associated with a neonatal morbidity that is comparable to that of an expectantly managed group with less severe disease.

To assess first trimester placental perfusion, reflected in uterine artery pulsatility index (PI), in pregnancies complicated by gestational diabetes mellitus (GDM), with or without pre-eclampsia (PE), compared to those that remain unaffected by GDM.

Uterine artery PI was measured at 11⁺⁰-13⁺⁶ weeks’ gestation in 1,037 singleton pregnancies that subsequently developed GDM and 56,649 normoglycaemic controls. The measured mean uterine artery PI was converted to multiple of the expected normal median (MoM), corrected for maternal weight, racial origin and gestational age, and the median MoM values in the two groups were compared.

The incidence of PE was higher in GDM than in controls (4.0% vs 2.3%; p=0.001). However, there were no significant differences in the median uterine artery PI MoM between the groups (1.00, interquartile range (IQR):0.82-1.21 MoM vs 1.00, IQR: 0.81-1.21 MoM; p=0.73). The median uterine artery PI in patients that developed PE was higher than in those that did not develop PE, regardless of development of GDM.

First trimester placental perfusion, as assessed by uterine artery Doppler examination, is not impaired in women who subsequently develop GDM. The increased prevalence of PE in women with GDM cannot be attributed to impaired placentation.

Miscarriage is the most common adverse outcome in Maternal-Fetal Medicine and has long term psychological impact. Discrepancies in diagnosis and treatment have prompted RCOG and NICE to extend miscarriage diagnostic criteria and ascertain diagnosis through a second opinion and/or a repeat scan. Clinicians should base management on expectant management as first-line treatment, but other options should be explored when indicated. Because of the high prevalence of chromosomal anomalies in first trimester loss, karyotyping was traditionally considered redundant. However, chromosomal studies provide valuable information about the cause of miscarriage, as well as a recurrence risk estimate. Thus, chorionic villus sampling could be offered routinely, unless CGH-arrays are used, to reduce the high rates of unsuccessful karyotyping. Of note, distinct recurrence risk can be obtained for both homotrisomy and heterotrisomy according to maternal age. Individualizing recurrence risk should be regarded as the recommended clinical practice, instead of suggesting an invasive procedure after any viable chromosomal anomaly. In the event of recurrent miscarriages, pregnancy rather than parental chromosomal studies are more relevant, and may eliminate further costly testing. The time has come to consider first trimester miscarriage not a trivial incident but a profound adverse life event. Building on evidence-based approach in management and counselling, future research will allow a more comprehensive treatment of women who experience miscarriage.

To determine whether there is an association between ultrasonographically assessed hyper- or hypocoiling of the umbilical cord and the presence of Down syndrome (trisomy 21). Furthermore, to provide reference values for the antenatal umbilical coiling index (aUCI) at a gestational age of 16–21 weeks and to determine whether these measurements are reliable and reproducible.

In a prospective longitudinal study of 737 pregnancies, the aUCI was measured between 16 and 21 weeks of gestation by ultrasound at the time of amniocentesis. The aUCI was calculated as the reciprocal value of the mean pitch of one complete coil in centimeters. We created reference curves and studied the relationship with trisomy 21 and other chromosomal defects. In 30 cases we studied the intraobserver and interobserver variation, using Bland-Altman plots with associated 95% limits of agreement and intraclass correlation coefficients.

aUCI was non-linearly related to gestational age at 16–21 weeks and reference curves were created for the mean aUCI, the 2.3^nd, the 10^th, the 90^th and 97.7^th percentile. There was no significant difference in aUCI values between the reference group (n=714) and cases with trisomy 21 (n=16) or other aneuploidies (n=7), (one-way ANOVA p=0.716). There was a good intra- and interobserver agreement.

The aUCI can be measured reliably and was related to gestational age at 16–21 weeks. The aUCI was not significantly associated with trisomy 21 or other chromosomal defects.

To assess the feasibility of a specific training program for ultrasound diagnosis of adnexal masses.

A two-month intensive training program was developed. Program protocol consisted of one-day intense theoretical course focused on clinical and ultrasonography issues related to adnexal masses and ovarian cancer followed by a four-week real-time ultrasound training in a reference center (about 25-30 adnexal masses evaluated per month) and a final four-week period for off-line assessment of 3D volumes from adnexal masses. In this later period the trainee evaluated five sets of 100 3D-volumes each. 3D-volumes contained gray-scale and power Doppler information and the trainee was provided with clinical data of each case (patient's age, menopausal status and complaints). 3D-volumes were from masses surgically removed and histologic diagnosis was available or from masses followed-up until resolution. After each set assessment, trainee's diagnostic performance was calculated (sensitivity and specificity) and then the trainee evaluated with the trainer each mass incorrectly classified. The objective was to achieve a sensitivity > 95% and specificity > 90%. LC-CUSUM graphics were plotted to assess the learning curve for trainees.

One trainer and two trainees with very low experience on gynecological ultrasound (one gynecologist and one radiologist) participated in this study. LC-CUSUM graphics showed that competence was achieved after 170 examinations. The objectives for diagnostic performance were achieved after the second set of 3D volumes (200 cases) for each trainee.

The proposed training program seems feasible. High diagnostic performance can be achieved after 200 cases analyzed and it is maintained after.

To investigate the added value of second trimester uterine artery Doppler relative to patient characteristics in the identification of nulliparous women at risk for pre-eclampsia.

For this individual patient data meta-analysis, studies published between January 1995 and December 2009 were identified in Medline and Embase. Eligible were studies in which Doppler assessment of the uterine arteries had been performed among pregnant women and in which gestational age at ultrasound, Doppler ultrasound findings, and the occurrence of pre-eclampsia were available. We invited corresponding authors to share their original datasets. Included were data of nulliparous women who had had second trimester uterine artery Doppler ultrasound examinations. Shared data were checked for consistency, recoded to acquire uniformity, and merged into a single dataset. We constructed random intercept logistic regression models for each of the patient and Doppler characteristics in isolation and for combinations. We compared goodness-of-fit, discrimination and calibration.

We analysed 8 datasets, reporting on 6,708 nulliparous women, of whom 302 (4.5%) developed pre-eclampsia. Doppler findings included higher, lower and mean Pulsatility Index (PI) and Resistance Index (RI), and any or bilateral notching. Of these, the best predictors were combinations of mean PI or RI and bilateral notching, with areas under the ROC curve (AUC) of 0.75 (95% CI: 0.56 to 0.95) and AUC 0.70 (0.66 to 0.74), respectively. Addition of Doppler findings to patient characteristics blood pressure or BMI significantly improved discrimination. A model with blood pressure, PI and bilateral notching had an AUC of 0.85 (0.67 to 1.00).

The addition of Doppler characteristics mean PI or RI and bilateral notching to patient characteristics blood pressure or BMI improves the identification of nulliparous women at risk for pre-eclampsia.

Levator avulsion has been shown to be a predictor of cystocele recurrence following anterior colporrhaphy (AC) . The aim of this study was to determine if levator avulsion is a risk factor for prolapse recurrence following AC with mesh.

Retrospective analysis of data obtained from three surgical audits for subjective and objective outcomes following AC with mesh. Recurrence was defined as either 1) cystocele ≥ Stage 2 (ICS POP-Q), 2) symptoms of vaginal lump/bulge or 3) cystocele on ultrasound, defined as maximum bladder descent to ≥10 mm below the symphysis pubis. Levator avulsion was diagnosed using tomographic ultrasound imaging (TUI).

209 patients (142 Perigee, 67 Prolift) were followed up at a mean of 2.2 years (3 months - 5.6 years). 24% (51/209) had recurrent prolapse symptoms, 33% (68/209) a clinical cystocele recurrence ≥ stage 2, and 26% (54/209) a recurrent cystocele on ultrasound. 28/80 (35%) women with levator avulsion had a significant sonographic cystocele recurrence (OR 2.24[CI 1.13-4.43]). This finding was confirmed after adjusting for potential predictors of prolapse recurrence on multivariate logistic regression (OR 2.13 (CI 1.04 – 4.39); p = 0.04).

Levator avulsion doubles the risk of cystocele recurrence after AC with transobuturator mesh.

To identify sonographic features suggestive of an obstructive mechanism in second-trimester fetuses with ventriculomegaly and describe developmental disorders related to pathological differentiation of the diencephalon, mesencephalon, and rhombencephalon which lead to obstruction of CSF flow.

Retrospective study of 11 fetuses referred for severe, second trimester ventriculomegaly of undetermined origin. Neurosonography was performed with a detailed analysis of the third ventricle, thalami, aqueduct, and cerebellum. The cerebral imaging data were correlated with neuropathological data in eight patients, with a focus on the level and aetiology of the obstruction.

Parenchymal thinning and reduction of the pericerebral spaces were highly suggestive of ventriculomegaly due to an obstructive mechanism. The ventriculomegaly was related to diencephalosynapsis (thalamic fusion and third ventricle atresia) in five cases and partial/complete aqueduct stenosis in six cases, and was associated with cerebellar hypoplasia in six cases, including rhombencephalosynapsis in two cases. In nine patients, disorders of the diencephalon, mesencephalon, and rhombencephalon were combined.

When facing severe isolated ventriculomegaly, of which sonographic features are suggestive of an obstructive mechanism, close examination of the third ventricle, thalami, Sylvius aqueduct, and cerebellum may reveal pathological differentiation of the diencephalon, mesencephalon or rhombencephalon, often in combination.

The Modified Oxford Score (MOS) has previously been found to have poor inter-rater reliability. Digital assessment of levator ani muscle (LAM) attachment to the pubic bone has shown to have acceptable reliability, with moderate correlation to transperineal ultrasonography (TPUS). However, no comparisons have been made in nullipara. Furthermore, no standardised classification for digital palpation has been described and correlated to TPUS. Our aim was to evaluate the inter-rater reliability of the validated MOS and to determine a reliable classification for digital assessment of LAM attachment and to correlate this to TPUS.

MOS palpation was performed in nullipara by two investigators. LAM attachment was evaluated using digital palpation, for which a novel classification was used. Findings were compared with TPUS.

25 nullipara were examined. There was agreement in MOS between the investigators in 64% (n=16), Cohen's kappa 0.66 (substantial agreement). There was agreement in palpation of LAM attachment in 96% (n=24), Cohen's kappa 0.90 (almost perfect agreement). TPUS showed no LAM detachment, apart from one patient with a partial detachment.

MOS revealed substantial agreement between the two investigators. In this group of nulliparous patients, there was good agreement between grades of LAM attachment, which correlated to TPUS. It therefore appears that these assessment tools are reproducible in nullipara, can be readily learned and reliably incorporated into clinical practice and research after appropriate training. Further evaluation to establish its clinical utility in postpartum women and women with (symptomatic) pelvic organ prolapse is awaited.

We aim to compare the variability of vascularization flow index (VFI) related to serial acquisitions between spatio-temporal image correlation (STIC) and conventional static three-dimensional (3D) power Doppler (PD), using both an in vitro and an in vivo models. Additionally we aim to evaluate whether the curves from VFI values obtained in a STIC dataset are visually stable and resemble the waveforms obtained in the spectral Doppler analysis.

The study was divided in two parts: in the first part (in vitro model) we scanned a flow phantom; while in the second part (in vivo model) we scanned a common carotid artery. Conventional static 3D and STIC PD datasets were alternately acquired from these two models. VFI values were assessed from 0.38 cm³ spherical samples of main flow region of the static 3D datasets and from every ‘frame’ of STIC datasets. The variance of the minimum, mean, and maximum VFI values from STIC datasets were compared with the variance of VFI values from static 3D datasets.

10 static 3D and 10 STIC datasets were acquired from each model. The analyses of the in vitro and in vivo models shown a significant reduction in the variance of VFI values obtained in STIC compared to static datasets. Additionally, we observed that curves of VFI values obtained across the frames contained in the STIC are stable across different datasets and they resemble the waveforms obtained by spectral Doppler in both models.

3DPD indices derived from STIC are more stable than those obtained from conventional static 3DPD datasets. The curves of VFI throughout a reconstituted cardiac cycle using STIC are repeatable and resemble those obtained from spectral Doppler analysis of the vessel.

Studies have suggested that biparietal diameter (BPD), measured at 11–13 weeks’ gestation, is reduced in open spina bifida. The aims of this study were to ascertain the reported association between reduced BPD in the first trimester and open spina bifida, and to investigate its predictive value in a single centre study.

This was a retrospective study in which BPD was measured at 11–13 weeks in 27 fetuses with isolated open spina bifida subsequently diagnosed at 16–24 weeks, and 7,775 unaffected controls. BPD values were converted into multiples of the expected median (MoM), after adjustment for crown-rump length and maternal characteristics. Multivariate logistic regression analysis was used to examine which of the maternal characteristics were significantly associated with spina bifida. The performance of screening was determined by receiver operating characteristic (ROC) curve analysis. BPD values at 11–13 weeks were compared with those measured in the second trimester using Z-scores.

BPD values at 11–13 weeks were below the 5^th centile in 44.4% of cases. In these fetuses, the BPD MoM value was significantly smaller than in the control group (0.930 vs 0.998 MoM, p<0.0001). Multivariate logistic regression analysis showed a significant contribution from maternal age (p=0.008) and BMI (p=0.028) to the association between BPD MoM and spina bifida. The detection rate using the BPD measurements in the first trimester was 55.6% for a false positive rate of 11.6%. In fetuses with open spina bifida, the BPD value Z-scores were significantly lower at 16–24 weeks compared to those recorded at 11–13 weeks [median −1.71 (range −3.98, 2.00) vs −1.30 (−3.75, 2.61), respectively, p=0.006].

Fetuses with open spina bifida have a smaller BPD in the first trimester. This property may be useful in early screening. It is likely that a combination of maternal characteristics such as age and BMI, fetal BPD and maternal serum AFP measured in the first trimester would provide a clinically useful screening test for open spina bifida.

Recordings of blood flow velocity waveform in the ductus venosus (DV) and the umbilical vein (UV) are routinely used in order to predict the fetal condition in high-risk pregnancies. This study investigates the relationship between pathological blood flow in the two vessels and perinatal outcome.

High-risk pregnancies (n=11865) admitted during 1993–2011 for blood flow examinations, including recordings of DV pulsatility index for veins (PIV) and UV pulsations, were included. The results were related to perinatal outcome, using the last Doppler examination prior to delivery in analysis.

Abnormal DV PIV was observed in 3,96%, intra-abdominal UV-pulsations in 1,3% and pulsations in the cord in 0,7% of the cases. As expected, the rate of UV-pulsations increased with increasing DV PIV z-score. Fetuses with a pathological DV PIV, but without UV pulsations showed no signs of compromise. This was also true for cases with a DV PIV >4 SD above the mean (53.7 % had a steady flow in the UV). In contrast, the occurrence of UV-pulsations seems to be an indicator of fetal compromise regardless of level of DV PIV.

Abnormal fetal venous blood velocity is related to adverse outcome of high-risk pregnancies. However, abnormal DV PIV is not an indicator of fetal compromise unless UV-pulsations are concurrently present and should be regarded as an artifact and not an indication for emergency delivery.

To evaluate the effect of early fetoscopic tracheal occlusion (22–24 weeks) on pulmonary response and neonatal survival in extremely severe isolated CDH.

Multicenter study involving fetuses with extremely severe CDH (lung-to-head ratio <0.70, liver herniation into the thoracic cavity, no other detectable anomalies). Between August 2010 and December 2011, eight fetuses had early FETO. Data were compared with 9 fetuses that had standard FETO and 10 cases without fetal procedure from January 2006 to July 2010. FETO was performed under maternal epidural anesthesia supplemented with fetal intramuscular anesthesia. Fetal lung size and vascularity were evaluated before and every 2 weeks after FETO by means ultrasounds. Postnatal therapy was equivalent for both treated fetuses and controls. Primary outcome was infant survival to 180 days and second outcome was fetal pulmonary response.

Maternal and fetal demographic characteristics, and obstetric complications, were similar in the three groups (p>0.05). The infant survival rate was significantly higher in the early FETO group (57.1%) compared to standard FETO (11.1%) and controls (0%) (p=0.02). Early FETO resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared to standard FETO (p<0.01).

Early FETO may improve infant survival by further increases of lung size and pulmonary vascularity in cases with extremely severe pulmonary hypoplasia in human isolated CDH. This study supports formal testing of the hypothesis with a randomized controlled trial.

To examine the feasibility of ultrasonographic imaging of foetal tympanic rings (TR).

An observational cohort study of eighty healthy foetuses of low-risk pregnancies divided into four gestational age subgroups (12^th week, 16^th week, 23^rd week, and 32^nd week) was performed. Each subgroup comprised twenty sequential foetal sonographic examinations. TR visualization was achieved by 2D and 3D sonography. A standard algorithm for TR examination was constructed using 3D-MPR display. The volume acquisition plane was directed to the infero-lateral aspect of the foetal temporal bone. Transvaginal scans were carried out in the 12^th and 16^th weeks, and transabdominal scans were performed in the 23^rd and 32^nd weeks. Study parameters included the infero-medial inclination angle (IMIA) of TR relative to the vertical head axis, the antero-medial inclination angle (AMIA) of TR relative to the antero-posterior head axis, the longest tympanic ring diameter (LTRD), and shortest tympanic ring diameter (STRD), measured perpendicular to the LTRD. The feasibility of TR demonstration was assessed in each gestational age subgroup.

TR appeared as a round-oval, thin, echogenic structure in the tangential plane to the infero-lateral surface of the foetal skull below the inferior border of the squamous part of the temporal bone. Higher demonstration rates were achieved in the 16^th and 23^rd weeks (90% and 80%, respectively). The LTRD and STRD showed a linear correlation with gestational age (r = 0.96 for both measurements; P < 0.01). The ranges of IMIA and AMIA in the study subgroups were from 41 to 60.4 degrees and from 17.3 to 23.4 degrees, correspondingly. Malleal manubrium was observed only in the examinations of the second half of pregnancy. It appeared as a bright echo within the upper area of the tympanic ring in 56% (9/16) and 82% (9/11) of the cases with proper TR imaging in the 23^rd and 32^nd-week subgroups, respectively.

This is the first report of the sonographic imaging of the foetal tympanic rings. TR demonstration in the second trimester is feasible. Discussion on the possible implications of our findings for prenatal diagnosis of congenital hearing loss is provided.

To evaluate if a standard complete anatomical fetal survey, as recommended based on ultrasound (US) examination guidelines was feasible using a standardized MRI protocol.

Based on guidelines for US-based examination, we built up a specific MRI protocol for fetal anatomical survey. This protocol was then prospectively tested in 100 women, at a median gestational age (GA) of 30 weeks, undergoing fetal MRI examination for various specific indications. Ability to perform fetal anatomical survey was analysed by two reviewers (A and B) based on 26 predefined anatomical criteria agreed upon yielding a score ranging from 0 to 26 (complete anatomical study). Reproducibility was analysed using percentage of agreement and modified Kappa statistics.

Mean (SD) [range] score for standardized anatomical survey was 24.6/26 (1.4) [15;26] and 24.2/26 (1.7) [15;26] according to A and B respectively (p=0.1). Satisfactory examination was achievable in >95%, 80-95% and <80% for 22, 2 and 2 and for 19, 4 and 3 anatomic criteria according to A and B respectively. For both reviewers, the two most difficult criteria to evaluate were aorta and pulmonary artery. Inter-reviewers agreement was above 90% for 22 of the 26 anatomical criteria and adjusted kappa coefficients for each criterion demonstrated good, moderate and poor agreement for 22, 2 and 2 criteria respectively.

Our data support the hypothesis that standardized fetal anatomical examination might be achieved and reproducible using MRI even though further effort should aim at improving fetal cardiac examination.

To assess the feasibility, accuracy and reproducibility of manipulating 3-dimensional (3D) volume sets in order to reconstruct optimal 2-dimensional (2D) planes for fetal biometry throughout gestation and compare them with those derived from real time 2D scanning.

Sixty five fetuses were evaluated at a gestational age of 14-41 weeks. For each fetus a duplicate set of 7 standard fetal measurements was taken by an experienced operator using 2D ultrasound and then 19 suboptimal 3D volumes from different predefined angles were captured and stored. These were manipulated and measured. The time taken to complete a full scan, both with 2D and 3D ultrasound, was also recorded. All measurement differences were expressed as gestational age specific z scores. For all comparisons Bland-Altman plots were used and limits of agreement calculated. The means and variances of the measurements were tested with a paired t-test and Pitman's test for differences in variance respectively. The difference between the time taken to perform a 2D and a 3D scan was tested with Wilcoxon signed ranks test.

Mean agreement between 2D and 3D ultrasound measurements was good with no statistically significant differences (i.e. no systematic error) unless the head was facing anterioposteriorly, or the long axis of the femur was at 60-90⁰ to the transducer.The variance (random error) for 3D was similar to 2D. Some volumes could not be reconstructed (7% for HC, 9% for AC and 11% for FL). The median time required to perform a full fetal biometric scan was significantly higher for 3D than for 2D (3:04mins vs 1:57mins, p<0.001).

Fetal biometry measurements derived from 3D volume acquisitions exhibited good agreement with real time 2D scanning with no extra systematic or random error. However, they were slower to obtain, not all volumes could be reconstructed, and those that came from ahead facing anterioposteriorly, or with the long axis of the femur at 60-90⁰ to the transducerwere systematically smaller.

Whether the regional elastic arteries is stiffened in preeclampsia has less been investigated. This study was aimed to characterize in vivo the carotid arterial intima-media thickness (IMT) and mechanical properties in women with preeclampsia by employing a radio-frequency ultrasound technique.

Twenty-two preeclampsia women and 28 age- and gestational-week matched (36.0 ±3.2 weeks vs. 35.8±2.4 weeks, p=0.802 ) normotensive women were included. All subjects were nulliparas. The preeclampsia women had a significantly higher arterial pressure than normotensive pregnancy (p<0.0001). All women underwent common carotid artery measurements with MylabTwice ultrasound instrument (Esaote, Italy) equipped with Automatic Quality IMT (QIMT) and Quality Arterial Stiffness (QAS) packages. Carotid IMT and arterial stiffness were evaluated before in all subjects. Follow up study was performed.

Carotid IMT (459±95 µm vs. 351±85 µm, p=0.0001) , internal diameter (7.8±0.5 mm vs. 7.2±0.4 mm, p<0.0001), pulse wave velocity (7.1±1.7 m/s vs. 6.0±1.1 m/s, p=0.024), augmentation index (7.1±8.8% vs. -5.6±7.3%, p<0.0001) and carotid arterial wall tension (55.0±6.5 mmHg/cm vs. 38.6±4.9 mmHg/cm, p<0.0001) were remarkably greater, and the distensibility coefficient (0.020±0.009 1/kPa vs. 0.029±0.011 1/kPa, p=0.006) was significantly smaller in preeclampsia compared to normotensive pregnancy and remained after adjusting for BMI and carotid pressures. Eighteen months after parturition, carotid diameter, pressure and wall tension was still greater in women with history of preeclampsia.

Carotid remodeling and arterial stiffening occur in preeclampsia and and may be partially recovered postpartum. QIMT and QAS techniques together could provide a comprehensive assessment of the carotid arterial remodeling.

In fetal tachycardia pharmacologic therapy with digoxin, flecainide and sotalol has been reported to be effective. In a recent retrospective multicentre study sotalol was considered to be less effective than the others in fetal SVT. The aim of this study is to re-evaluate the efficacy and safety of maternally administered sotalol in the treatment of fetal tachycardia.

Charts of 30 consecutive referrals with M-mode echocardiographically documented fetal tachycardia were reviewed retrospectively and discussed with reports from literature.

A total of 28 patients were treated with first line sotalol (SVT: 18; AF: 10). Fetal hydrops was present in six patients (SVT: 5, AF: 1). All hydropic patients converted antenatally to sinus rhythm (SR) (67% with sotalol as a single therapy; 33% after addition of flecainide). Of the nonhydropic patients, 91% converted to SR (90% with sotalol only, 10% after addition of flecainide or digoxin). In 9% (AF) rate control was achieved. There was no mortality. No serious drug-related adverse events were observed. Postnatally, rhythm disturbances were detected in ten patients: two were still in AF. In eight SVT was observed within three weeks postnatally, five of whom within 72 hours.

Sotalol can be recommended as drug of first choice in the treatment of fetal AF and has shown to be an effective and safe first line treatment option for SVT, at least in the absence of hydrops. Postnatal maintenance therapy after successful prenatal therapy is not necessarily indicated, as the risk of recurrence is low beyond 72 hours of age.

Prospective cohort study to assess the usability of virtual-reality (VR) simulation for obstetric ultrasound trainees.

Twenty-six participants were recruited; 18 obstetric ultrasound trainees (with little formal ultrasonography training) and eight certified experts. They all performed five sequential VR-simulated crown-rump length (CRL) scans in a single session and three repetitions of bi-parietal diameter (BPD), occipito-frontal diameter (OFD), and femur length (FL). Outcome measures included mean percentage deviation from target for all measurements. Time taken to perform each type of scan was recorded.

The mean percentage difference for the first scan was significantly greater for the trainee group than for the expert group for BPD (p=0.035), OFD (p=0.010), FL (p=0.008) and for time taken for first the CRL (p<0.001) and fetal biometry scan (p=0.015), demonstrating trainees were initially significantly less accurate and less efficient. Over subsequent scans, the trainees became more accurate for all measurements with a significant improvement shown for OFD and FL (p<0.05). The time for trainees to complete CRL and fetal biometry scans decreased significantly (all p<0.05) with repetition, to near-expert efficiency.

All sonographers were able to use the simulator and produce clinically meaningful biometry results. With repetition beginners quickly approached near-expert levels of accuracy and speed. These data demonstrate that obstetricians with minimal experience can improve their ultrasonographic skills with short phase VR-simulation training. The speed of improvement suggests that VR simulation might be useful for a warm-up exercise before clinical training sessions to limit the impact of training on clinical service.

To evaluate the 2-year neurodevelopmental outcome of full-term, small-for-gestational-age (SGA) newborns with normal placental function, according to current criteria based on umbilical artery Doppler.

A cohort of consecutive full-term, SGA newborns with normal prenatal umbilical artery Doppler was compared with a group of full-term, appropriate-for-gestational-age (AGA) infants sampled from our general neonatal population. Neurodevelopmental outcome was evaluated at 24-months corrected age with the Bayley scale for infant and toddler development, third edition (Bayley-III), which evaluates cognitive, language, motor, social-emotional, and adaptive competencies. The effect of the study group on each domain was adjusted with multiple analysis of covariance and logistic regression for gestational age at delivery, socio-economic status, gender, tobacco smoking, and breastfeeding.

A total of 223 infants (111 SGA and 112 AGA) were included. The groups differed significantly on socio-economic status and gestational age at delivery. All studied neurodevelopmental domains were poorer in the SGA group, reaching significance for the cognitive (100.2 vs. 92.9, adjusted p=0.027), language (101 vs. 94.7, adjusted p=0.025), motor (100 vs. 94.2, adjusted p=0.027), and adaptive (96.5 vs. 89.2, adjusted p=0.012) scores. Likewise, the SGA group had a higher risk of low scores in language (odds ratio [OR] 2.63 adjusted p=0.045) and adaptive (OR 2.72 adjusted p=0.009) domains.

Compared to normal sized babies, full-term SGA infants, without currently used criteria defining placental insufficiency, have lower 2-year neurodevelopmental scores. These data challenge the concept that SGA fetuses with normal umbilical artery Doppler are “constitutionally small” and otherwise completely normal.

The purpose of this study was to investigate changes in human placental oxygenation during maternal hyperoxia by using the non-invasive blood oxygen level dependent (BOLD) magnetic resonance imaging (MRI) technique.

Eight healthy pregnant women in gestational week 28 to 36 were included in the study. By using a facial mask maternal hyperoxia was induced for 5 minutes. The BOLD MRI scan was performed using a 1.5 Tesla system with the following parameters: repetition time=8000 ms, echo-time=50 ms and flip angle= 90.

In the BOLD image the normoxic placenta appeared heterogeneous with darker areas located to the fetal side and brighter areas to the maternal side. During hyperoxia the placenta became brighter and the structure more homogeneous. The BOLD signal of the total placenta (ΔBOLD_tot) increased by 15.2 ± 3.2% (mean ± SD), (p<0.0001). The increase was predominantly seen in the dark areas in the fetal part of the placenta (ΔBOLD_fet) 32.1 ± 9.3% when compared to the bright areas in the maternal part (ΔBOLD_mat) 5.4 ± 3.5%.

During hyperoxia placental oxygenation was increased predominantly in the darker areas. This finding and the anatomic location of the dark placental areas suggest that the darker areas represent the fetal circulation of the placenta. To our knowledge this is the first study that successfully visualizes changes in placental oxygenation by using the BOLD MRI technique.

To examine whether the cavum septi pellucidi (CSP) is larger in second and third trimester fetuses with chromosomal abnormalities than in euploid fetuses.

Retrospective study utilizing stored 2D images of second and third trimester fetuses between 18 and 40 week’ gestation from the Department of prenatal medicine at University of Tuebingen/ Germany,from the Center for Prenatal Diagnosis and Genetics in Nuremberg/ Germany and from the ultrasound department of the Hospital Bad Canstatt, Stuttgart/ Germany. The width of the CSP was measured by placing the callipers on the inner portion of its lateral borders. Two operators measured the CSP width. Both were blinded to the fetal karyotype and to the measurements obtained by the other operator. The normal range in euploid fetuses was computed based on the BPD by applying univariate regression analysis. The CSP width in euploid and aneuploid fetuses was transformed into z-scores and compared using student's t-test. Univariate regression analysis was used to determine the dependency of the z-scores and the head biometry.

The study population consisted of 267 euploid pregnancies and 81 with trisomy 21, 50 with trisomy 18 and 8 with trisomy 13. In the euploid group, mean CSP width was 4.5(range 1.8 – 7.4) mm. Regression analysis showed a significant dependency between the CSP width and the BPD (CSP width = 0.658 + 0.064 x BDP in mm, r=0.781, p<0.0001). The 95^th centile increased from 3.2 to 7.1mm for a BPD of 40 to 100 mm. In the group of fetuses with trisomy 21, 18 and 13, mean CSP width was 5.7 (range 2.8 – 10.5) mm, 7.9 (range 3.5 – 12.8) mm and 5.8 (range 4.0 – 9.0) mm, respectively. In 42.0% of the fetuses with trisomy 21, the CSP width was above the 95^th centile. In trisomy 18 and 13, the CSP width was above the 95^th centile in 92.0% and 37.5% of the cases respectively.

A large CSP width should trigger a detailed ultrasound examination to further assess the risk for chromosomal abnormalities.

To study the relationship between abnormal vaginal flora (AVF) in the first trimester as a risk factor for shortening cervix length (CL) at second and third trimester, and to assess the combination of these factors in predicting preterm delivery.

1026 unselected low risk women seen before 16 weeks of pregnancy underwent sampling of vaginal fluid for wet mount microscopy at a central laboratory blinded to clinical data. Disappearance of lactobacilli and bacterial vaginosis (BV) were scored according to standardized definitions. Specific cultures were performed for M hominis,U urealyticum, aerobic vaginitis (AV) and vaginal colonization with Candida. CL was measured by transvaginal ultrasound at 10–14, 20-24 and at 30-34 weeks, and gestational age at delivery was recorded.

Short cervix (CL below the lower quartile) at 10–14 weeks is related to a lower CL at 20-24 and 30-34 weeks of gestation (p=0.01, p=0.005 respectively). Short cervix at 20-24 weeks, but not at 10–14 weeks, was predictive for preterm birth. In patients with M. hominis and/or with severe AV at 10–14 weeks, the cervix appeared shorter at 20–24 and at 30–34 weeks than in other women. Increased risk for preterm birth in women with a shorter cervix at 10–14 weeks and AVF could not be proved by this study.

Presence of AV or M. hominis is associated with a shorter cervix at 20–24 and 30–34 weeks. Although a short cervix at 10–14 weeks increases the likelihood of having a short cervix later in pregnancy, it was not a prerequisite for AVF to be associated with preterm delivery. Therefore, in the pathogenesis of preterm birth, certain types of AVF may be involved directly in the process of cervical shortening, rather than being exposed to the intrauterine cavity more readily by a short cervix in the early stages of pregnancy. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.

Human fetal cardiac intervention has hitherto typically involved a percutaneous transventricular approach. In fetal lambs, a transhepatic approach to access the fetal intra-abdominal veins after exteriorization of the uterus by laparotomy has been described. We aimed to develop a percutaneous transhepatic technique for catheterization of the fetal heart at mid-gestation that avoids maternal laparotomy.

In 10 fetal lambs (90–97 days' gestation), access to the fetal venous system was attempted by percutaneous puncture with a 5-F sheath into the umbilical vein (n = 1) or a 16-gauge IV-catheter into the hepatic vein (n = 9). This was followed by cardiac catheterization using a 1.8–2.6-F tapered coronary catheter. Euthanasia and postmortem examination were performed immediately postprocedure in two cases, or after normal term delivery in the remaining cases that survived the procedure.

In one case fetal position precluded procedural attempts, and in another, the fetus, accessed by a 5-F sheath, died from umbilical hemorrhage. In eight cases, access to the fetal hepatic vein was achieved. In seven of these cases, the access catheter was advanced into the inferior vena cava, followed by catheterization of the right atrium (all cases) and four cardiac chambers (three cases). One fetus died during cardiac catheterization owing to right ventricle perforation, and the other seven fetuses were alive at the end of the procedure (87.5% survival). Immediate postmortem after euthanasia in two of the fetuses that survived the procedure detected intraperitoneal bleeding (4 mL and 20 mL), while postnatal postmortem examination following uneventful delivery at term in the remaining five fetuses revealed no vascular or cardiac trauma.

Ultrasound-guided percutaneous transhepatic cardiac catheterization is feasible in mid-gestational fetal sheep. This technique has the potential for translation into human fetal cardiac and circulatory interventions. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

To define risk cut-offs with corresponding detection rates (DR) and false-positive rates (FPR) in screening for trisomy 21 using maternal age and combinations of first-trimester biomarkers in order to determine which women should undergo contingent maternal blood cell-free (cf) DNA testing.

From singleton pregnancies undergoing screening for aneuploidies at three UK hospitals between March 2006 and May 2012, we analyzed prospectively collected data on the following biomarkers: fetal nuchal translucency thickness (NT) and ductus venosus pulsatility index for veins (DV-PIV) at 11 + 0 to 13 + 6 weeks' gestation and serum free β-human chorionic gonadotropin (β-hCG), pregnancy-associated plasma protein-A (PAPP-A), placental growth factor (PlGF) and alpha-fetoprotein (AFP) at 8 + 0 to 13 + 6 weeks. Estimates of risk cut-offs, DRs and FPRs were derived for combinations of biomarkers and these were used to define the best strategy for contingent cfDNA testing.

In contingent screening, detection of 98% of fetuses with trisomy 21 at an overall invasive testing rate < 0.5% can be potentially achieved by offering cfDNA testing to about 36%, 21% and 11% of cases identified by first-line screening using the combined test alone, using the combined test with the addition of serum PlGF and AFP and using the combined test with the addition of PlGF, AFP and DV-PIV, respectively.

Effective first-trimester screening for trisomy 21, with DR of 98% and invasive testing rate < 0.5%, can be potentially achieved by contingent screening incorporating biomarkers and cfDNA testing. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To explore the feasibility of routine maternal blood cell-free (cf) DNA testing in screening for trisomies 21, 18 and 13 at 10 weeks' gestation.

In this prospective study, women attending The Fetal Medicine Centre in London, UK, between October 2012 and April 2013, with singleton pregnancy and live fetus with CRL 32–45 mm, were screened for trisomies 21, 18 and 13 by cfDNA testing at 10 weeks and the combined test at 12 weeks.

cfDNA testing was performed in 1005 singleton pregnancies with a median maternal age of 37 (range, 20–49) years. Risks for trisomies were provided for 957 (95.2%) cases and in 98.0% these were available within 14 days from sampling. In 48 (4.8%) cases no result was provided due to problems with delivery to the laboratory, low fetal fraction or assay failure. Repeat sampling was performed in 40 cases and a result obtained in 27 (67.5%) of these. In 11 cases the risk score for trisomy 21 and in five cases that for trisomy 18 was > 99%, in one the risk for trisomy 13 was 34% and in 968 the risk for each of the three trisomies was < 0.01%. The suspected trisomies were confirmed by karyotyping after chorionic villus sampling (CVS), except in one case of trisomy 18 in which the karyotype was normal. On the basis of the maternal age distribution of the study population, the expected and observed numbers for each of the three trisomies were similar. Both cfDNA and combined testing detected all trisomies, but the estimated false-positive rates (FPR) were 0.1% and 3.4%, respectively.

Routine screening for trisomies 21, 18 and 13 by cfDNA testing at 10 weeks is feasible and has a lower FPR than does combined testing, but abnormal results require confirmation by CVS. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Cardiac dysfunction is common in the recipient fetus of twin–twin transfusion syndrome (TTTS). In this study, we aimed to document the severity of fetal cardiac dysfunction in Stage IV TTTS (fetal hydrops) and assess evolution of cardiac function longitudinally after fetoscopic laser surgery.

We reviewed obstetric ultrasound examination data, pre- and postoperative echocardiograms and neonatal outcomes for 22 cases of Stage IV TTTS undergoing fetoscopic laser ablation of placental anastomoses between 1998 and 2011. Myocardial performance index, atrioventricular valve flow patterns, ventricular shortening fraction, ventricular hypertrophy, outflow tract obstruction and venous Doppler waveforms were assessed.

Nineteen fetuses (86.4%) had ascites, eight (36.4%) had pleural effusions, nine (40.9%) had a pericardial effusion and 12 (54.5%) had subcutaneous edema at presentation. Preoperatively, cardiac function was grossly abnormal in all. Eight fetuses (36.4%) had functional pulmonary atresia and one (4.5%) had functional aortic atresia. Seventy-seven percent of recipient fetuses survived until birth. Postoperative echocardiographic follow-up (mean, 26 days) showed that indices of fetal cardiac function improved considerably, but never completely normalized. Six of the eight fetuses with functional pulmonary atresia (75.0%), as well as the fetus with functional aortic atresia, survived to birth. In all cases, the functional atresia resolved within 48 h of laser ablation therapy and none had structural valve anomalies at birth. All fetal effusions resolved after the laser.

Fetoscopic laser ablation of placental anastomoses reverses cardiac dysfunction and valvulopathy, even in the most severe cases of TTTS. However, recovery takes longer than in early stage disease. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To estimate intra- and interobserver reproducibility and reliability of assessment of the color content in adnexal masses at color/power Doppler ultrasound examination for observers with different levels of experience, and to determine if they change after a consensus meeting.

Digital clips with color/power Doppler information on 103 adnexal masses were evaluated independently four times, twice before and twice after a consensus meeting, by four experienced and three less experienced ultrasound examiners. The color content of the adnexal mass was estimated using the International Ovarian Tumor Analysis color score and a 100-mm visual analog scale (VAS score). Intraobserver repeatability was estimated for each observer. Interobserver agreement was estimated for the four most experienced observers (six pairs), for the three less experienced observers (three pairs), and for four other pairs of observers, each pair consisting of one of the experienced and one of the less-experienced observers.

Intra- and interobserver agreement for the color score was moderate to very good, percentage agreement ranging from 48 to 82.5% (kappa, 0.52–0.82) before and from 59 to 90% (kappa, 0.60–0.88) after the consensus meeting. For seven of 13 pairs of observers, interobserver agreement improved after the consensus meeting. Intraobserver intraclass correlation coefficient (ICC) values for the VAS score ranged from 0.80 to 0.92 before and from 0.75 to 0.94 after the consensus meeting, but limits of agreement were wide (± 20–35 mm). For six of the seven observers the ICC values were higher after the consensus meeting than before. Interobserver ICC values for the VAS score ranged from 0.77 to 0.88 before and from 0.77 to 0.91 after the consensus meeting, but limits of agreement were wide (± 30–40 mm). For 10 of 13 pairs of observers the ICC values improved after the consensus meeting.

Intra- and interobserver agreement for the color score was good, especially after the consensus meeting, but there is room for improvement. VAS score results varied substantially within and between observers both before and after the consensus meeting. General consensus needs to be reached about how to interpret color/power Doppler ultrasound findings in adnexal masses. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

To validate the efficacy and safety of our clinical protocol for expectant management of selected women diagnosed with tubal ectopic pregnancy.

This was a prospective observational study carried out in the early pregnancy unit of a London inner-city university teaching hospital from 1^st January 2008 to 31^st May 2011. All women presenting with suspected early pregnancy complications were assessed clinically and by transvaginal ultrasound. Those with a conclusive ultrasound diagnosis of tubal ectopic pregnancy were selected for either surgical or expectant management. Selection criteria for expectant management were clinical stability with no or minimal abdominal pain, no evidence of significant hemoperitoneum on ultrasound scan, ectopic pregnancy measuring < 30 mm in mean diameter with no evidence of embryonic cardiac activity, serum β-human chorionic gonadotropin (β-hCG) < 1500 IU/L and the woman's consent. All women selected for expectant management were followed up as outpatients until the ectopic pregnancy regressed spontaneously (resolution of clinical symptoms, serum β-hCG < 20 IU/L/negative urine pregnancy test) or surgical intervention was required. We recorded the rate of interventions, complications and length of follow-up.

During the study period 339/11 520 (2.9% (95% CI, 2.59–3.21%)) women were diagnosed with tubal ectopic pregnancy. Six women opted to participate in an ongoing randomized controlled trial and were excluded from further analysis. One hundred and sixty-five (49.5% (95% CI, 44.2–55.0%)) of the 333 remaining women met the criteria for expectant management; 146/333 (43.8% (95% CI, 38.5–49.1%)) of them opted for expectant management and 104/333 (31.2% (95% CI, 26.2–36.2%)) of all tubal ectopics resolved without requiring any intervention. All women with failed expectant management were treated by laparoscopic salpingectomy/salpingotomy and none of them required a blood transfusion.

Our clinical protocol for expectant management of tubal ectopic pregnancies eliminates the need for medical or surgical treatment in more than a third of women diagnosed with tubal ectopic pregnancy with a minimum risk of adverse outcome. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Chromosomal microarray analysis (CMA) is utilized in prenatal diagnosis to detect chromosomal abnormalities not visible by conventional karyotyping. A prospective cohort of women undergoing fetal CMA and karyotyping following abnormal prenatal ultrasound findings is presented in the context of a systematic review and meta-analysis of the literature describing detection rates by CMA and karyotyping.

We performed a prospective cohort study of 243 women undergoing CMA alongside karyotyping when a structural abnormality was detected on prenatal ultrasound. A systematic review of the literature was also performed. MEDLINE (1970–Dec 2012), EMBASE (1980–Dec 2012) and CINAHL (1982–June 2012) databases were searched electronically. Selected studies included > 10 cases and prenatal CMA in addition to karyotyping. The search yielded 560 citations. Full papers were retrieved for 86, and 25 primary studies were included in the systematic review.

Our cohort study found an excess detection rate of abnormalities by CMA of 4.1% over conventional karyotyping when the clinical indication for testing was an abnormal fetal ultrasound finding; this was lower than the detection rate of 10% (95% CI, 8–13%) by meta-analysis. The rate of detection for variants of unknown significance (VOUS) was 2.1% (95% CI, 1.3–3.3%) when the indication for CMA was an abnormal scan finding. The VOUS detection rate was lower (1.4%; 95% CI, 0.5–3.7%) when any indication for prenatal CMA was meta-analyzed.

We present evidence for a higher detection rate by CMA than by karyotyping not just in the case of abnormal ultrasound findings but also in cases of other indications for invasive testing. It is likely that CMA will replace karyotyping in high-risk pregnancies. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Evidence for the role of first-trimester ultrasound in predicting outcome in twin pregnancies is conflicting. The aim of this study was to determine the association between crown–rump length (CRL) discordance and adverse perinatal outcome in twin pregnancies.

This was a retrospective study of all twin pregnancies of known chorionicity from a large regional cohort over a 10-year period. Terminations of pregnancy, cases with fetal or chromosomal abnormalities and monoamniotic pregnancies were excluded. Receiver–operating characteristics (ROC) curve and logistic regression analyses were performed to evaluate the association between CRL discordance and stillbirth, neonatal mortality, intrauterine growth restriction, preterm birth (PTB) at < 34 weeks' gestation and birth weight (BW) and ultrasound estimated fetal weight (EFW) discordance of ≥ 25%.

A total of 2155 twin pregnancies were analyzed, of which 420 were monochorionic (MC) and 1735 dichorionic (DC). There were 42 fetal losses before 24 weeks' gestation and 23 perinatal deaths. CRL discordance was poorly predictive for fetal loss at < 24 weeks (area under the ROC curve (AUC), 0.54 (95% CI, 0.46–0.62)), perinatal loss (AUC, 0.52 (95% CI, 0.41–0.64)), BW discordance (AUC, 0.61 (95% CI, 0.56–0.65)), BW < 5^th centile (AUC, 0.56 (95% CI, 0.53–0.59)), EFW discordance (AUC, 0.55 (95% CI, 0.51–0.60)) and PTB at < 34 weeks (AUC, 0.50 (95% CI, 0.47–0.54)). Overall mortality was significantly higher in MC (5.0%) than in DC (2.6%) twins (P = 0.016). Logistic regression analysis demonstrated that chorionicity (odds ratio 2.09 (95% CI, 1.06–4.10); P = 0.033) independently contributed to determining mortality, while CRL discordance (P = 0.201) did not. Adjusting for chorionicity did not improve the detection of adverse outcomes using CRL discordance.

In the absence of aneuploidy or structural fetal abnormality, CRL discordance is of poor predictive value for adverse perinatal outcome in both MC and DC twin pregnancies. CRL discordance should not be used routinely to identify twin pregnancies at high risk of adverse perinatal outcome. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To evaluate the association between first-trimester growth discordance and adverse pregnancy outcome in dichorionic twin pregnancies.

This was a retrospective cohort study of consecutive women with dichorionic twin pregnancies undergoing an ultrasound scan at our institution between 7 and 14 weeks' gestation. Study groups were defined by the presence or absence of ≥ 11% crown–rump length (CRL) discordance. Pregnancies were excluded if one twin was dead on initial ultrasound or if a termination was performed. The primary outcome was loss of one or both fetuses before 20 weeks. Secondary outcomes included fetal anomaly, fetal demise after 20 weeks (stillbirth), small-for-gestational-age (SGA) at birth, admission to the neonatal intensive care unit (NICU) and preterm delivery before 34 weeks.

Of 805 dichorionic twin pregnancies undergoing first-trimester ultrasound, 610 met the inclusion criteria. Eighty-six had ≥ 11% CRL discordance and, of these, nine (10.5%) had a fetal loss at < 20 weeks (risk ratio (RR) 7.8 (95% CI, 3.0–20.5)). In the surviving pregnancies, an increased risk of fetal anomalies was seen (27.3 vs 17.4%, RR 1.6 (95% CI, 1.1–2.4)). In surviving pregnancies unaffected by anomalies, no increased risk of stillbirth, SGA, NICU admission or delivery before 34 weeks was noted in the discordant group. A post-hoc power analysis demonstrated 80% power to detect a five-fold increase in the risk of stillbirth and 90% power to detect a two-fold increase in other outcomes.

Dichorionic pregnancies in which a CRL discordance of at least 11% is noted are at increased risk for fetal anomalies and fetal loss prior to 20 weeks' gestation. However, patients can be reassured that, in the absence of structural anomalies, CRL discordance does not appear to be associated with other adverse outcomes in continuing pregnancies, although the power to detect small increases in the risk of stillbirth may have been limited by the sample size. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

Monochorionic (MC) twins are at increased risk of early fetal loss secondary to vascular complications such as twin–twin transfusion syndrome (TTTS). This study compared the early perinatal loss rates between MC and dichorionic (DC) twins in an era of invasive treatment for TTTS.

This was a retrospective study of all twin pregnancies of known chorionicity from a large regional cohort of nine hospitals over a 10-year period. Ultrasound data were matched to hospital delivery records and to a mandatory national register of pregnancy losses. Prospective risk of pregnancy loss from 14 to 24 weeks' gestation was calculated and the survival trend of MC and DC twins was analyzed using Kaplan–Meier survival analysis.

The analysis included 3117 twin pregnancies (605 MC and 2512 DC). The total risk of early pregnancy loss (miscarriage and neonatal death) before 24 weeks was significantly higher in MC twins (60.3 per 1000 fetuses) than in DC twins (6.6 per 1000 fetuses), with a relative risk of 9.18 (95% CI, 6.0–13.9). Survival analysis showed a significant difference in overall and early mortality between MC and DC twins (log-rank test, P < 0.0001), while no difference was noted after 24 weeks' gestation (log-rank test, P = 0.08).

Early pregnancy loss is significantly more common in MC than in DC twins, but no difference in the prospective risk of mortality between MC and DC twins is evident after 24 weeks' gestation. The observed early mortality rate has almost halved in comparison with previous studies in the published literature. Early detection and prompt treatment of complications in MC twins are likely to have contributed to this improvement in outcome. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

Customized growth charts developed for singleton pregnancies have been shown to be more effective than population-based ones at identifying small-for-gestational age (SGA) fetuses at risk for intrauterine fetal death (IUFD). We sought to compare the association between SGA and IUFD in twins using customized growth charts designed for twin gestations compared to those designed for singletons.

This was a retrospective cohort study using a database including singleton and twin pregnancies undergoing ultrasound examination between 16 and 20 weeks' gestation. After excluding preterm births < 34 weeks, congenital anomalies and stillbirths, we identified 51 150 singleton births. Coefficients for significant physiological and pathological variables affecting birth weight for singletons were derived using backward stepwise multiple regression. The same process was repeated for twin births (1608 pairs), also adjusting for chorionicity. Customized growth charts for each pregnancy were derived using these two regression models for optimal birth weight at term and a proportionality equation. The association between SGA < 10^th percentile, defined using the twin and singleton-customized charts, and IUFD were compared. Statistical analysis, including calculation of adjusted odds ratios (OR) for IUFD and screening accuracy using each chart, was performed.

The derived coefficients for optimal birth weight for twins were different from those for singletons, with lower constants and root mean square error (3422 and 288.9, respectively, in twins vs 3543 and 416 in singletons). Among 3786 twin infants, IUFD was seen in 123 (3.2%). The numbers of fetuses identified as SGA were 575 (15.2%) and 504 (13.3%) by the singleton and twin charts, respectively. Fetuses classified as SGA by the twin-specific customized charts were at a significantly increased risk for IUFD (adjusted OR, 2.3 (95%CI, 1.4–3.5)), whereas those classified as SGA by the singleton-customized charts were not (adjusted OR, 1.2 (95% CI, 0.7–2.0)).

Customized charts designed specifically for twins are more effective at identifying twin pregnancies at risk for IUFD than are those derived using singleton birth data. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

The degree of actual intertwin birth weight (BW) or ultrasound estimated fetal weight (EFW) discordance that justifies elective delivery is yet to be established. The main aim of this study was to ascertain the performance of BW and ultrasound EFW discordance in the prediction of perinatal loss in twin pregnancies.

This was a retrospective study of all twin pregnancy births from a large regional cohort of nine hospitals over a 10-year period. Intertwin BW and ultrasound EFW discordance were analyzed in relation to the occurrence of stillbirth or neonatal death of one or both twins from 26 weeks' gestation as obtained from a mandatory national register. Receiver–operating characteristics (ROC), survival and logistic regression analyses were performed to evaluate the contribution of weight discordance in determining perinatal loss.

A total of 2161 twin pregnancies were included in the analysis. The area under the ROC curve for the prediction of perinatal loss was similar for BW and ultrasound EFW discordance (P = 0.62). Kaplan–Meier analysis showed that twins with BW or EFW of ≥ 25% discordance had a significantly lower survival trend than did those with lesser degrees of discordance (P < 0.001). The hazard ratios for the risk of total perinatal loss in twins with a BW or EFW discordance of ≥ 25% were 7.29 (95% CI, 4.37–12.00) and 7.28 (95% CI, 4.46–11.92), respectively. Logistic regression analysis demonstrated that BW discordance and gestational age, but not chorionicity or individual fetal size percentile, were independently associated with perinatal mortality.

An EFW discordance of ≥ 25% represents the optimal cut-off for the prediction of stillbirth and neonatal mortality irrespective of chorionicity or individual fetal size. A policy of increased fetal surveillance commencing from 26 weeks' gestation might be reasonable for pregnancies beyond this cut-off, but this would require confirmation in large-scale prospective trials. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To establish gestational age-specific reference ranges for amniotic fluid measurements in monochorionic diamniotic twin pregnancies, to compare them with previously reported singleton and twin reference ranges and to examine the rationale for using a gestational age-dependent cut-off to define polyhydramnios in twin–twin transfusion syndrome, as is the practice in most European centers.

We retrospectively evaluated amniotic fluid volume in 32 monochorionic diamniotic twin pregnancies that were followed longitudinally at 2-week intervals from the first trimester until birth. Amniotic fluid volume was assessed by measuring the deepest vertical pocket in both amniotic sacs. We used multilevel modeling to estimate the gestational age-specific reference ranges for deepest vertical pocket measurements.

Based on 429 observations in 64 fetuses, we constructed gestational age-specific reference ranges from 11 weeks until term. The deepest pocket increased from the first trimester to reach a maximum at 26 weeks, followed by a gradual decrease towards term. Measurements between 18 and 28 weeks were comparable to those in singleton pregnancies. However, before 18 weeks values were higher, whereas after 28 weeks they were lower, as compared to singleton references.

In monochorionic twin pregnancies, the deepest vertical pocket is a gestational age-dependent measurement. Therefore, a gestational age-dependent definition of polyhydramnios in twin–twin transfusion syndrome, as used by most European centers, seems a logical approach. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To evaluate the incidence and risk factors of adverse perinatal outcome in complicated monochorionic twin pregnancies treated with selective feticide.

This was a retrospective analysis of prospectively collected data from a consecutive, national cohort. All monochorionic twin pregnancies treated with selective feticide at Leiden University Medical Center between June 2000 and November 2011 were included. Obstetric and neonatal data were recorded. The primary outcome measure was adverse perinatal outcome, including fetal or neonatal demise or severe neonatal morbidity.

Data on perinatal outcome were obtained in all cases (n = 131). Overall perinatal survival rate was 67.2% (88/131). Median gestational age at delivery was 34 (interquartile range, 23–38) weeks. Neonatal mortality and morbidity rate in liveborn children was 4.3% (4/92) and 12.0 % (11/92), respectively. Severe cerebral injury was detected in three children. The overall incidence of adverse perinatal outcome was 41.2% (54/131). Median gestational age at occurrence of preterm prelabor rupture of membranes (PPROM) was 19.0 weeks and 32.0 weeks in cases with and without adverse perinatal outcome, respectively (P = 0.017). Liveborn children with adverse perinatal outcome were born at a lower median gestational age (29.0 weeks) than were children without adverse perinatal outcome (38.0 weeks) (P < 0.001).

The risk of adverse perinatal outcome after selective feticide is high and associated with low gestational age at occurrence of PPROM and low gestational age at delivery. Long-term follow-up to assess neurodevelopmental outcome in survivors is required. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To evaluate maternal left ventricular (LV) systolic and diastolic function during normal pregnancy by non-invasive measures of LV contractility incorporating loading conditions.

Sixty-five women were examined using echocardiography, including tissue Doppler and two-dimensional speckle tracking, and subclavian artery pulse trace recordings at gestational weeks 14–16, 22–24 and 36, and at 6 months postpartum.

The mean ± SD age of the women was 32.0 ± 4.6 years. Cardiac output and LV end-diastolic volume were on average 20% and 23% higher, respectively, during pregnancy, compared to that at 6 months postpartum (both, P < 0.01). LV ejection fraction, global peak systolic strain and rate-corrected LV velocity of circumferential fiber shortening (Vcfc) were 11%, 6% and 6% lower, respectively, at 36 weeks' gestation compared to at 6 months postpartum (all, P < 0.01). Afterload, measured as LV end-systolic wall stress (ESWS) increased by 10% between 14–16 and 36 weeks' gestation (P < 0.01). Analysis of the relationship between Vcfc and ESWS revealed that LV contractility was lower during pregnancy than at 6 months postpartum. Changes in diastolic function were demonstrated by 11% lower mitral early diastolic (E) wave velocity, 8% lower tissue Doppler early diastolic velocity (e′) and 13% higher left atrial area (all P < 0.01) during pregnancy. Tissue Doppler E/e′ remained unaltered (P = 0.78).

During normal pregnancy, LV contractility is lower than it is at 6 months postpartum. This is associated with increased LV and left atrial area, whereas filling pressures are unchanged. These findings suggest that pregnancy exerts a larger load on the cardiovascular system than previously assumed. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

To investigate the ‘I-shaped’ sign as a novel echocardiographic marker for antenatal diagnosis of d-transposition of the great arteries (dTGA) in routine cardiac examination, and to compare its prevalence in fetuses with dTGA, those with other congenital heart diseases (CHDs) and those with normal structural hearts.

This retrospective evaluation involved 1134 fetuses undergoing echocardiography to screen for CHD over a 4-year period. I-shaped sign was defined as the characteristic appearance of the aortic arch, resembling the letter ‘I’, from the most anterior to the most posterior point of the descending aorta visible in the three vessels and trachea view. The frequency of this sign was evaluated in cases with dTGA, those with other cardiac defects and those with normal cardiac structures.

CHD was diagnosed in 671 (59.1%) cases, of which 31 (4.6%) had dTGA. I-shaped sign was observed in 30/31 (96.8%) cases of dTGA, compared with 31/640 (4.8%) cases with other cardiac anomalies, which included single ventricle with pulmonary atresia or severe pulmonary stenosis, hypoplastic left heart syndrome with aortic atresia, corrected transposition of the great arteries, and double outlet right ventricle with malposition of the great arteries. I-shaped sign was detected significantly more frequently in the dTGA group compared with the normal group and with the other CHDs group (both P < 0.001) and had 96.8% sensitivity and 97.1% specificity for diagnosis of dTGA. Importantly, I-shaped sign was never observed in fetuses with structurally normal hearts.

Detection on echocardiography of an extremely long vessel with a marked I-shape should raise suspicion of cardiac anomaly, especially dTGA. This marker may therefore aid in the prenatal diagnosis of dTGA during routine ultrasound examination. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

To develop a model to predict the success of a trial of vaginal birth after Cesarean section (VBAC) based on sonographic measurements of Cesarean section (CS) scar features, demographic variables and previous obstetric history.

We used transvaginal sonography (TVS) to examine the CS scar of 320 consecutive pregnant women. TVS was carried out at 11–13, 19–21 and 34–36 weeks' gestation and prospective measurements of the scar were recorded at each visit according to a defined protocol. A logistic regression model to predict success of VBAC was developed for those patients with a visible scar on ultrasound and only one previous CS. The model was evaluated using bootstrap validation.

There were 131 women with one previous CS and a visible scar, of whom 10 underwent CS prior to labor and were excluded from analysis. Successful VBAC was achieved in 74/121 (61%) of the remaining cases. The prediction model developed was based on patient age, previous history of VBAC, residual myometrial thickness (RMT) and the change in RMT from the first to the second trimester (ΔRMT). The internally validated area under the receiver–operating characteristics curve was 0.62 when measurements of RMT and ΔRMT were excluded, but 0.94 when scar information was incorporated into the model.

Ultrasound measurements of CS scar, namely RMT and the change in RMT from the first to the second trimester of pregnancy, when incorporated into a mathematical model, can predict accurately a successful trial of labor in patients with one previous CS. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To investigate clinical features and ultrasound findings in cases of placental site trophoblastic tumor (PSTT).

Fourteen cases of PSTT treated at our institution between May 2004 and October 2010 were identified and the clinical features and findings on transvaginal sonography (TVS) were investigated. Pathological confirmation of PSTT was obtained in all cases.

The most frequent symptoms associated with PSTT were abnormal vaginal bleeding, which was present in 11 cases, and amenorrhea, which was present in five cases. The interval from antecedent pregnancy to diagnosis was 4–36 (median, 12.5) months. Blood serum was positive for beta-human chorionic gonadotropin (β-hCG) at the time of ultrasound examination, although the level was generally low, with a median of 166.2 IU/L (range, 4.5–3480.2). Sonographic presentation of PSTT was classified into one of three types according to the characteristics observed on TVS: Type I, heterogeneous solid mass in the uterine cavity (four cases), with minimal to a moderate degree of vascularization on color Doppler imaging; Type II, heterogeneous solid mass in the myometrium (six cases), with minimal to a high degree of vascularization (only one case was highly vascularized); and Type III, cystic lesions in the myometrium (four cases) with a high degree of vascularization (lacunar-type lesions).

Combined with clinical features, characteristics demonstrated by TVS provide evidence for the suspicion of PSTT and could contribute to clinical decision making. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

To evaluate preoperative real-time dynamic transvaginal sonography (TVS) in the prediction of pouch of Douglas (POD) obliteration in women undergoing laparoscopy for suspected endometriosis.

This was a multicenter prospective observational study undertaken from January 2009 to November 2011. All women with symptoms suggestive of endometriosis who were scheduled for laparoscopy underwent detailed preoperative TVS, in particular to ascertain whether the POD was obliterated. POD obliteration was assessed using a real-time TVS technique called the ‘sliding sign’. Preoperative TVS sliding sign findings were then compared to gold standard laparoscopic POD findings.

One hundred consecutive women with preoperative TVS and laparoscopic outcomes were included in the final analysis. Mean age was 32.8 years and mean age at diagnosis of endometriosis was 27.4 years. At laparoscopy, 84/100 (84%) were found to have some form of endometriosis (73% peritoneal endometriosis, 35% ovarian endometrioma(s), 33% deep infiltrating endometriosis). At laparoscopy, 30/100 (30%) had an obliterated POD and 19/30 (63.3%) of these women also had evidence of bowel endometriosis. The sonographic sliding sign technique had an accuracy of 93.0%, sensitivity of 83.3%, specificity of 97.1%, positive predictive value of 92.6%, negative predictive value of 93.2%, positive likelihood ratio of 29.2 and negative likelihood ratio of 0.17 in the prediction of POD obliteration (P = 1.8E−16).

Preoperative real-time dynamic TVS evaluation using the sliding sign seems to establish with a high degree of certainty whether the POD is obliterated. Given the increased risk of deep infiltrating endometriosis in women with POD obliteration, the TVS sliding sign technique may also be useful in the identification of women who may be at a higher risk for bowel endometriosis. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

To evaluate whether the presence of uterorectal adhesions demonstrated by transvaginal sonography (TVS) could aid as a simple sonographic predictor for deep infiltrating endometriosis (DIE) of the rectum in patients with symptoms suggestive of endometriosis.

This was a prospective multicenter study of women scheduled for laparoscopy because of symptoms suggestive of endometriosis. Patients were assessed prospectively using TVS before laparoscopy and radical resection of disease followed by histological confirmation. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, accuracy and positive (LR+) and negative (LR−) likelihood ratios were calculated for the observation of a negative uterine ‘sliding sign’ on TVS in predicting the presence of DIE of the rectum.

In total, 117 patients underwent laparoscopy and resection. Thirty-four (29%) patients had DIE of the rectum. A negative sliding sign on TVS predicted DIE of rectum with a sensitivity of 85%, specificity of 96%, PPV of 91%, NPV of 94%, accuracy of 93.1%, LR + of 23.6 and LR– of 0.15.

Sonographic demonstration of uterorectal adhesions reflected by a negative uterine sliding sign is an easy and practical method for prediction of the presence of DIE involving the rectum. This could be a valuable ‘red flag’ sign for triaging patients to tertiary referral centers and specialized clinics for detailed investigation. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

To investigate the feasibility of identifying pelvic segments of normal ureters and measuring their size on standard transvaginal ultrasound examination.

This was a prospective observational study from June to July 2012. All women in the study underwent a transvaginal ultrasound examination performed for various indications either by an expert or by an intermediate-level operator. A standardized assessment of the pelvic organs was performed, recording any congenital or acquired uterine pathology and ovarian abnormalities. Visualization of pelvic segments of both ureters was attempted in all cases. The success in finding the ureters, the time required to identify them and their dimensions at rest and while exhibiting peristalsis were all recorded.

A total of 245 consecutive women were included in the study. In all women at least one ureter was successfully identified. Both ureters were seen in 227 women (92.7% (95% CI, 89.4–96.0%)). In 17 (6.9% (95% CI, 3.7–10.1%)) the left ureter was not seen and in one woman (0.4% (95% CI, 0.0–1.2%)) the right ureter could not be visualized (P < 0.001). There were no significant differences in the median time required to visualize the right and left ureters (9.0 (interquartile range (IQR), 6.0–14.0) s vs 8.0 (IQR, 6.0 –14.0) s, respectively; P = 0.9). The median diameter of the right ureter was 1.7 (IQR, 1.4–2.2) mm at rest and 2.9 (IQR, 2.4–3.6) mm during peristalsis. The median diameter of the left ureter was 1.9 (IQR, 1.6–2.3) mm at rest and 2.9 (IQR, 2.4–3.6) mm during peristalsis.

Pelvic segments of normal ureters can be identified in most women on transvaginal ultrasound examination. Visualization of the ureters could be integrated into the routine pelvic ultrasound examination, particularly in women presenting with pelvic pain or in those with suspected pelvic endometriosis. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.