How automated techniques ease functional assessment of the fetal heart: Applicability of two-dimensional speckle-tracking echocardiography for comprehensive analysis of global and segmental cardiac deformation using fetalHQ®.

BACKGROUND: Prenatal echocardiographic assessment of fetal cardiac function has become increasingly important. Fetal two-dimensional speckle-tracking echocardiography (2D-STE) allows the determination of global and segmental functional cardiac parameters. Prenatal diagnostics is relying increasingly on artificial intelligence, whose algorithms transform the way clinicians use ultrasound in their daily workflow. The purpose of this study was to demonstrate the feasibility of whether less experienced operators can handle and might benefit from an automated tool of 2D-STE in the clinical routine. METHODS: A total of 136 unselected, normal, singleton, second- and third-trimester fetuses with normofrequent heart rates were examined by targeted ultrasound. 2D-STE was performed separately by beginner and expert semiautomatically using a GE Voluson E10 (FetalHQ®, GE Healthcare, Chicago, IL). Several fetal cardiac parameters were calculated (end-diastolic diameter [ED], sphericity index [SI], global longitudinal strain [EndoGLS], fractional shortening [FS]) and assigned to gestational age (GA). Bland-Altman plots were used to test agreement between both operators. RESULTS: The mean maternal age was 33 years, and the mean maternal body mass index prior to pregnancy was 24.78 kg/m2. The GA ranged from 16.4 to 32.0 weeks (average 22.9 weeks). Averaged endoGLS value of the beginner was -18.57% ± 6.59 percentage points (pp) for the right and -19.58% ± 5.63 pp for the left ventricle, that of the expert -14.33% ± 4.88 pp and -16.37% ± 5.42 pp. With increasing GA, right ventricular endoGLS decreased slightly while the left ventricular was almost constant. The statistical analysis for endoGLS showed a Bland-Altman-Bias of -4.24 pp ± 8.06 pp for the right and -3.21 pp ± 7.11 pp for the left ventricle. The Bland-Altman-Bias of the ED in both ventricles in all analyzed segments ranged from -.49 mm ± 1.54 mm to -.10 mm ± 1.28 mm, that for FS from -.33 pp ± 11.82 pp to 3.91 pp ± 15.56 pp and that for SI from -.38 ± .68 to -.15 ± .45. CONCLUSIONS: Between both operators, our data indicated that 2D-STE analysis showed excellent agreement for cardiac morphometry parameters (ED and SI), and good agreement for cardiac function parameters (EndoGLS and FS). Due to its complexity, the application of fetal 2D-STE remains the domain of scientific-academic perinatal ultrasound and should be placed preferably in the hands of skilled operators. At present, from our perspective, an implementation into clinical practice "on-the-fly" cannot be recommended.

Semi-Automatic Measurement of Fetal Cardiac Axis in Fetuses with Congenital Heart Disease (CHD) with Fetal Intelligent Navigation Echocardiography (FINE).

Congenital heart disease (CHD) is one of the most common organ-specific birth defects and a major cause of infant morbidity and mortality. Despite ultrasound screening guidelines, the detection rate of CHD is limited. Fetal intelligent navigation echocardiography (FINE) has been introduced to extract reference planes and cardiac axis from cardiac spatiotemporal image correlation (STIC) volume datasets. This study analyses the cardiac axis in fetuses affected by CHD/thoracic masses (n = 545) compared to healthy fetuses (n = 1543) generated by FINE. After marking seven anatomical structures, the FINE software generated semi-automatically nine echocardiography standard planes and calculated the cardiac axis. Our study reveals that depending on the type of CHD, the cardiac axis varies. In approximately 86% (471 of 542 volumes) of our pathological cases, an abnormal cardiac axis (normal median = 40-45°) was detectable. Significant differences between the fetal axis of the normal heart versus CHD were detected in HLHS, pulmonary atresia, TOF (p-value < 0.0001), RAA, situs ambiguus (p-value = 0.0001-0.001) and absent pulmonary valve syndrome, DORV, thoracic masses (p-value = 0.001-0.01). This analysis confirms that in fetuses with CHD, the cardiac axis can significantly deviate from the normal range. FINE appears to be a valuable tool to identify cardiac defects.

A Clinical Approach to Semiautomated Three-Dimensional Fetal Brain Biometry-Comparing the Strengths and Weaknesses of Two Diagnostic Tools: 5DCNS+TM and SonoCNSTM.

(1) Objective: We aimed to evaluate the accuracy and efficacy of AI-assisted biometric measurements of the fetal central nervous system (CNS) by comparing two semiautomatic postprocessing tools. We further aimed to discuss the additional value of semiautomatically generated sagittal and coronal planes of the CNS. (2) Methods: Three-dimensional (3D) volumes were analyzed with two semiautomatic software tools, 5DCNS+™ and SonoCNS™. The application of 5DCNS+™ results in nine planes (axial, coronal and sagittal) displayed in a single template; SonoCNS™ depicts three axial cutting sections. The tools were compared regarding automatic biometric measurement accuracy. (3) Results: A total of 129 fetuses were included for final analysis. Our data indicate that, in terms of the biometric quantification of head circumference (HC), biparietal diameter (BPD), transcerebellar diameter (TCD) and cisterna magna (CM), the accuracy of SonoCNS™ was higher with respect to the manual measurement of an experienced examiner compared to 5DCNS+™, whereas it was the other way around regarding the diameter of the posterior horn of the lateral ventricle (Vp). The inclusion of four orthogonal coronal views in 5DCNS+™ gives valuable information regarding spatial arrangements, particularly of midline structures. (4) Conclusions: Both tools were able to ease assessment of the intracranial anatomy, highlighting the additional value of automated algorithms in clinical use. SonoCNS™ showed a superior accuracy of plane reconstruction and biometry, but volume reconstruction using 5DCNS+™ provided more detailed information, which is needed for an entire neurosonogram as suggested by international guidelines.

Application of Semiautomatic Fetal Intelligent Navigation Echocardiography (FINE) in Twin Pregnancies: Half the Work or Twice the Effort?

OBJECTIVE: To assess the performance of fetal intelligent navigation echocardiography (FINE, 5D Heart™) for automated volumetric investigation of the fetal heart in twin pregnancies. METHODS: Three hundred twenty-eight twin fetuses underwent fetal echocardiography in the second and third trimesters. Spatiotemporal image correlation (STIC) volumes were obtained for a volumetric investigation. The volumes were analyzed using the FINE software, and the data were investigated regarding image quality and many properly reconstructed planes. RESULTS: Three hundred and eight volumes underwent final analysis. 55.8% of the included pregnancies were dichorionic twin pregnancies, and 44.2% were monochorionic twin pregnancies. The mean gestational age (GA) was 22.1 weeks, and the mean maternal BMI was 27.3 kg/m2. The STIC-volume acquisition was successful in 100.0% and 95.5% of cases. The overall depiction rates of FINE were 96.5% (twin 1) and 94.7% (twin 2), respectively (p = 0.0849, not significant). In 95.9% (twin 1) and 93.9% (twin 2), at least 7 planes were reconstructed properly (p = 0.6056, not significant). CONCLUSION: Our results indicate that the FINE technique used in twin pregnancies is reliable. No significant difference between the depiction rates of twin 1 and twin 2 could be detected. In addition, the depiction rates are as high as those derived from singleton pregnancies. Due to the challenges of fetal echocardiography in twin pregnancies (i.e., greater rates of cardiac anomaly and more difficult scans), the FINE technique might be a valuable tool to improve the quality of medical care in those pregnancies.

How Automated Techniques Ease Functional Assessment of the Fetal Heart: Applicability of MPI+™ for Direct Quantification of the Modified Myocardial Performance Index.

(1) Objectives: In utero functional cardiac assessments using echocardiography have become increasingly important. The myocardial performance index (MPI, Tei index) is currently used to evaluate fetal cardiac anatomy, hemodynamics and function. An ultrasound examination is highly examiner-dependent, and training is of enormous significance in terms of proper application and subsequent interpretation. Future experts will progressively be guided by applications of artificial intelligence, on whose algorithms prenatal diagnostics will rely on increasingly. The objective of this study was to demonstrate the feasibility of whether less experienced operators might benefit from an automated tool of MPI quantification in the clinical routine. (2) Methods: In this study, a total of 85 unselected, normal, singleton, second- and third-trimester fetuses with normofrequent heart rates were examined by a targeted ultrasound. The modified right ventricular MPI (RV-Mod-MPI) was measured, both by a beginner and an expert. A calculation was performed semiautomatically using a Samsung Hera W10 ultrasound system (MPI+™, Samsung Healthcare, Gangwon-do, South Korea) by taking separate recordings of the right ventricle's in- and outflow using a conventional pulsed-wave Doppler. The measured RV-Mod-MPI values were assigned to gestational age. The data were compared between the beginner and the expert using a Bland-Altman plot to test the agreement between both operators, and the intraclass correlation was calculated. (3) Results: The mean maternal age was 32 years (19 to 42 years), and the mean maternal pre-pregnancy body mass index was 24.85 kg/m2 (ranging from 17.11 to 44.08 kg/m2). The mean gestational age was 24.44 weeks (ranging from 19.29 to 36.43 weeks). The averaged RV-Mod-MPI value of the beginner was 0.513 ± 0.09, and that of the expert was 0.501 ± 0.08. Between the beginner and the expert, the measured RV-Mod-MPI values indicated a similar distribution. The statistical analysis showed a Bland-Altman bias of 0.01136 (95% limits of agreement from -0.1674 to 0.1902). The intraclass correlation coefficient was 0.624 (95% confidence interval from 0.423 to 0.755). (4) Conclusions: For experts as well as for beginners, the RV-Mod-MPI is an excellent diagnostic tool for the assessment of fetal cardiac function. It is a time-saving procedure, offers an intuitive user interface and is easy to learn. There is no additional effort required to measure the RV-Mod-MPI. In times of reduced resources, such assisted systems of fast value acquisition represent clear added value. The establishment of the automated measurement of the RV-Mod-MPI in clinical routine should be the next level in cardiac function assessment.

Lennart Nilsson (1922-2017) - Pioneer of embryo photography and his work Ett barn blir till.

'Making the invisible visible' is a requirement of a coveted prize for scientific photography - the Lennart Nilsson Award - which is named after the pioneer of human embryo photography. There is no way of avoiding his influence if the hitherto invisible is to be made visible, the intangible almost tangible, the unimaginable made imaginable, and mysteries otherwise hidden from the human eye are to be processed in a popular-scientific way and visualized in an artistic way by means of scientific-medical imaging techniques. Whilst Lennart Nilsson used state-of-the-art imaging technology within the rapidly evolving field of endoscopy, he also created what is probably the best-selling illustrated book of all times with A Child Is Born contributing to both the further understanding of early prenatal development, as well as achieving worldwide popularity.

Applicability of a semiautomated volumetric approach (5D CNS+™) for detailed antenatal reconstruction of abnormal fetal CNS anatomy.

BACKGROUND: The aim of this study was to evaluate the accuracy and reliability of a semiautomated volumetric approach (5D CNS+™) when examining fetuses with an apparent abnormal anatomy of the central nervous system (CNS). METHODS: Stored 3D volumes extracted from a cohort of > 1.400 consecutive 2nd and 3rd trimester pregnancies (range 15-36 gestational weeks) were analyzed using the semiautomatic software tool 5D CNS+™, enabling detailed reconstruction of nine diagnostic planes of the fetal brain. All 3D data sets were examined and judged for plane accuracy, the need for manual adjustment, and fetal CNS anomalies affecting successful plane reconstruction. RESULTS: Based on our data of 91 fetuses with structural cerebral anomalies, we were able to reveal details of a wide range of CNS anomalies with application of the 5D CNS+™ technique. The corresponding anatomical features and consecutive changes of neighboring structures could be clearly demonstrated. Thus, a profound assessment of the entire altered CNS anatomy could be achieved in nearly all cases. The comparison with matched controls showed a significant difference in volume acquisition (p < 0.001) and in need for manual adjustment (p < 0.001) but not in the drop-out rates (p = 0.677) of both groups. CONCLUSION: 5D CNS+™ is applicable in the majority of cases with brain lesions and constitutes a reliable tool even if the integrity of the fetal CNS is compromised by structural anomalies. Using volume data that were acquired in identical cutting sections needed for conventional biometry allows for detailed anatomic surveys grossly independent of the examiner's experience.

Maximal Reduction of STIC Acquisition Time for Volumetric Assessment of the Fetal Heart-Benefits and Limitations of Semiautomatic Fetal Intelligent Navigation Echocardiography (FINE) Static Mode.

(1) Objective: To scrutinize the reliability and the clinical value of routinely used fetal intelligent navigation echocardiography (FINE) static mode (5DHeartStatic™) for accelerated semiautomatic volumetric assessment of the normal fetal heart. (2) Methods: In this study, a total of 296 second and third trimester fetuses were examined by targeted ultrasound. Spatiotemporal image correlation (STIC) volumes of the fetal heart were acquired for further volumetric assessment. In addition, all fetal hearts were scanned by a fast acquisition time volume (1 s). The volumes were analyzed using the FINE software. The data were investigated regarding the number of properly reconstructed planes and cardiac axis. (3) Results: A total of 257 volumes were included for final analysis. The mean gestational age (GA) was 23.9 weeks (14.3 to 37.7 weeks). In 96.9 (standard acquisition time, FINE standard mode) and 94.2% (fast acquisition time, FINE static mode) at least seven planes were reconstructed properly (p = 0.0961, not significant). Regarding the overall depiction rate, the standard mode was able to reconstruct 96.9% of the planes properly, whereas the static mode showed 95.2% of the planes (p = 0.0098). Moreover, there was no significant difference between the automatic measurement of the cardiac axis (37.95 + 9.14 vs. 38.00 + 8.92 degrees, p = 0.8827, not significant). (4) Conclusions: Based on our results, the FINE static mode technique is a reliable method. It provides similar information of the cardiac anatomy compared to conventional STIC volumes assessed by the FINE method. The FINE static mode has the potential to minimize the influence of motion artifacts during volume acquisition and might therefore be helpful concerning volumetric cardiac assessment in daily routine.

La Machine: Obstetric Phantoms of Madame Du Coudray Back to the Roots.

For 300 years now, obstetrics has drawn on the concept of simulation training to not only teach anatomy and physiology theoretically, but to literally infuse it practically. In an 18th century scientific culture, which was predominantly patriarchal, the French royal midwife Angelique Marguerite Le Boursier du Coudray excelled in this field. Using La Machine, one of the first obstetric phantoms, she taught thousands of midwives and even physicians. The exponential increase in publications on obstetric simulations in recent years continues to underline their current relevance, and Madame du Coudray was once at the forefront with her mannequin, probably the most sophisticated phantom of its time, a symbiosis of practical-robust architecture and anatomical-theoretical accuracy. In retrospect, it is therefore worthwhile to take a closer look at this pioneer and her obstetric phantoms, applied in the first national simulation-based training course, and to evaluate them in the overall picture of the development of anatomically correct replicas for practice-oriented training with detailed, flexible exercise - back to the roots.

Semiautomatic Assessment of Fetal Fractional Limb Volume for Weight Prediction in Clinical Praxis: How Does It Perform in Routine Use?

OBJECTIVES: Semiautomatic fractional limb volume (FLV) models have recently produced promising results for fetal birth weight (BW) estimation. We tested those models in a more unselected population hypothesizing that the FLV models would improve accuracy and precision of fetal BW estimation compared to the Hadlock model. METHODS: We compared the performance of different BW prediction models: Hadlock (biparietal diameter [BPD], abdominal circumference (AC), femur diaphysis length) and modified Lee thigh volume (TVol) and arm volume (AVol) (BPD, AC, automated fractional TVol, and AVol). Accuracy (systematic errors, mean percent differences) and precision (random errors, ± 1 SD of percent differences) were calculated. RESULTS: A total of 75 fetuses were included for final analysis. The Hadlock model showed the most consistent results with accurate BW estimation not significantly different from zero (-0.37 ± 8.53%). The modified fractional thigh and arm volume models were less accurate but trended toward more precise results (-2.63 ± 7.69% and -3.85 ± 7.47%, respectively). In addition, the modified TVol model showed the trend to predict more BWs within ±10% of the actual BW compared to the Hadlock model (81.3 versus 74.67%, ns). CONCLUSIONS: Based on our results, fetal weight estimation using the modified semiautomatic FLV models generates less accurate results in third-trimester fetuses compared to the Hadlock model. Those models recently published might improve the results of BW prediction by showing a higher precision than conventional models, especially in small and large fetuses. Further studies are needed to investigate the clinical usefulness of the new models.

Presence of Cervical Vertebral Anomalies with Concomitant Non-Communicating Hydrocephalus and Multicystic Kidney in a Female Fetus: Where VACTERL-H Meets MURCS.

BACKGROUND: Congenital multisystemic lesions with co-occurrence of non-random malformations, such as VACTERL-H or MURCS association, often pose serious threads to the newborn and still constitute an antenatal diagnostic dilemma. CASE REPORT: A malformed fetus with VACTERL-H association at 20 gestational weeks had a skin-covered neural tube defect (NTD) of the lower cervical spine, concomitant hydrocephalus, as well as unilateral multicystic dysplastic kidney and the suspicion of mullerian duct anomaly as potentially assigned to MURCS association. DISCUSSION/CONCLUSION: We were able to demonstrate how well-defined, standardized volumetric reconstruction of diagnostic views displaying fetal pathology in utero might aid early and precise diagnosis of multi-organ malformations. Application of modern diagnostic imaging tools is helpful in delineation of the most likely diagnoses (VACTERL-H vs. MURCS) as further specified during detailed pathologic work-up and might consequently facilitate individually tailored interdisciplinary counseling, as in the case presented here.

The Use of Artificial Intelligence in Automation in the Fields of Gynaecology and Obstetrics - an Assessment of the State of Play.

The long-awaited progress in digitalisation is generating huge amounts of medical data every day, and manual analysis and targeted, patient-oriented evaluation of this data is becoming increasingly difficult or even infeasible. This state of affairs and the associated, increasingly complex requirements for individualised precision medicine underline the need for modern software solutions and algorithms across the entire healthcare system. The utilisation of state-of-the-art equipment and techniques in almost all areas of medicine over the past few years has now indeed enabled automation processes to enter - at least in part - into routine clinical practice. Such systems utilise a wide variety of artificial intelligence (AI) techniques, the majority of which have been developed to optimise medical image reconstruction, noise reduction, quality assurance, triage, segmentation, computer-aided detection and classification and, as an emerging field of research, radiogenomics. Tasks handled by AI are completed significantly faster and more precisely, clearly demonstrated by now in the annual findings of the ImageNet Large-Scale Visual Recognition Challenge (ILSVCR), first conducted in 2015, with error rates well below those of humans. This review article will discuss the potential capabilities and currently available applications of AI in gynaecological-obstetric diagnostics. The article will focus, in particular, on automated techniques in prenatal sonographic diagnostics.

A 'holistic' sonographic view on congenital heart disease - How automatic reconstruction using fetal intelligent navigation echocardiography (FINE) eases the unveiling of abnormal cardiac anatomy part I: Right heart anomalies.

Attempting a comprehensive examination of the fetal heart remains challenging for unexperienced operators as it emphasizes the acquisition and documentation of sequential cross-sectional and sagittal views and inevitably results in diminished detection rates of fetuses affected by congenital heart disease. The introduction of four-dimensional spatio-temporal image correlation (4D STIC) technology facilitated a volumetric approach for thorough cardiac anatomic evaluation by the acquisition of cardiac 4D datasets. By analyzing and re-arranging of numerous frames according to their temporal event within the heart cycle, STIC allows visualization of cardiac structures as an endless cine loop sequence of a complete single cardiac cycle in motion. However, post-analysis with manipulation and repeated slicing of the volume usually requires experience and in-depth anatomic knowledge, which limits the widespread application of this advanced technique in clinical care and unfortunately leads to the underestimation of its diagnostic value to date. Fetal intelligent navigation echocardiography (FINE), a novel method that automatically generates and displays nine standard fetal echocardiographic views in normal hearts, has shown to be able to overcome these limitations. Very recent data on the detection of congenital heart defects (CHDs) using the FINE method revealed a high sensitivity and specificity of 98% and 93%, respectively. In this two-part manuscript, we focused on the performance of FINE in delineating abnormal anatomy of typical right and left heart lesions and thereby emphasized the educational potential of this technology for more than just teaching purposes. We further discussed recent findings in a pathophysiological and/or functional context.

Lymphangioma of the fetal neck within the PIK3CA-related-overgrowth spectrum (PROS): A case report.

The delineation of the prenatal diagnostic key features of PIK3CA-related overgrowth spectrum disorders will assume a crucial part in future and a prenatal diagnosis of the causing mutations would provide physicians with a simplified interdisciplinary perinatal management.

A "holistic" sonographic view on congenital heart disease: How automatic reconstruction using fetal intelligent navigation echocardiography eases unveiling of abnormal cardiac anatomy part II-Left heart anomalies.

Volume ultrasound has been shown to provide valid complementary information on fetal anatomy. Four-dimensional assessment (4D) of the fetal cardiovascular system using spatial-temporal image correlation (STIC) allows for detailed examination of a highly complex organ from the early second trimester onward. There is compelling evidence that this technique harbors quite a number of diagnostic opportunities, but manual navigation through STIC volume datasets is highly operator dependent. In fact, STIC is not incorporated yet into daily practice. Application of the novel fetal intelligent navigation echocardiography (FINE) considerably simplifies fetal cardiac volumetric examinations. This automatic technique applied on cardiac volume datasets reportedly has both high sensitivity and specificity for the detection of congenital heart defects (CHDs). Part I reviewed current data regarding detection rates of CHDs and illustrated the additional value of an automatic approach in delineating cardiac anatomy exemplified by congenital lesions of the right heart. In part II of this pictorial essay, we focused on left heart anomalies and aimed to tabulate recent findings on the quantification of normal and abnormal cardiac anatomy.

Feasibility of Semiautomatic Fetal Intelligent Navigation Echocardiography for Different Fetal Spine Positions: A Matter of "Time"?

OBJECTIVES: We investigated the feasibility of a semiautomatic approach for assessments of the fetal heart (fetal intelligent navigation echocardiography [FINE]) in cases of optimal and unfavorable fetal spine positions. METHODS: In this study, a total of 1693 spatiotemporal image correlation volumes of first-, second-, and third-trimester fetuses were evaluated by experts using the FINE approach. The data were analyzed regarding proper reconstruction of the diagnostic cardiac planes depending on the fetal spine position. RESULTS: A total of 1531 volumes were included. The volumes were divided into 4 groups depending on the fetal spine position: 5-7 o'clock, 4 + 8 o'clock, 3 + 9 o'clock, and 2 + 10 o'clock. In total, 93.2% of the diagnostic planes were displayed properly. Between 5 and 7 o'clock, 94.9% of the diagnostic planes were displayed properly. The correct depiction rates in the other groups were 92.4% (4 + 8 o'clock; n = 538; P = 0.0027), 88.3% (3 + 9 o'clock; n = 156; P < .0001), and 87.3% (2 + 10 o'clock; n = 41; P = .0139). In total, the highest dropout rates were found in the sagittal planes: ductal arch, 13.9%; aortic arch, 10.5%; and venae cavae, 12.0%. CONCLUSIONS: Based on our results, the FINE technique is an effective method, but its feasibility depends on the fetal position. The use of this semiautomatic work flow-based approach supports evaluation of the fetal heart in a standardized manner. Semiautomatic evaluation of the fetal heart might be useful in facilitating the detection of fetal cardiac anomalies.

Validation of a semiautomated volumetric approach for fetal neurosonography using 5DCNS+ in clinical data from > 1100 consecutive pregnancies.

OBJECTIVE: The aim of this study was to evaluate the validity of a semiautomated volumetric approach (5DCNS+) for the detailed assessment of the fetal brain in a clinical setting. METHODS: Stored 3D volumes of > 1100 consecutive 2nd and 3rd trimester pregnancies (range 15-36 gestational weeks) were analyzed using a workflow-based volumetric approach 5DCNS+, enabling semiautomated reconstruction of diagnostic planes of the fetal central nervous system (CNS). All 3D data sets were examined for plane accuracy, the need for manual adjustment, and fetal-maternal characteristics affecting successful plane reconstruction. We also examined the potential of these standardized views to give additional information on proper gyration and sulci formation with advancing gestation. RESULTS: Based on our data, we were able to show that gestational age with an OR of 1.085 (95% CI 1.041-1.132) and maternal BMI with an OR of 1.022 (95% CI 1.041-1.054) only had a slight impact on the number of manual adjustments needed to reconstruct the complete volume, while maternal age and fetal position during acquisition (p = 0.260) did not have a significant effect. For the vast majority (958/1019; 94%) of volumes, using 5DCNS+ resulted in proper reconstruction of all nine diagnostic planes. In less than 1% (89/9171 planes) of volumes, the program failed to give sufficient information. 5DCNS+ was able to show the onset and changing appearance of CNS folding in a detailed and timely manner (lateral/parietooccipital sulcus formation seen in < 65% at 16-17 gestational weeks vs. 94.6% at 19 weeks). CONCLUSIONS: The 5DCNS+ method provides a reliable algorithm to produce detailed, 3D volume-based assessments of fetal CNS integrity through a standardized reconstruction of the orthogonal diagnostic planes. The method further gives valid and reproducible information regarding ongoing cortical development retrieved from these volume sets that might aid in earlier in utero recognition of subtle structural CNS anomalies.

Semiautomatic Fetal Intelligent Navigation Echocardiography Has the Potential to Aid Cardiac Evaluations Even in Less Experienced Hands.

OBJECTIVES: To investigate the interobserver and intraobserver variability and corresponding learning curve in a semiautomatic approach for a standardized assessment of the fetal heart (fetal intelligent navigation echocardiography [FINE]). METHODS: A total of 30 stored spatiotemporal image correlation volume data sets of second-trimester fetuses were evaluated by 3 physicians with different levels of expertise in fetal echocardiography by using the FINE approach. Data were analyzed regarding the examination time and proper reconstruction of the diagnostic cardiac planes. The completions and numbers of correct depictions of all diagnostic planes were evaluated by a blinded expert (time t0). To determine interobserver and intraobserver variability, the volumes were reassessed after a 4-week training interval (time t1). RESULTS: All operators were able to perform the investigation on all 30 volumes. At t0, the interobserver variability between the beginner and both the advanced (P = .0013) and expert (P < .0001) examiners was high. Focusing on intraobserver variability at t1, the beginner showed a marked improvement (P = .0087), whereas in advanced and expert hands, no further improvement regarding proper achievement of all diagnostic planes could be noticed (P > .999; P = .8383). The beginner also showed improvement in the mean investigation time (t0, 82.8 seconds; t1, 73.4 seconds; P = .0895); nevertheless, the advanced and expert examiners were faster in completing the examination (t1, advanced, 20.9 seconds; expert, 28.3 seconds; each P < .0001). CONCLUSIONS: Based on our results, the FINE technique is a reliable and easily learned method. The use of this semiautomatic work flow-based approach supports evaluation of the fetal heart in a standardized and time-saving manner. A semiautomatic evaluation of the fetal heart might be useful in facilitating the detection of fetal cardiac anomalies.

Neural Tube Defects in Embryonic Life: Lessons Learned From 340 Early Pregnancy Failures.

OBJECTIVES: The aim of this study was to evaluate the feasibility of sonographic assessment of the embryonic/fetal neural tube in nonviable pregnancies and to determine the defect incidence. METHODS: Prospective analysis of transvaginally acquired 3-dimensional (3D) multiplanar and 3D surface-rendered volume sets of 340 cases of missed abortion between March 2010 and September 2015 was performed. Data regarding karyotype and postmortem examination as well as demographic features and the outcomes of subsequent pregnancies were evaluated. RESULTS: In 223 cases, an embryo/fetus was detected and considered suitable for further evaluation: in 37 of 223 (16.6%) embryos/fetuses, a neural tube defect was present: 27 of 37 cephaloceles, 5 of 37 anencephalies/exencepahlies, 3 of 37 spina bifidas, 1 of 37 caudal regression syndrome, and 1 of 37 iniencephaly. Additional alterations were not observed. In 7 of 37 cases karyotyping was carried out and showed no aneuploidy. Eight subsequent pregnancies had a favorable outcome, with 1 ending in an intrauterine fetal death during the 22nd week of gestation. Maternal folic acid supplementation was provided for all subsequent pregnancies. No neural tube defects occurred. CONCLUSIONS: Sonographic 3D evaluation of complete neural tube closure in embryonic/fetal demise is technically feasible and can be achieved in embryos with a crown-rump length greater than 8 mm. In 26 of 37 cases a defective closure site could be allocated to high-risk areas known for early embryonic demise. Regardless of the etiology of different neural tube defects, high-dose folic acid prophylaxis must be recommended in all cases. Sonographic evaluation of the neural tube, including 3D surface-rendered images, should be offered to every woman with a missed abortion because of the impact on subsequent pregnancies.