Antenatal Imaging Research Articles

Placental Changes in Perinatal DeathAn Observational Study from a Tertiary Care Centre in North Karnataka

Introduction: Placenta is poetically described as a diary which bears the events of intrauterine life; hence examining them, especially in perinatal death can provide valuable information regarding the cause of death and sometimes gives an idea about recurrence of such events. Aim: To describe the various placental lesions in perinatal death and compare them with equal number of normal placentae. Materials and Methods: This prospective, comparative, crosssectional study was conducted in tertiary care centre, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India. All placentae, irrespective of the gestational age, received in the Department of Pathology, from October 1st 2017 to March 31st 2019 were collected after taking an informed consent. A total of 539 cases were received in this time frame, of which 121 (22.45%) were dead and included in the study and were compared with 121 normal placentae (alive), without any maternal co-morbidities. The placentae were grossed and assessed according to Amsterdam guidelines. The significance of the difference observed was established by Chi-square test using Statistical Package for Social Sciences software (SPSS) version 21.0. Results: Of these 121 cases, 89 (73.5%) cases had placental changes, whereas 32 (26.5%) cases were devoid of placental changes. Placental infarct and increased syncytial knots were seen contributing maximum to foetal death in 31 (25.6%) cases followed by chorioamnionitis. Rare cases like Twin Reversed Arterial Perfusion (TRAP) syndrome, Persistent Right Umbilical Vein (PRUV), maternal floor infarct were also reported. Conclusion: Despite many antenatal imaging advances, placental examination still remains valuable in diagnosing cause of death and growth restriction in the foetus especially recurrent causes, favouring clinical intervention in those cases.

Management of Abdominal Pregnancy

<h3>Study Objective</h3> Abdominal pregnancy (AP) accounts for 1-2% of all extrauterine gestations and is associated with 80% perinatal mortality. Despite advancements in antenatal care and imaging, the standard management protocol for AP is not yet established. In this series, we report two cases of interval surgical management of AP following medical treatment. <h3>Design</h3> Case Series. <h3>Setting</h3> Academic institution. <h3>Patients or Participants</h3> Two patients. <h3>Interventions</h3> Pregnancy interruption medically and subsequent surgical removal. <h3>Measurements and Main Results</h3> Case 1 33-year-old P0 with history of uterine fibroids presents with abdominal pain. Imaging demonstrated a 12-week fetus in the rectouterine space. Fetal intracardiac KCl and intra-sac methotrexate were administered with a plan for close outpatient follow up. She re-presented with severe sepsis and underwent emergent surgery for pelvic abscesses. Case 2 37-year-old P0010 with a prior abdominal myomectomy at 13-weeks' gestation presented for scheduled antenatal ultrasound. AP was identified on the posterior uterine wall. Fetal intracranial digoxin was administered and the patient was followed with serial beta-human chorionic gonadotropin (bHCG). bHCG remained persistently elevated for 6 months and underwent robotic-assisted laparoscopic removal of products of conception. <h3>Conclusion</h3> Abdominal pregnancy is a rare and complex entity which encompasses a broad spectrum of clinical presentations. There is a range of methods described to manage AP with the majority of cases managed by primary surgical intervention. In this series, our cases of AP were initially managed medically, with planned interval surgery in order to decrease morbidity of primary surgical intervention. Possible complications related to AP include intra-abdominal hemorrhage, sepsis, and persistent products of conception. Currently, a consensus regarding the management of AP and related complications does not exist. We recommend a high clinical suspicion, multidisciplinary approach, and strict follow-up in order to optimize maternal outcomes.

Impact of COVID- 19 on continuity of essential health services in various health care institutions in district Amritsar, Punjab, India

From a point in time where the human race declared itself the master of the universe to this point in time where it is facing an existential threat from the contagion- Covid 19 pandemic has exposed the vulnerability of the human race to a wipeout. The disruption of physical, mental, social, emotional and financial health and health systems is unprecedented. Study the impact of Covid 19 on continuity of essential health services in various health care institutions in district Amritsar, Punjab.: Online survey was conducted through google forms using questionnaire adapted from the World Health Organization-Pulse Survey on Continuity of Essential Health Services during Covid 19 pandemic. Respondents were personnel working at public and Ayushman Bharat empaneled private health care institutions. Response rate was 60% (55 out of 92 health care institutions personnel responded) A highly significant difference was observed between the public and the private health care sector in provision of antenatal care (Mann Whitney U statistic= 78.00, p=.004) and imaging and radio diagnosing services (Mann Whitney U statistic= 48.00, p=.000) while a significant difference was observed in provision of service of institutional delivery (Mann Whitney U statistic= 112.00, p=.046). All the other essential health services were similarly affected in the public and private health sector institutes. Financial difficulties faced during the lockdown was the single most common reason stated for disruption of essential health services. There was a significant difference in level of satisfaction experienced by health care personnel from public and private sector (Mann Whitney U statistic= 94.00, p=.02). Thematic analysis of the data on improving preparedness to minimize disruption in essential health services yielded the themes pertaining to creating a robust public health care infrastructure including use of e-health technology in the district and recruitment of adequate health care man power according to set norms.

Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses

PurposeTo investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. Study designA retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. ResultsAntenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d – 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. ConclusionThis series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.

CSF shunting in myelomeningocele-related hydrocephalus and the role of prenatal imaging.

Hydrocephalus is commonly associated with myelomeningocele (MMC). Indication and timing of cerebrospinal fluid (CSF) shunting are still a topic of discussion. The aim of this study was to investigate whether the analysis of prenatal cerebral imaging studies could provide information that is predictive of the necessity of CSF shunting in the postnatal period. Among 73 infants operated on because of MMC between January 2003 and June 2020, 50 had undergone prenatal and postnatal MRI studies and were considered for analysis. For each patient, frontal horn width, atrial ventricle diameter, third ventricle diameter, and subarachnoid spaces (sinocortical width, craniocortical width, and the interhemispheric width) have been measured on prenatal, postnatal, and a follow-up MRI study. The need of CSF shunting device placement in relation to prenatal and early postnatal MRI data was investigated. Of the 50 infants, 31 (62%) developed a progressive hydrocephalus. Of these, 30 needed a CSF shunt and the majority of them (n=29) was operated on within 28 days after birth. One patient needed CSF shunt implantation at 45 days after birth and one child developed a late progressive hydrocephalus, successfully treated by ETV alone, at 14.2 months of age. All patients with an atrial ventricle diameter greater than 1.9 cm and a 3rd ventricle diameter larger than 0.3 cm on antenatal third trimester imaging have undergone CSF shunting within 1 month after birth. Conversely, all the children that did not undergo a CSF shunt placement showed an atrial cerebral ventricle diameter inferior to 1.2 cm and a 3rd ventricle width < 0.3 cm on antenatal imaging. Frontal horn width and subarachnoid CSF spaces' evolution did not seem to play a role. The prenatal MRI assessment of the associated prenatal ventriculomegaly in MMC provides parameters that have a predictive value heralding the probability of a CSF diversion procedure after birth. In the same way, the analysis of intrauterine MRI studies may identify those subjects that are less at risk of developing a progressive hydrocephalus after birth, therefore encouraging a more cautious attitude towards the early implantation of CSF shunting devices in the current clinical practice.

Maternal and fetal incidental findings on antenatal magnetic resonance imaging

BackgroundMagnetic resonance imaging (MRI) examinations are increasingly used in antenatal clinical practice. Incidental findings are a recognized association with imaging and although in some circumstances their identification can alter management, they are often associated with increased anxiety, for both patient and clinician, as well as increased health care costs.ObjectiveThis study aimed to evaluate the incidence of unexpected findings in both the mother and fetus during antenatal MRI examinations.Materials and methodsA retrospective study was undertaken over a five-year period at St.. Thomas’ Hospital in London. Maternal incidental findings were recorded from all clinical reports of all fetal MRIs performed (for clinical reasons and in healthy volunteers) during this period. Fetal incidental findings were recorded only in cases where women with uncomplicated pregnancies were participating as healthy volunteers.ResultsA total of 2,569 MRIs were included; 17% of women had maternal incidental findings. Of these, 1,099 were women with uncomplicated pregnancies who undertook research MRIs as healthy volunteers; fetal incidental findings were identified in 12.3%.ConclusionIncidental findings are a common occurrence in antenatal MRI. Consideration should be given to counseling women appropriately before imaging and ensuring that robust local protocols are in place for follow-up and further management of such cases.

Prenatal diagnosis of Meier-Gorlin syndrome 7: a case presentation

BackgroundMeier-Gorlin syndrome 7 (MGS7) is a rare autosomal recessive condition. We reported a fetus diagnosed with Meier-Gorlin syndrome 7. The antenatal sonographic images were presented, and compound heterozygous mutations of CDC45 on chromosome 22 were identified by whole-exome sequencing (WES).Case presentationFetal growth restriction (FGR), craniosynostosis, and brachydactyly of right thumb were found in a fetus of 28th gestational weeks. The fetus was diagnosed as MGS7 clinically. After extensive counseling, the couple opted for prenatal diagnosis by cordocentesis and termination of pregnancy. Karyotype analysis and WES were performed. Chromosomal karyotyping showed that the fetus was 46, XY. There were 2 mutations of CDC45, the causal gene of MGS7 on chromosome 22, which were inherited from the couple respectively were identified by WES. Facial dysmorphism, brachydactyly of right thumb, and genitalia abnormally were proved by postpartum autopsy, and craniosynostosis was confirmed by three-dimensional computed tomography (3D-CT) reconstruction.ConclusionsIt is possible to detect multiple clinical features of Meier-Gorlin syndrome in prenatal sonography. Deteriorative FGR complicated with craniosynostosis indicates MGS7. Combination of 2D and 3D ultrasonography helps to detect craniosynostosis. The affected fetus was confirmed a compound heterozygote of CDC45 related MGS by whole-exome sequencing, which is critical in identifying rare genetic diseases.

Outcome of fetuses with congenital cytomegalovirus infection and normal ultrasound at diagnosis: systematic review and meta-analysis.

To report the outcome of fetuses with congenital cytomegalovirus (CMV) infection and normal ultrasound at the time of diagnosis, and to evaluate the rate of an additional anomaly detected only on magnetic resonance imaging (MRI). Medline, EMBASE, CINAHL and Cochrane databases were searched for studies reporting on the outcome of fetuses with congenital CMV infection. Inclusion criteria were fetuses with confirmed CMV infection and normal ultrasound assessment at the time of the initial evaluation. The outcomes observed were an anomaly detected on a follow-up ultrasound scan, an anomaly detected on prenatal MRI but missed on ultrasound, an anomaly detected on postnatal assessment but missed prenatally, perinatal mortality, symptomatic infection at birth, neurodevelopmental outcome and hearing and visual deficits. Neurodevelopmental outcome was assessed only in cases of isolated CMV infection confirmed at birth. Subgroup analysis was performed according to the trimester in which maternal infection occurred. Random-effects meta-analysis of proportions was used to analyze the data. Twenty-six studies were included, comprising 2603 fetuses with congenital CMV infection, of which 1178 (45.3%) had normal ultrasound at the time of diagnosis and were included in the analysis. The overall rate of an associated central nervous system (CNS) anomaly detected on a follow-up ultrasound scan was 4.4% (95% CI, 1.4-8.8%) (32/523; 15 studies), while the rates of those detected exclusively on prenatal MRI or on postnatal imaging were 5.8% (95% CI, 1.9-11.5%) (19/357; 11 studies) and 3.2% (95% CI, 0.3-9.0%) (50/660; 17 studies), respectively. The rate of an associated extra-CNS anomaly detected on a follow-up ultrasound scan was 2.9% (95% CI, 0.8-6.3%) (19/523; 15 studies), while the rates of those detected exclusively on MRI or on postnatal imaging were 0% (95% CI, 0.0-1.7%) (0/357; 11 studies) and 0.9% (95% CI, 0.3-1.8%) (4/660; 17 studies), respectively. Intrauterine death and perinatal death each occurred in 0.7% (95% CI, 0.3-1.4%) (2/824; 23 studies) of cases. In cases without an associated anomaly detected pre- or postnatally, symptomatic infection was found in 1.5% (95% CI, 0.7-2.7%) (6/548; 19 studies) of infants, the overall rate of a neurodevelopmental anomaly was 3.1% (95% CI, 1.6-5.1%) (16/550; 19 studies), and hearing problems affected 6.5% (95% CI, 3.8-10.0%) (36/550; 19 studies) of children. Subanalyses according to the trimester in which maternal infection occurred were affected by the very small number of included cases and lack of comparison of the observed outcomes in the original studies. Compared with fetuses infected in the second or third trimester, those infected in the first trimester had a relatively higher risk of having an additional anomaly detected on follow-up ultrasound or MRI, abnormal neurodevelopmental outcome and hearing problems. In fetuses with congenital CMV infection in which no anomalies are detected on prenatal ultrasound or MRI, the risk of adverse postnatal outcome is lower than that reported previously in the published literature when not considering the role of antenatal imaging assessment. The results from this review also highlight the potential role of MRI, even in fetuses with no anomalies detected on ultrasound, as an anomaly can be detected exclusively on MRI in about 6% of cases. The findings from this study could enhance prenatal counseling of pregnancies with congenital CMV infection with normal prenatal imaging. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Performance of antenatal imaging to predict placenta accreta spectrum degree of severity.

ABSTRACTIntroductionIn cases of placenta accreta spectrum, a precise antenatal diagnosis of the suspected degree of invasion is essential for the planning of individual management strategies at delivery. The aim of this work was to evaluate the respective performances of ultrasonography and magnetic resonance imaging for the antenatal assessment of the severity of placenta accreta spectrum disorders included in the database. The secondary objective was to identify descriptors related to the severity of placenta accreta spectrum disorders.Material and methodsAll the cases included in the database for which antenatal imaging data were available were analyzed. The rates of occurrence of each ultrasound and magnetic resonance imaging descriptor were reported and compared between the Group “Accreta‐Increta” (FIGO grades 1 & 2) and the Group “Percreta” (FIGO grade 3).ResultsAntenatal imaging data were available for 347 women (347/442, 78.5%), of which 105 were included in the Group “Accreta – Increta” (105/347, 30.2%) and 213 (213/347, 61.4%) in the Group “Percreta”. Magnetic resonance imaging was performed in addition to ultrasound in 135 women (135/347, 38.9%). After adjustment for all ultrasound descriptors in multivariate analysis, only the presence of a bladder wall interruption was associated with a significant higher risk of percreta (Odds ratio 3.23, Confidence interval 1.33–7.79). No magnetic resonance imaging sign was significantly correlated with the degree of severity.ConclusionsThe performance of ultrasound and magnetic resonance imaging to discriminate mild from severe placenta accreta spectrum disorders is very poor. To date, the benefit of additional magnetic resonance imaging has not been demonstrated.

When a rare condition creates a scientific society: The history of the International Society for Placenta Accreta Spectrum (IS-PAS).

Almost 10years ago, clinicians at multiple locations all over Europe observed an increased number of antenatally undiagnosed cases of placenta accreta spectrum (PAS) resulting in significant morbidity and the occasional maternal death. Even with an improvement in antenatal imaging, the management of severe PAS remains challenging. One solution to improve understanding in rare but potentially lethal conditions is international collaboration. Consequently, a European working group was formed, which over the next few years grew into an international society, the IS-PAS. The collective goals are to develop a large shared database of cases, generate high-quality research into all aspects of PAS, and improve education of both healthcare professionals and patients. The first results of this collaboration are presented within this supplement.

646 Characterizing placenta accreta spectrum in patients without prior cesarean delivery

Placenta accreta spectrum (PAS) is a disease of abnormal placentation that often necessitates hysterectomy at the time of delivery. Suspicion for PAS is informed by a combination of sonographic markers and patient history, most notably a prior cesarean section (CS). The a priori risk of PAS in a patient without prior CS is extremely low and not well described in the literature. Our aim is to evaluate differences in patient risk factors, ultrasound findings and outcomes in those with confirmed PAS with and without a prior CS. This retrospective cohort study included all subjects who underwent a cesarean hysterectomy for histologically confirmed PAS at a single academic institution between 2011 and 2020. Antenatal ultrasound images were reviewed in a blinded fashion for 8 placental findings. Perinatal and delivery outcomes were abstracted. Subjects with a prior CS were compared to those without prior CS. Our primary outcome was 3 or more placental findings concerning for PAS on antenatal ultrasound. Outcomes were compared using univariate and bivariate analyses. Of the 91 subjects who underwent a cesarean hysterectomy for PAS, 9 had no history of prior CS. Those without a prior CS had fewer ultrasound findings compared to those with a prior CS (3 or more ultrasound findings: 22% vs 81%, p=0.001). Those without a prior CS had less depth of invasion on pathology, delivered at a later gestational age, had shorter hospital stays and were less likely to require Gyn Oncology or Urology involvement (all p<0.05). Transfusion rates were similar, however the amount of blood products required was significantly lower for those without a prior CS (p<0.05 for pRBC, FFP and platelets). PAS without prior CS is characterized by fewer ultrasound findings making it a challenging diagnosis antenatally. Despite this, outcomes for this group of patients tend to be more favorable, possibly due to the lesser degree of placental invasion. Further research comparing differences between those with and without prior CS may help to describe different subtypes of PAS.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Size and Volume Charts for Fetal Adrenal Gland: A Prospective Study in Indian Population

AbstractThe fetal adrenal gland plays a pivotal role in perinatal survival. Because imaging the fetal adrenal gland is not part of routine antenatal ultrasonography (US), there is a paucity of available data about imaging techniques. The purpose of this study was to construct gestational age-wise data for fetal adrenal gland size and volume (2D US measurements) for 20, 21, 22 and 32 weeks of gestation and define a technique to measure the gland ultrasonographically. One year prospective study, at a single centre. 87 consecutive pregnant women with uncomplicated singleton pregnancy were included. Exclusion criteria were multiple pregnancy, maternal complications, congenital anomalies or fetal growth abnormality and a previous child suffering with Congenital Adrenal Hyperplasia (CAH). All measurements were made in 2 dimensional ultrasonography. In coronal sections of the fetal abdomen, fetal adrenal glands were identified just above the upper pole of the kidney to measure length and breadth. With the fetal spine in an anterior position, fetal adrenals were identified on either side of the spine and the width was measured. The gestational age included was 20, 21, 22 and 32 weeks. Both fetal adrenal glands could be visualised and identified in all cases (100%). Length, breadth, width and volume of both the glands for the above gestational ages with 95% confidence limit have been calculated. Antenatal imaging of the fetal adrenal gland can be done by 2D US if indicated.

VP38.11: Antenatal magnetic resonance imaging of fetal skeletal system

VP38.11: Antenatal magnetic resonance imaging of fetal skeletal system

VP32.01: Raine syndrome: case report and literature review of different antenatal imaging modalities

VP32.01: Raine syndrome: case report and literature review of different antenatal imaging modalities

VP45.15: Impact of intensive care considerations on maternal and neonatal complications of COVID‐19 in pregnancy

We present a case of a COVID-19-positive grand multiparous woman at 29 weeks gestation with rapid development of acute respiratory distress syndrome needing direct admission from A&E to intensive care unit. SARS-CoV2 is a new strain of coronavirus causing COVID-19 infection and was declared a global pandemic by WHO in March 2020. Although pregnant women do not appear more susceptible to the infection than the general population, pregnancy alters the immune system and response to viral infections can cause more severe symptoms. In our case, the woman had no pre-existing medical problems but deteriorated rapidly with ARDS from admission and later developed posterior reversible encephalopathy syndrome (PRES). The case highlights the unique physiological, ethical and intensive care management considerations and dilemmas in the care of the critically ill pregnant women with COVID-19 in the antenatal, intrapartum and postnatal periods. It also underlines the importance of multidisciplinary involvement in managing these cases with emphasis on the physiological maternal adaptations that the obstetricians are more familiar with than the intensive care teams. This is important in deciding the timing of delivery. In this case, the neonate tested negative for COVID-19. Though the neonate had normal antenatal imaging at 20 weeks, the baby developed hydrocephalus with dilatation of the lateral and third ventricles and extensive periventricular white matter cavitation in three weeks.

A donor twin discordant with Peters anomaly in a twin\u2013twin transfusion syndrome case: a case report

BackgroundPeters anomaly is a rare form of anterior segment ocular dysgenesis, the antenatal image of Peters anomaly had not been reported. We herein showcased a discordant finding of Peters anomaly in a monozygotic twin complicated with twin-twin transfusion syndrome (TTTS) and exhibited its antenatal sonographic images,Case presentationA 38-year-old gravida 2 para 1 pregnant woman visited our clinic at the gestational age of 18 weeks where TTTS stage III was diagnosed and the following laser therapy was done successfully. Ten days after the surgery, the follow-up ultrasound detected the opacity of both fetal eyeballs in the donor twin and thus congenital cataract was suspected initially. Then magnetic resonance imaging (MRI) examination was arranged at the gestational age of 23 weeks, and no central nervous system or other anomaly was found. At the 29 weeks of gestation, the opacity of both fetal eyeballs of the donor twin did not clear. The pregnancy resulted in cesarean section at the gestational age of 37 weeks indicated by malpresentation where two male live births were born. Examination under anesthesia was arranged for donor twin after delivery and Peters anomaly was diagnosed based on central corneal opacity with iridocorneal and corneolenticular adhesions.ConclusionsThe prenatal image of Peters anomaly may present as the opacity of the fetal eyeballs similar to congenital cataract. Some cases of the Peters anomaly had been reported with a genetic abnormality, but since our case presented discordant presentation in monozygotic twin pregnancy where both twins are supposed to share the same genetic make-up, therefore other factors that are epigenetic may be held accountable. Nevertheless, a genetic origin of the anomaly in our case cannot be excluded.

The incidence, maternal, fetal and neonatal consequences of single intrauterine fetal death in monochorionic twins: A prospective observational UKOSS study.

Report maternal, fetal and neonatal complications associated with single intrauterine fetal death (sIUFD) in monochorionic twin pregnancies. Prospective observational study. UK. 81 monochorionic twin pregnancies with sIUFD after 14 weeks gestation, irrespective of cause. UKOSS reporters submitted data collection forms using data from hospital records. Aetiology of sIUFD; surviving co-twin outcomes: perinatal mortality, central nervous system (CNS) imaging, gestation and mode of delivery, neonatal outcomes; post-mortem findings; maternal outcomes. The commonest aetiology was twin-twin transfusion syndrome (38/81, 47%), "spontaneous" sIUFD (22/81, 27%) was second commonest. Death of the co-twin was common (10/70, 14%). Preterm birth (<37 weeks gestation) was the commonest adverse outcome (77%): half were spontaneous and half iatrogenic. Only 46/75 (61%) cases had antenatal CNS imaging, of which 33 cases had known results of which 7/33 (21%) had radiological findings suggestive of neurological damage. Postnatal CNS imaging revealed an additional 7 babies with CNS abnormalities, all born at <36 weeks, including all 4 babies exhibiting abnormal CNS signs. Major maternal morbidity was relatively common, with 6% requiring ITU admission, all related to infection. Monochorionic twin pregnancies with single IUD are complex and require specialist care. Further research is required regarding optimal gestation at delivery of the surviving co-twin, preterm birth prevention, and classifying the cause of death in twin pregnancies. Awareness of the importance of CNS imaging, and follow-up, needs improvement.

Prenatal visualisation of the torcular herophili by means of a Doppler technology highly sensitive for low-velocity flow in the expert assessment of the posterior fossa: a prospective study.

To evaluate the usefulness of a Doppler technology highly sensitive for low-velocity flow in the antenatal imaging of the torcular herophili (TH) in the second trimester of pregnancy. Prospective study. Referral Fetal Medicine Unit. Non-consecutive series of singleton pregnancies submitted to antenatal neurosonogram between 20 and 28weeks of gestation. A midsagittal section of the fetal brain was obtained by insonating through the anterior fontanelle, then the MV-Flow™ and LumiFlow™ presets were selected to visualise the TH as the posterior confluence of the superior sagittal sinus and the straight sinus. Evaluation of the anatomic relationship of the TH with the 'transpalatal line' joining the upper bony palate to the fetal skull. A total of 99 pregnant women were recruited, including one fetus with open spina bifida, one with Dandy-Walker malformation (DWM) and two with Blake's pouch cysts. In normal fetuses, the TH appeared to lie on or just below the 'transpalatal line'. In the cases of Blake's pouch cyst, the position of the TH appeared normal if compared with controls, whereas in DWM a supra-elevated position of the TH in respect of the transpalatal line was demonstrated. Finally, in the fetus with Chiari II malformation the TH was identified below the 'transpalatal plane'. Prenatal ultrasound visualisation of the TH by means of newly developed Doppler technologies characterised by high sensitivity for low-velocity flow is feasible and allows the indirect evaluation of the insertion of cerebellar tentorium in the second trimester. Prenatal imaging of the torcular herophili using a Doppler technology highly sensitive for low-velocity flow.

Antenatally detected liver and biliary pathology

Liver and biliary pathology in the neonate are rare and include a broad range of structural, neoplastic, infectious, genetic, and metabolic diseases. While most conditions present postnatally, antenatal detection is increasing given recent advances in antenatal imaging capabilities. In certain structural or obstructive liver diseases, antenatal detection now proves essential to help guide treatment and prevent morbidity. We review the epidemiology, pathophysiology, common antenatal diagnostic findings, and recommendations for surgical liver and biliary pathology in the neonate.

A boy with a congenital cerebellar mass

Tumorigenesis of medulloblastoma is believed to be associated with granule cell progenitor neurogenesis of the cerebellum. Nevertheless, congenital medulloblastomas are rarely found. Here, we report a case of congenital medulloblastoma that showed spontaneous albeit transient regression. A one-month-old baby presented with abnormal antenatal and postnatal imaging findings. Upon ultrasonography at 26 weeks of gestational age, Dandy-Walker malformation with vermian hypoplasia and cystic change was suspected. Brain MRI at 1 week after birth revealed gadolinium-enhancing lesions in the cerebellum with apparent infiltrative features along the cerebellar folia accompanied by three independent cysts in the upper and inferolateral sides of the lesion. Serial MRIs taken up to 5 months of age showed a decrease in the size and extent of enhancing solid portions. The baby did not show any abnormal signs or developmental delay. MRI at the age of 7 months showed enlargement of the lesion, and surgery was performed. The lesion was diagnosed as medulloblastoma with histologically extensive nodularity (MBEN), genetically SHH-activated and TP53-wildtype. This case provides an unusual chance of observing an early phase of medulloblastoma development and raises a suspicion that medulloblastoma may initiate itself very early in cerebellar organogenesis and progress later at a certain time of postnatal development.