Routine Anomaly Scan Research Articles

Probe motion during mid-trimester fetal anomaly scan in the clinical setting: A prospective observational study

IntroductionThis study aims to investigate probe motion during full mid-trimester anomaly scans. MethodsWe undertook a prospective, observational study of obstetric sonographers at a UK University Teaching Hospital. We collected prospectively full-length video recordings of routine second-trimester anomaly scans synchronized with probe trajectory tracking data during the scan. Videos were reviewed and trajectories analyzed using duration, path metrics (path length, velocity, acceleration, jerk, and volume) and angular metrics (spectral arc, angular area, angular velocity, angular acceleration, and angular jerk). These trajectories were then compared according to the participant level of expertise, fetal presentation, and patient BMI. ResultsA total of 17 anomaly scans were recorded. The average velocity of the probe was 12.9 ± 3.4 mm/s for the consultants versus 24.6 ± 5.7 mm/s for the fellows (p = 0.02), the average acceleration 170.4 ± 26.3 mm/s2 versus 328.9 ± 62.7 mm/s2 (p = 0.02), and the average jerk 7491.7 ± 1056.1 mm/s3 versus 14944.1 ± 3146.3 mm/s3 (p = 0.02), the working volume 9.106 ± 4.106 mm3 versus 29.106 ± 11.106 mm3 (p = 0.03), respectively. The angular metrics were not significantly different according to the participant level of expertise, the fetal presentation, or to patients BMI. ConclusionSome differences in the probe path metrics (velocity, acceleration, jerk and working volume) were noticed according to operator’s level.

Role of Fetal Second Trimester 2D Ultrasound Facial Parameters in Down Syndrome Detection

Abstract Introduction Down syndrome (DS) is the most common genetic cause of intellectual disability in humans. Various screening techniques are available, including the detection of facial characteristics of DS fetuses by prenatal ultrasonographic markers. Very few studies have tested the predictive validity of the markers in the Indian population. Objective This article determines the role of second trimester ultrasound in predicting DS using facial markers, namely, nasal bone length (NBL), prenasal thickness (PNT), NBL/PNT ratio, and PNT/NBL ratio in the Indian population Materials and Methods This prospective observational study recruited singleton pregnant women at 14 to 28 weeks of gestation with no comorbidities. Women with maternal disorders, abnormal amniotic fluid, and fetal structural anomalies were excluded. Three images of the midsagittal plane were obtained during a routine anomaly or well-being scan. The single “best” image was used for analysis. Scatter plots with regression lines and percentile curves for each gestation were created. Developed nomograms and scattered plots were validated by recruiting DS fetuses (diagnosed by amniocentesis and fetal karyotype). Results This study included 450 normal fetuses for developing nomograms, which were verified by matching 45 DS fetuses. The diagnostic accuracy of NBL, PNT, NBL/PNT ratios and PNT/NBL ratios was found to be 94, 99, 95, and 94.8, respectively. Sensitivity and specificity were found to be 51.11, 42.42, 48.89, 65.4 and 99, 96, 99.56, and 96.7 for NBL, PNT, NBL/PNT ratio, and PNT/NBL ratio, respectively. False negative rate and false positive rate were 38.89, 57.58, 51.11, 34.6 and 1, 4, 0.44, 3.3 for NBL, PNT, NBL/PNT ratio, PNT/NBL ratio, respectively. Conclusion High diagnostic accuracy was found for PNT, followed by NBL/PNT ratio, PNT/NBL ratio, and NBL. However, considering sensitivity and specificity markers together, we found the NBL/PNT ratio as a good diagnostic marker in predicting DS. Furthermore, the NBL/PNT ratio performs slightly better than its inverse counterpart (PNT/NBL ratio) for detecting DS fetuses, primarily because it produced less false positive cases.

Atypicality index as an add-on to combined first-trimester screening for chromosomal aberrations.

To compute a set of atypicality indices based on combined first-trimester screening (cFTS) markers and second-trimester estimated fetal weight (EFW), and to demonstrate their potential in identifying pregnancies at reduced or increased risk of chromosomal aberrations following a low-risk cFTS result. The atypicality index quantifies the unusualness of an individual set of measurements relative to a reference distribution and can be computed from any variables or measurements available. A score of 0% on the atypicality index represents the most typical profiles, while a score of 100% indicates the highest level of atypicality. From the Danish Fetal Medicine Database, we retrieved data on all pregnant women seen for cFTS in the Central Denmark Region between January 2008 and December 2018. All pregnancies with a cytogenetic or molecular analysis obtained prenatally, postnatally or following pregnancy loss or termination were identified. A first-trimester atypicality index (AcFTS) was computed based on nuchal translucency (NT) thickness, maternal serum free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A). Furthermore, a second-trimester index (AcFTS + EFW) was computed from cFTS markers and EFW from a routine second-trimester anomaly scan. All pregnancies were stratified into subgroups based on their atypicality levels and their cFTS risk estimates. The risk of chromosomal aberrations in each subgroup was then compared with the overall prevalence, and a graphical presentation of the multivariate measurement profiles was developed. We retrieved data on 145 955 singleton pregnancies, of which 9824 (6.7%) were genetically examined. Overall, 1 in 122 (0.82% (95% CI, 0.77-0.87%)) of all pregnancies seen for cFTS were affected by a fetal chromosomal aberration, and in screen-negative pregnancies (cFTS trisomy 21 risk < 1 in 100 and/or trisomy 18/13 risk < 1 in 50), 0.41% (95% CI, 0.38-0.44%) were affected. In screen-negative pregnancies with a typical first-trimester profile (AcFTS < 80%), the risk of chromosomal aberrations was significantly reduced (0.28%) compared with the overall risk. The risk of chromosomal aberrations increased with higher atypicality index to 0.49% (AcFTS [80-90%)), 1.52% (AcFTS [90-99%)) and 4.44% (AcFTS ≥ 99%) and was significantly increased in the two most atypical subgroups. The same applied for the second-trimester atypicality index, with risks of chromosomal aberrations of 0.76% and 4.16% in the two most atypical subgroups (AcFTS + EFW [90-99%) and AcFTS + EFW ≥ 99%, respectively). As an add-on to cFTS, the atypicality index identifies women with typical measurement profiles, which may provide reassurance, whereas atypical profiles may warrant specialist referral and further investigation. In pregnancies identified as low risk on cFTS but with a highly atypical distribution of NT, PAPP-A and β-hCG, the risk of a chromosomal aberration is substantially increased. The atypicality index optimizes the interpretation of pre-existing prenatal screening profiles and is not limited to cFTS markers or EFW. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Incorporation of vasa previa screening into a routine anomaly scan: A single center cohort study.

Vasa previa (VP), defined as unprotected fetal vessels traversing the membranes over the cervix, is associated with a high perinatal mortality when undiagnosed prenatally. Conversely, prenatal diagnosis with ultrasound and cesarean delivery before the membranes rupture is associated with excellent outcomes. However, controversy exists regarding screening for VP. In the UK, routine screening for VP is not recommended. The objective of this study was to report the incidence of VP and our experience in the detection of VP with a universal screening protocol at the time of the second-trimester fetal anomaly scan with third-trimester confirmation in an unselected population of pregnancies. We performed a single-center historical cohort study of all pregnant women who underwent routine second-trimester anomaly screening scans at West Middlesex University Hospital, London, UK, between 2012 and 2016. Over 5 years, every patient undergoing routine anomaly screening was evaluated for VP using a systematic protocol during their 20-week anomaly scan. Suspected cases of VP were rescanned in the third trimester by specialist sonographers with an interest in VP. The primary outcomes were the incidence and detection of VP. During the study period, 24 690 anatomy scans were performed. A total of 64 patients were identified as having potential VP at the second-trimester anomaly screening scan, of which 19 were confirmed by the specialist sonographer in the third trimester and at delivery. The screen positive rate was 0.26% (95% confidence interval [CI] 0.20%-0.32%). VP at birth was found in 19/24690 births (1:1299 [95% CI: 1:832-1:2030] births). Universal screening for VP using our protocol had a sensitivity of 100% and a specificity of 99.78% (95% CI: 99.72%-99.84%). The false-positive rate of the second-trimester screen was 0.18% (95% CI: 0.13-0.24). There were no false positives or false negatives at delivery. Of the 19 patients with confirmed VP, 17 had scheduled cesarean deliveries, and two required emergency deliveries due to antepartum hemorrhage. One baby died, giving a perinatal mortality of 5%. VP complicates approximately 1:1300 pregnancies. Routine screening for VP yielded a 100% detection rate. We suggest the inclusion of structured VP assessment in standard fetal anomaly screening programs.

Cost-effectiveness of universal routine sonographic cervical-length measurement at 19 to 25 weeks’ gestation

National second-trimester scanning of cervical length was introduced in Israel in 2010, and in the decade thereafter, a significant systematic reduction in preterm birth and in the delivery of low birthweight babies was found among singletons. In this study, we sought to estimate the cost-effectiveness of a national policy mandating second-trimester cervical length screening by ultrasound, followed by vaginal progesterone treatment for short cervical length in comparison with no screening strategy. We constructed a decision model comparing 2 strategies, namely (1) universal cervical length screening, and (2) no screening strategy. This study used the national delivery registry of Israel's Ministry of Health. All women diagnosed with a second-trimester cervical length <25 mm were treated with vaginal progesterone and were monitored with a bimonthly ultrasound scan for cervical dynamics and threat of early delivery. Preterm birth prevalence associated with short cervical length, the efficacy of progesterone in preterm birth prevention, and the accuracy of cervical length measurements were derived from previous studies. The cost of progesterone and bimonthly sonographic surveillance, low birthweight delivery, newborn admission to intensive care units, the first-year costs of managing preterm birth and low birthweight, and instances of handicaps and the cost of their follow-up were extracted from the publicly posted registry of Israel's Ministry of Health and Israel Social Securities data. Monte Carlo simulations decision tree mode, Tornado diagrams, and 1- and 2-way sensitivity analyses were implemented and the base case and sensitivity to parameters that were predicted to influence cost-effectiveness were calculated. Without cervical length screening, the discounted quality-adjusted life years were 30.179, and with universal cervical length screening, it increased to 30.198 (difference of 0.018 quality-adjusted life years). The average cost of no screening for cervical length strategy was $1047, and for universal cervical length screening, it was reduced to $998. The calculated incremental cost-effectiveness ratio was -$2676 per quality-adjusted life year (dividing the difference in costs by the difference in quality-adjusted life years). Monte Carlo simulation of cervical length screening of 170,000 singleton newborns (rounded large number close to the number of singleton newborns in Israel) showed that 95.17% of all babies were delivered at gestational week ≥37 in comparison with 94.46% of babies with the no screening strategy. Given 170,000 singleton births, the national savings of screening for short cervical length when compared with no cervical length screening amounted to $8.31M annually, equating to $48.84 for a base case, and the incremental cost-effectiveness ratio for each case of low birthweight or very low birthweight avoided was -$14,718. A cervical length <25 mm was measured for 30,090 women, and of those, 24,650 were false positives. The major parameters that affected the incremental cost-effectiveness ratio were the incidence of preterm birth, the specificity of cervical length measurements, and the efficacy of progesterone treatment. At a preterm birth incidence of <3%, universal screening does not lead to a cost saving. National universal cervical length screening should be incorporated into the routine anomaly scan in the second trimester, because it leads to a drop in the incidence of preterm birth and low birthweight babies in singleton pregnancies, thereby saving costs related to the newborn and gaining quality-adjusted life years.

Predictive value of fetal growth trajectory from 20 weeks of gestation onwards for severe adverse perinatal outcome in low-risk population: secondary analysis of IRIS study.

The placental dysfunction underlying fetal growth restriction (FGR) may result in severe adverse perinatal outcome (SAPO) related to fetal hypoxia. Traditionally, the diagnostic criteria for FGR have been based on fetal size, an approach that is inherently flawed because it often results in either over- or underdiagnosis. The anomaly ultrasound scan at 20 weeks' gestation may be an appropriate time at which to set a benchmark for growth potential of the individual fetus. We hypothesized that the fetal growth trajectory from that point onwards may be informative regarding third-trimester placental dysfunction. The aim of this study was to investigate the predictive value for SAPO of a slow fetal growth trajectory between 18 + 0 to 23 + 6 weeks and 32 + 0 to 36 + 6 weeks' gestation in a large, low-risk population. This was a post-hoc data analysis of the IUGR Risk Selection (IRIS) study, a Dutch nationwide cluster-randomized trial assessing the (cost-)effectiveness of routine third-trimester sonography in reducing SAPO. In the current analysis, for the first ultrasound examination we used ultrasound data from the routine anomaly scan at 18 + 0 to 23 + 6 weeks' gestation, and for the second we used data from an ultrasound examination performed between 32 + 0 and 36 + 6 weeks' gestation. Using multilevel logistic regression, we analyzed whether SAPO was predicted by a slow fetal growth trajectory, which was defined as a decline in abdominal circumference (AC) and/or estimated fetal weight (EFW) of more than 20 percentiles or more than 50 percentiles or as an AC growth velocity (ACGV) < 10th percentile (p10). In addition, we analyzed the combination of these indicators of slow fetal growth with small-for-gestational age (SGA) (AC or EFW < p10) and severe SGA (AC/EFW < 3rd percentile) at 32 + 0 to 36 + 6 weeks' gestation. Our sample included the data of 6296 low-risk singleton pregnancies, among which 82 (1.3%) newborns experienced at least one SAPO. Standalone declines in AC or EFW of > 20 or > 50 percentiles or ACGV < p10 were not associated with increased odds of SAPO. EFW < p10 between 32 + 0 and 36 + 6 weeks'gestation combined with a decline in EFW of > 20 percentiles was associated with an increased rate of SAPO. The combination of AC or EFW < p10 between 32 + 0 and 36 + 6 weeks' gestation with ACGV < p10 was also associated with increased odds of SAPO. The odds ratios of these associations were higher if the neonate was SGA at birth. In a low-risk population, a slow fetal growth trajectory as a standalone criterion does not distinguish adequately between fetuses with FGR and those that are constitutionally small. This absence of association may be a result of diagnostic inaccuracies and/or post-diagnostic (e.g. intervention and selection) biases. We conclude that new approaches to detect placental insufficiency should integrate information from diagnostic tools such as maternal serum biomarkers and Doppler ultrasound measurements. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Comparison between trans-vaginal and trans-abdominal ultrasound examination of the cervix in the second trimester of pregnancy: a prospective study.

To compare transvaginal (TV) and trans-abdominal (TA) ultrasound assessment of cervical length (CL) at the time of the second-trimester scan for fetal anomalies. This was a prospective study including consecutive pregnant women attending the low-risk ultrasound clinic of two fetal medicine centres in Italy. The inclusion criteria were women between 19+0 and 22+0weeks of gestation, attending the prenatal ultrasound clinic for the routine second trimester screening for fetal anomalies. The primary outcome was to compare the CL measurement obtained at TV compared to TA ultrasound; the secondary outcome was to report the inter and intra-observer variability of CL measured with the two different approaches. All women underwent TV and TA assessment of the cervix performed by two experienced certified operators, blinded to each other. Intra-class correlation coefficients (ICC) and Bland-Altman analyses were used to analyse the data. Two hundred and fifty women were included in the analysis. All women had anteverted uterus. The mean gestational age at ultrasound was 20.7±0.7weeks; 1.2 % (3/250) scans were performed at 19weeks, 49.2 % (123/250) at 20weeks, 44.8 % (112/250) at 21weeks and 4.8 % (12/250) at 22weeks of gestations. Identification of the major landmarks of CL at TA ultrasound was achieved in all the included cases. There was good reliability between CL measured at TA (ICC 0.95, 95 % CI 0.93-0.97 for observer 1 and 0.92 %, 95 % CI0.89-0.94 for observer 2) and TV ultrasound 0.97, 95 % CI0.96-0.98 for observer 1 and 0.96, 95 % CI 0.95-0.97 for observer 2). There was also good reliability between the two observers for both the TA and TV assessment of the CL. Mean TA CL was 41.4±5.5 for observer 1 and 40.5±4.8 for observer 2 with no significant differences between the two measurements (mean difference 0.92 mm, 95 % CI-9.7 to 11.2). Likewise, there was no difference between the CL measured at TV ultrasound between the two observers (mean difference-0.83 mm, 95 % CI-5.97 to 4.30). Finally, there was no difference in the mean CL measured at TA compared to TV, either considering the overall population of women (mean difference:-0.43, 955 CI-8.65 to 7.79), or when stratifying the analysis according to the parity status and the operator. Among experienced operators, there was no difference between TV and TA ultrasound assessment of the CL at the time of the routine anomaly scan for fetal anomaly.

Prenatal diagnosis of bilobate placenta: incidence, risk factors and impact on pregnancy outcomes.

To investigate the incidence and risk factors of bilobate placenta, as well as to assess its impact on preeclampsia (PE), preterm delivery (PTD) and small-for-gestational age (SGA)neonates. A prospective study of singleton pregnancies, undergoing routine anomaly scan at 20+0-23+6 gestational weeks, was conducted, between 2018 and 2022. The impact of prenatally diagnosed bilobate placenta on PE, PTD and SGA was assessed. Multivariate logistic regression models were employed to assess the independent association between bilobate placenta and the main pregnancy outcomes, using specific confounders. Additionally, a risk factor analysis was performed. The study population included 6,454 pregnancies; the incidence of prenatally diagnosed bilobate placenta was 2.0 % (n=129). Bilobate placenta was associated with PE (aOR: 1.721; 95 % CI: 1.014-2.922), while no statistically significant association was found between this anatomical variation and SGA (aOR: 1.059; 95 % CI: 0.665-1.686) or PTD (aOR: 1.317; 95 % CI: 0.773-2.246). Furthermore, pregnancies with prenatally diagnosed bilobate placenta had an increased prevalence of abnormal cord insertion (marginal or velamentous) (9.8 vs. 27.1 %; p<0.001) and increased mean UtA PI z-score (0.03 vs. 0.23; p=0.039). Conception via ART (aOR: 3.669; 95 % CI: 2.248-5.989), previous history of 1st trimester miscarriage (aOR: 1.814; 95 % CI: 1.218-2.700) and advancing maternal age (aOR: 1.069; 95 % CI: 1.031-1.110) were identified as major risk factors for bilobate placenta. Bilobate placenta, excluding cases of co-existing vasa previa, is associated with higher incidence of PE, increased mean UtA PI z-score and higher probability of abnormal cordinsertion, but not with increased risk for SGA or PTD. It is more common in pregnancies following ART and in women with a previous 1st trimester miscarriage.

First-trimester choroid-plexus-to-lateral-ventricle disproportion and prediction of subsequent ventriculomegaly.

Ventriculomegaly can be associated with long-term neurodevelopmental impairment. Prenatal diagnosis of ventriculomegaly is most commonly made at the routine second-trimester anomaly scan. The value of first-trimester ultrasound has expanded to early diagnosis and screening of fetal abnormalities. The objective of this study was to assess the predictive accuracy of first-trimester choroid-plexus-to-lateral-ventricle-or-head ratios for development of ventriculomegaly at a later gestational age. This was a case-control study of fetuses with isolated ventriculomegaly diagnosed after 16 weeks' gestation and a control group of normal fetuses (without ventriculomegaly). The exclusion criteria included aneuploidy, genetic syndrome and/or other brain abnormality. Stored two-dimensional first-trimester ultrasound images were analyzed blindly offline and fetal biometry was performed in the axial view of the fetal head. The ratios of choroid plexus area (PA) to lateral ventricular area (VA), choroid plexus length (PL) to lateral ventricular length (VL), choroid plexus diameter (PD) to lateral ventricular diameter (VD) and PA to biparietal diameter (BPD) were measured at 11 + 0 to 13 + 6 weeks' gestation. Intra- and interobserver variability of measurement of these fetal head biometric parameters at 11 + 0 to 13 + 6 weeks' gestation were assessed in 20 normal fetuses using intraclass correlation coefficients with 95% CI. The accuracy of first-trimester biometric measurements for prediction of ventriculomegaly was assessed using the area under the receiver-operating-characteristics curves (AUC). The analysis included 683 singleton pregnancies, of which 102 fetuses were diagnosed with ventriculomegaly. Ventriculomegaly was mild in 86 (84.3%) cases and severe in the other 16 (15.7%). All first-trimester fetal choroid-plexus-to-lateral-ventricle/head ratios were significantly lower in cases with ventriculomegaly compared with controls (P < 0.001), with good inter- and intraobserver agreement (≥ 0.95) for the majority of the fetal head biometric parameters assessed. On adjusting for crown-rump length, optimism-adjusted AUC values obtained after cross-validation showed that both PL/VL ratio (AUC, 0.87 (95% CI, 0.73-0.98)) and PA/VA ratio (AUC, 0.90 (95% CI, 0.82-0.98)) had good predictive accuracy for severe ventriculomegaly. The PA/BPD ratio (AUC, 0.73 (95% CI, 0.54-0.90)) had modest predictive ability, which was significantly lower compared with that of the PA/VA ratio and PL/VL ratio (P = 0.003 and P = 0.001, respectively). The predictive accuracy of PD/VD ratio was low with an AUC of 0.65 (95% CI, 0.47-0.84). Optimism-adjusted AUC values obtained after cross-validation showed that PA/VA ratio offered the highest predictive accuracy for mild ventriculomegaly with an AUC of 0.84 (95% CI, 0.79-0.89), followed by PL/VL ratio (AUC, 0.82 (95% CI, 0.76-0.88)), PA/BPD ratio (AUC, 0.76 (95% CI, 0.69-0.82)) and PD/VD ratio (AUC, 0.75 (95% CI, 0.67-0.81)). Calibration plots showed that both PA/VA and PL/VL ratios had good calibration. First-trimester prediction of ventriculomegaly using ratios of fetal choroid plexus to lateral ventricle/head appears promising. Future prospective studies are needed to validate the predictive accuracy of these ultrasound markers as a screening tool for ventriculomegaly. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal Diagnosis of Isolated Single Umbilical Artery: Incidence, Risk Factors and Impact on Pregnancy Outcomes.

Objectives: To assess the incidence of prenatally diagnosed isolated single umbilical artery (iSUA) and its impact on major pregnancy outcomes, as well as to investigate potential risk factors. Materials and methods: A prospective study of singleton pregnancies, undergoing routine anomaly scans at 20+0-24+0 weeks of gestation, was carried out from 2018 to 2022. The effect of sonographically detected iSUA on small-for-gestational-age neonates (SGA) and preterm delivery (PTD) was evaluated using parameterized Student's t-test, nonparametric Mann-Whitney U test and the chi-square test. Multivariable logistic regression models were implemented to assess the independent association between iSUA and the main outcomes, as well as with potential risk factors, while adjusting for specific confounders. Results: The study population included 6528 singleton pregnancies and the incidence of prenatally diagnosed iSUA was 1.3%. Prenatally diagnosed iSUA had a statistically significant association with both SGA neonates (aOR: 1.909; 95% CI: 1.152-3.163) and PTD (aOR: 1.903; 95% CI: 1.035-3.498), while no association was identified between this sonographic finding and preeclampsia. With regard to risk factors, conception via assisted reproductive technology (ART) was associated with increased risk of iSUA (aOR: 2.234; 95% CI: 1.104-4.523), while no other independent predictor for the development of this anatomical variation was identified. Conclusions: Prenatally diagnosed iSUA seems to be associated with a higher incidence of SGA and PTD and is more common in pregnancies following ART, which constitutes a novel finding.

The use of a modified rescue cervical cerclage in a diamniotic dichorionic twin pregnancy that had cervical dilatation

AbstractObjectiveWe describe the successful utilization of a modified rescue cerclage in a 32‐year‐old G4 P1213 woman of Afro‐Caribbean descent with a Diamniotic Dichorionic twin gestation who presented at 20 weeks and 2 days for a routine anomaly scan and was found to have a dilated (1.7 cm) and short (0.49 cm) cervix.DesignA standard prophylactic cervical cerclage was done at 12 weeks' gestation using Mersilene™ tape. For the rescue cerclage, the client was placed in a steep Trendelenburg position, with back filling of the bladder. The cervix was grasped with ring forceps, and an inflated foley balloon catheter was introduced into the cervical opening to aid in reduction of membranes. In addition to the initial cerclage, two 1‐ Prolene™ sutures were inserted distally to the tape and a second Mersilene™ tape was inserted proximally at the vesicocervical junction (reinforcement cerclages). The first Prolene™ was to provide additional structural support to prevent prolapse of the membrane. The second Prolene™ was used to close the external cervical or to minimize the risk of an ascending infection. The procedure was uneventful and postoperatively she was treated with antibiotics, vaginal micronized progesterone and venous thromboembolism prophylaxis. The membranes remained intact.ResultThe twins were successfully delivered by a scheduled repeat caesarean section at 36 weeks with Twin 1 Apgar scores of 9 and 9 at 1 and 5 min, respectively, and Twin 2 Apgar scores of 8 and 10, respectively.ConclusionIn the context of a challenging obstetric history as in this case, a more aggressive approach inclusive of reinforcement cerclage may be considered. The successful outcomes in this case further reiterates the need for larger clinical trials with pregnant individuals with larger cervical dilations at entry.

Correlation of Cervical Length, Anterior Uterocervical Angle, and Cervical Elastography with the Incidence of Preterm Labor

Abstract Objectives The aim of this study is to find the correlation of cervical length, anterior uterocervical angle, and cervical elastography with the incidence of preterm labor through evaluation by transvaginal ultrasonography during routine anomaly scan and to analyze the correlation of the parameters with each other. Methods Cross-sectional comparative study was undertaken on singleton pregnant women coming for anomaly scan between 18 and 24 weeks. Cervical length and anterior uterocervical angle were measured in the mid-sagittal section. Strain elastography was used for measuring cervical strain. Color map was obtained for the entire cervix and the color code for the degree of cervical stiffness was noted. Results Though the mean value of cervical length was significantly lower in preterm group (3.2 cm) than in term group (3.6 cm), it was more than the cutoff value of 2.5 cm, below which it is routinely considered as short cervix indicative of preterm labor. Mean value of anterior uterocervical angle was significantly higher in women with preterm (112.3 degrees) delivery than those with term (82.2 degrees) delivery. Mean strain values of cervical elastography were significantly different in term (0.130) and preterm groups (0.179). Color code in elastography was independent of preterm labor. There was a significant positive correlation of cervical length with gestational age at delivery (GAD). A significant negative correlation was observed between acute anterior uterocervical angle with the GAD. Conclusion Anterior uterocervical angle has a definitive role in the prediction of preterm labor and so it can be combined with the conventional cervical length screening in identifying women with normal cervical length who are at high risk of preterm labor. Cervical elastography assesses the cervical consistency and also has the potential for identifying high-risk women.

Antenatal diagnosis of Sirenomelia, the Mermaid syndrome with bilateral renal agenesis

A 26-year-old non-diabetic primigravida with 4 months of amenorrhea was appointed for a routine second-trimester anomaly scan. On inspection, the gravid abdominal girth of the lady did not correlate with her gestational age. Ultrasonographic examination showed a single live intrauterine gestation with anhydramnios. There was an absence of bilateral kidneys and urinary bladder with lying down adrenal sign suggestive of bilateral renal agenesis. The fetus also revealed caudal dysgenesis in the form of fusion of both lower limbs, seen as a single leg with 1 upturned foot and fused toes. There were no identifiable external genitalia and anus. The parents went ahead with medical termination of pregnancy after being informed about the condition and its incompatibility with life.

Foetal Cardiac Dimensions in 18-40 Weeks of Gestation from Tamil Nadu, India: A Cross-sectional Study

Introduction: Foetal echocardiography helps in the identification of congenital anomalies of the heart and arrhythmias. It is usually done from 18 to 22 weeks of gestation but it can also be done as early as 12-13 weeks of gestation through transvaginal ultrasound. Measurement of cardiac dimensions in the foetus plays a major role in the early detection of cardiac defects including hypoplastic right and left heart. In addition, the measurement of foetal cardiac dimensions is useful in the evaluation of foetuses with heart failure due to foetal anaemia, which is secondary to Rh alloimmunisation or Bart’s disease. Aim: To construct a reference centile curve for foetal cardiac dimensions from 18 to 40 weeks of gestation for the Indian population residing in Tamil Nadu state. Materials and Methods: This was a cross-sectional study performed between January 2020 and July 2021. A total of 345 antenatal mothers, who came to the Department of Radiology, SRM Medical College and Research Centre, Chennai, India, for for routine anomaly and growth scans were included in the study. Cardiac longitudinal and transverse diameters were measured on 2D images, when the heart was maximally distended in a fourchamber view at the end of the diastole. Left atrial longitudinal and transverse diameters, right atrial longitudinal and transverse diameters, left ventricular longitudinal and transverse diameters, right ventricular longitudinal and transverse diameters interatrial septum thickness interventricular septum thickness cardiac longitudinal and transverse diameters were measured. Results: The mean values at 18 and 40 weeks of gestation for left atrial longitudinal and transverse diameters, right atrial longitudinal and transverse diameters, left ventricular longitudinal and transverse diameters, right ventricular longitudinal and transverse diameters, interatrial septum thickness, interventricular septum thickness, cardiac longitudinal, and transverse diameters were 0.73,0.65,0.72,0.66,0.83,0.62,0.75, 0.62,0.1,0.1,1.71,1.72 cm and 2.22,1.71,2.31,1.9,3.21,1.71,3.3, 1.84,0.3,0.3,5.02,3.84 cm, respectively. Conclusion: The normal reference ranges for foetal cardiac dimensions can be a useful tool in the early identification of cardiac remodeling in congenital heart disease.

Clinical workflow of sonographers performing fetal anomaly ultrasound scans: deep-learning-based analysis.

Despite decades of obstetric scanning, the field of sonographer workflow remains largely unexplored. In the second trimester, sonographers use scan guidelines to guide their acquisition of standard planes and structures; however, the scan-acquisition order is not prescribed. Using deep-learning-based video analysis, the aim of this study was to develop a deeper understanding of the clinical workflow undertaken by sonographers during second-trimester anomaly scans. We collected prospectively full-length video recordings of routine second-trimester anomaly scans. Important scan events in the videos were identified by detecting automatically image freeze and image/clip save. The video immediately preceding and following the important event was extracted and labeled as one of 11 commonly acquired anatomical structures. We developed and used a purposely trained and tested deep-learning annotation model to label automatically the large number of scan events. Thus, anomaly scans were partitioned as a sequence of anatomical planes or fetal structures obtained over time. A total of 496 anomaly scans performed by 14 sonographers were available for analysis. UK guidelines specify that an image or videoclip of five different anatomical regions must be stored and these were detected in the majority of scans: head/brain was detected in 97.2% of scans, coronal face view (nose/lips) in 86.1%, abdomen in 93.1%, spine in 95.0% and femur in 92.3%. Analyzing the clinical workflow, we observed that sonographers were most likely to begin their scan by capturing the head/brain (in 24.4% of scans), spine (in 23.2%) or thorax/heart (in 22.8%). The most commonly identified two-structure transitions were: placenta/amniotic fluid to maternal anatomy, occurring in 44.5% of scans; head/brain to coronal face (nose/lips) in 42.7%; abdomen to thorax/heart in 26.1%; and three-dimensional/four-dimensional face to sagittal face (profile) in 23.7%. Transitions between three or more consecutive structures in sequence were uncommon (up to 13% of scans). None of the captured anomaly scans shared an entirely identical sequence. We present a novel evaluation of the anomaly scan acquisition process using a deep-learning-based analysis of ultrasound video. We note wide variation in the number and sequence of structures obtained during routine second-trimester anomaly scans. Overall, each anomaly scan was found to be unique in its scanning sequence, suggesting that sonographers take advantage of the fetal position and acquire the standard planes according to their visibility rather than following a strict acquisition order. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Establishing Normal Range of Fetal Pulmonary Artery and Fetal Aortic Diameter in 18-26 Weeks of Gestation in Pakistani Population

Congenital heart diseases constitute almost 0.8 to 1.2% of newborn illnesses globally however unfortunately 64% of them remained undiagnosed on conventional anamoly scan which uses four chamber view for cardiac evaluation. In developed countries, other than routine anomaly scan, the three vessel view(3VV) has been added to look for any potential outflow tract anomalies which increased the sensitivity of screening CHD however this view is not routinely used in our clinical practice due to lack of expertise and less awareness regarding the importance of this view . We aimed to establish normal reference values of fetal pulmonary and fetal aorta diameter value using 3VV so that its routine use can increase diagnostic accuracy of anamoly scan in our population. Methodology: This is a non probability convenient study investigating healthy pregnant females between 18-26weeks of gestation conducted from 04-02-2022 to 04-08-2022. After formal ethical approval, 56 patients were included in the study. After achieving 3VV,fetal pulmonary artery and fetal aorta diameter were evaluated and mean values were calculated for each gestational week. Results: The mean age of pregnant females included is 27.3 + 4.4 years (range 20 -37 years). The pulmonary artery diameter ranged from 2.3mm at 18 week of gestation to 3.6mm at 26 week of gestation. Fetal PAD is observed to correlate linearly (r=0.887) with gestational age and linear regression equation derived as PAD= (-0.52) +0.15(GA). Mean fetal aortic diameter was calculated ranged from 1.5mm at 18 week of gestation to 1.6mm at 26week of gestation. Fetal aorta diameter correlation with gestational was found to be 0.164 showing weak correlation along with insignificant regression analysis hence the regression equation cannot be formulated for fetal aorta. Conclusion: Normal mean values of fetal pulmonary artery and fetal aorta from 18-26weeks of gestation were calculated. Linear relationship was found between pulmonary artery diameter and gestational age. However weak correlation noted between fetal aorta diameter and gestational age was noted. Keywords: Fetal pulmonary artery; fetal aorta; anamoly scan; three vessel view(3VV); normal range.

Late amniocentesis: better late than never? A single referral centre experience.

Several congenital abnormalities present late in pregnancy necessitating invasive testing to rule out genetic/infectious causes at late gestation. Not many studies have described the indications/safety of a late gestation amniocentesis. All records of amniocentesis performed beyond 24weeks were reviewed and evaluated for indications, positive yield and complications. About 187 women had an amniocentesis after 24weeks for various indications with CNS abnormalities beingthe commonest. The total yield of positive findings was 14.60% (22/150; excluding 2 VOUS). CNS, multiple system involvement and skeletal system anormalities yielded maximum results. About 32.05% abnormalities could have potentially been detected at the time of a routine anomaly scan. Amongst all the deliveries, 2.1% delivered spontaneously within a week of the procedure and about 5.4% delivered spontaneously within a month of the procedure. The study emphasises the need for additional accreditation (FMF, ISUOG) of sonographers to ensure the detection of anomalies at the routine 18-20weeks scan. Inspite of a normal mid-trimester scan, central nervous system and gastrointestinal abnormalities presented more commonly after 24weeks. The high positive yield in our study highlights the importance of testing even in late pregnancy beyond the legal age of termination. The test could clearly stratify the pregnancies with a poor outcome whilst reassuring the others. The procedure itself did not lead to a neonatal death due to prematurity.

Uniform International Method to Measure Cervical Length: Are We There Yet?

Introduction: Cervical length is an important predictor of spontaneous preterm birth. So far, the best way to measure cervical length has not been established. We aimed to compare the incidence of short cervical length between three methods of cervical length measurement with and without the inclusion of cervico-isthmic complex (CIC) (six methods in total) and to determine the positive predictive value for spontaneous preterm birth. Material and Methods: We performed a prospective single-center cohort study in women with a singleton pregnancy between August 2014 and December 2018. During the routine fetal anomaly scan (18–22 weeks), women were offered transvaginal ultrasound for cervical length measurement to screen for the risk of spontaneous preterm birth. Each cervix was measured in six different ways: single-line, two-line, and tracing method between the internal and external os of the cervix with and without CIC. We evaluated the predictive value of the different measurements for spontaneous delivery before 37 weeks using positive predictive values. Results: Our final study population comprised 1,691 women. The overall rate of preterm birth <37 weeks was 8.0% (4.6% spontaneous, 3.4% iatrogenic preterm birth). The mean gestational age at cervical length measurement was 19+6 weeks. The different measuring techniques resulted in significant different cervical lengths, showing a maximum difference of >8 mm between the techniques (41.04 mm [SD 7.1] with one-line without CIC and 49.18 [SD 9.05] mm with trace with CIC) with an incidence of short cervical length below <25 mm ranging from 0.4% to 1.1% (p = 0.18). The positive predictive values for spontaneous preterm birth <37 weeks ranged from 42.9% to 20.0%. Conclusion: Different measurement methods for cervical length resulted in statistically significant differences in measured cervical length. Depending on the chosen cut-off this translates to different incidences of short cervical length and influences the number of women designated as high risk for preterm birth and receiving treatment. For interpretation and comparability between (inter-) national studies, it is important to adequately report on the employed technique. Future research should focus on determining the optimal measuring technique and a universal method of measurement.

The Additional Role of the 3-Vessels and Trachea View in Screening for Congenital Heart Disease.

Background and Objectives: Although frequent and associated with high mortality and morbidity rate, congenital heart disease (CHD) has a suboptimal prenatal detection rate, with significant variation according to the scanning protocol. The aim of this study was to evaluate the role of the 3-vessels and trachea view (3VT) in detecting CHD, with or without the use of Color Doppler, with an emphasis on major CHD. Materials and Methods: We performed a retrospective study on 1596 unselected pregnant patients presenting at 11–37 weeks of gestation for a routine anomaly scan. We selected all CHD cases, and we analyzed the performance of the 4-chamber (4C) and 3VT view in detecting CHD. Results: A total of 46 fetuses with CHD were identified, yielding a 2.86% overall incidence, and 0.87% for major CHD. Grayscale 4C detected 47.8% of all CHD, going up to 71.7% by adding grayscale 3VT, with no major CHD remaining undetected by combining grayscale 4C and 3VT. Conclusions: Grayscale 4C and 3VT views are effective in detecting major CHD, thus proving their utility even in a low resource setting.

RARE CASE OF PULMONARY SEQUESTRATION DIAGNOSED ANTENATALLY.

Iind trimester anomaly scans play a vital role in identifying the anatomical abnormalities in the fetus and thus help in planning and prognosis of pregnancy. Pulmonary sequestration is an not a common condition in which a separate lung tissue is formed, which is not a anatomical structures of the lung tissue, not its blood supply, neither perform any function also. A 26 years old mother, visited our department for routine anomaly scan. Transabdominal ultrasound examination revealed a well-dened echogenic mass seen just below the left hemidiaphragm which showed vascular supply directly from the aorta. This conrmed our diagnosis of pulmonary sequestration. We further evaluated with Fetal MRI which showed T2 high signal and T1 iso signal mass, suspicion of sequestration and esophageal duplication cyst was considered. The pregnancy was carefully followed by serial scans and a male baby delivered without any complications. Postnatally abdominal ultrasonography performed showed echogenic mass seen below the left diagram which showed feeding artery from the aorta.