Insights into the Evolution of Spermatogenesis-Related Ubiquitin-Proteasome System Genes in Abdominal Testicular Laurasiatherians.

During embryonic development in mammals, the testicles generally descend into the scrotum, making the testicular temperature 2-4 °C lower than the core temperature via heat exchange and clearance, and thus more beneficial for normal spermatogenesis. Failure to descend, known as cryptorchidism, carries a series of risks such as infertility and testicular cancer. However, some mammals have evolved abdominal testes while maintaining healthy reproduction. To explore the underlying molecular mechanism, we conducted comparative genomic analyses and functional assays on the spermatogenesis-related ubiquitin-proteasome system (UPS) genes essential to sperm formation in representative laurasiatherians. Here, positive selection and rapid evolution of spermatogenesis-related UPS genes were identified in the abdominal testicular laurasiatherians. Moreover, potential convergent amino acids were found between distantly related species with similar abdominal testicles and functional analyses showed RNF8 (V437I) in abdominal testicular species (437I) has a stronger ubiquitination ability, which suggests that the mammals with abdominal testes might exhibit enhanced sperm cell histone clearance to maintain sperm formation. This evidence implies that, in response to "cryptorchidism injury", spermatogenesis-related UPS genes in the abdominal testicular species might have undergone adaptive evolution to stabilize sperm formation. Thus, our study could provide some novel insights into the reproductive adaptation in abdominal testicular mammals.

Relationship Between Maternal Bone Biomarkers and Fetal Adiposity Through Normal Pregnancy.

PURPOSE: To examine the association of maternal bone markers [sclerostin, soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteocalcin, 25-hydroxyvitamin D3] with fetal intra-abdominal and subcutaneous adipose tissue deposition and birthweight during normal pregnancy. METHODS: One hundred pregnant women (aged 30.4 ±â€…5.6 years, mean ±â€…SD) with prepregnancy body mass index = 24.1 ±â€…4.6 kg/m2 were seen prospectively during each trimester. At each visit they were submitted to anthropometric measurements, a fasting blood sampling, a 75-g oral glucose tolerance test, and a fetal ultrasonogram. At birth, neonates had birth weight measurement. RESULTS: In the second trimester, maternal sclerostin concentrations correlated positively with fetal abdominal circumference and birth weight; maternal sRANKL concentrations correlated positively with fetal abdominal subcutaneous fat thickness, sagittal abdominal diameter, and abdominal circumference. Fetuses born to mothers with greater (>254 ng/mL), compared to fetuses born to mothers with lower (≤254ng/mL), sRANKL concentrations had greater abdominal circumference, sagittal diameter, and abdominal subcutaneous fat thickness. Maternal serum sclerostin concentrations were the best positive predictors of birth weight. In the third trimester maternal sclerostin concentrations correlated positively with fetal sagittal abdominal diameter; maternal sRANKL concentrations positively correlated with fetal abdominal circumference and fetal abdominal sagittal diameter. CONCLUSIONS: Maternal bone markers sclerostin and sRANKL may relate to fetal intra-abdominal adipose tissue deposition through as yet unknown direct or indirect mechanisms, thus contributing to birthweight.

Automatic quality assessment for 2D fetal sonographic standard plane based on multitask learning.

ABSTRACT: The quality control of fetal sonographic (FS) images is essential for the correct biometric measurements and fetal anomaly diagnosis. However, quality control requires professional sonographers to perform and is often labor-intensive. To solve this problem, we propose an automatic image quality assessment scheme based on multitask learning to assist in FS image quality control. An essential criterion for FS image quality control is that all the essential anatomical structures in the section should appear full and remarkable with a clear boundary. Therefore, our scheme aims to identify those essential anatomical structures to judge whether an FS image is the standard image, which is achieved by 3 convolutional neural networks. The Feature Extraction Network aims to extract deep level features of FS images. Based on the extracted features, the Class Prediction Network determines whether the structure meets the standard and Region Proposal Network identifies its position. The scheme has been applied to 3 types of fetal sections, which are the head, abdominal, and heart. The experimental results show that our method can make a quality assessment of an FS image within less a second. Also, our method achieves competitive performance in both the segmentation and diagnosis compared with state-of-the-art methods.

Prenatal diagnosis of abdominal lymphatic malformations.

Abdominal lymphatic malformations (LM) are rare congenital malformations of the lymphatic system, representing only 2% of all LM in newborns. They may arise from intra-abdominal solid organs (such as the liver, pancreas, kidneys, spleen, adrenal glands, and gastrointestinal tract), mesentery, omentum, and retroperitoneum. Mesenteric LM are the most commonly seen, with retroperitoneal LM being the second most common. Fetal abdominal LM could be associated with karyotypic or other abnormalities, including skin edema, hydrops fetalis, and polyhydramnios, and prenatal diagnosis and perinatal counseling for these LM are important. Prenatal ultrasound (US) and magnetic resonance imaging (MRI) have led to an increased diagnosis of abdominal LM and improved monitoring and intervention postnatally. This article provides an overview of fetal abdominal LM, including the prenatal diagnoses, differential diagnoses, comprehensive illustrations of the imaging findings, treatments, and fetal outcomes.

Training the trainees: a pilot study of inter-observer discrepancy and learning curve in the maternal foetal unit of a tertiary centre.

Our study aims to present the preliminary findings of an ongoing prospective cohort study that assesses the trainees' ability to perform foetal biometry during the third trimester of pregnancy. Sixty-three women with third-trimester singleton pregnancies were included. A biometry scan was performed byboth residents and a foetal medicine specialist in the Third department of Obstetrics and Gynaecology of Attikon University Hospital. For each case, the ultrasonographic measurements of the two operator groups were compared. The mean difference of the resident group compared to the specialist group was: for the biparietal diameter +1.3 mm (CI 95%, range -10.6 to +13,3, ±1.96 SD), for the occipitofrontal diameter -2.6 mm (CI 95%, range -31.5 to +26.2), for the anterior-posterior abdominal diameter -2.6 mm (CI 95%, range -17.9 to +12.8), for the transverse abdominal diameter -0.7 mm (CI 95%, range -17.1 to +15.7) and for the femur length -1.1 mm (CI 95%, range -11.7 to +9.6). We observed that, among all biometric parameters, the most accurate -based on the specialist group were the head circumference measurements. The highest discrepancy was noted for the abdominal assessment. Given that foetal biometry is of utmost importance in obstetrical clinical evaluation and management, a study that highlights the weaknesses of residents in this field could open new horizons in optimising the learning procedure.Impact statementWhat is already known on this subject? After review of the literature, we found only a few studies on inter- and intra-observer discrepancy in foetal biometry measurements among specialists.What the results of this study add? To our knowledge, our study is the first to evaluate residents' capacity of performing a biometry scan, by comparing their measurements to those of MFM specialists.What the implications are of these findings to clinical practice and/or further research? The need for constant evaluation of residents is indisputable. Our study could help to improve their ultrasound skills by giving emphasis on residents' weaknesses. With further research on this subject, a standard system of evaluation could be formed and determine the duration and type of training required for each resident.

Fetal growth velocity standards from the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project.

BACKGROUND: Human growth is susceptible to damage from insults, particularly during periods of rapid growth. Identifying those periods and the normative limits that are compatible with adequate growth and development are the first key steps toward preventing impaired growth. OBJECTIVE: This study aimed to construct international fetal growth velocity increment and conditional velocity standards from 14 to 40 weeks' gestation based on the same cohort that contributed to the INTERGROWTH-21st Fetal Growth Standards. STUDY DESIGN: This study was a prospective, longitudinal study of 4321 low-risk pregnancies from 8 geographically diverse populations in the INTERGROWTH-21st Project with rigorous standardization of all study procedures, equipment, and measurements that were performed by trained ultrasonographers. Gestational age was accurately determined clinically and confirmed by ultrasound measurement of crown-rump length at <14 weeks' gestation. Thereafter, the ultrasonographers, who were masked to the values, measured the fetal head circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and femur length in triplicate every 5 weeks (within 1 week either side) using identical ultrasound equipment at each site (4-7 scans per pregnancy). Velocity increments across a range of intervals between measures were modeled using fractional polynomial regression. RESULTS: Peak velocity was observed at a similar gestational age: 16 and 17 weeks' gestation for head circumference (12.2 mm/wk), and 16 weeks' gestation for abdominal circumference (11.8 mm/wk) and femur length (3.2 mm/wk). However, velocity growth slowed down rapidly for head circumference, biparietal diameter, occipitofrontal diameter, and femur length, with an almost linear reduction toward term that was more marked for femur length. Conversely, abdominal circumference velocity remained relatively steady throughout pregnancy. The change in velocity with gestational age was more evident for head circumference, biparietal diameter, occipitofrontal diameter, and femur length than for abdominal circumference when the change was expressed as a percentage of fetal size at 40 weeks' gestation. We have also shown how to obtain accurate conditional fetal velocity based on our previous methodological work. CONCLUSION: The fetal skeleton and abdomen have different velocity growth patterns during intrauterine life. Accordingly, we have produced international Fetal Growth Velocity Increment Standards to complement the INTERGROWTH-21st Fetal Growth Standards so as to monitor fetal well-being comprehensively worldwide. Fetal growth velocity curves may be valuable if one wants to study the pathophysiology of fetal growth. We provide an application that can be used easily in clinical practice to evaluate changes in fetal size as conditional velocity for a more refined assessment of fetal growth than is possible at present (https://lxiao5.shinyapps.io/fetal_growth/). The application is freely available with the other INTERGROWTH-21st tools at https://intergrowth21.tghn.org/standards-tools/.

Anatomy-based diagnostic criteria for complex body wall anomalies (CBWA).

BACKGROUND: Precise diagnosis and classification of CBWA cases can be challenging. BSA are considered when there is a body wall anomaly, skeletal abnormalities, and the umbilical cord is anomalous, absent or rudimentary, and LBWC when there is a body wall and structural limb anomalies with or without craniofacial abnormalities. METHODS: PubMed was searched for body stalk anomalies, limb body wall complex, body stalk anomalies and amniotic band syndrome, and limb body wall complex and amniotic band syndrome. Sixty nine articles were selected and reviewed. This article systematically classifies the variants of CBWA in 218 cases, the study is based on the embryological and anatomical criteria established by Martín-Alguacil and Avedillo to study BSA in the pig. RESULTS: Eight different BSA presentation were defined. One hundred and eighty nine cases were classified as BSA, from which five were Type I, nine Type II, 20 Type III, 57 Type IV, 11Type V, 24 Type VI, 11 Type VII, and 52 Type VIII. Twenty six cases presented cranial phenotype, 114 abdominal phenotype, 42 cranio/abdominal overlapping phenotype, and five without defined phenotype. In addition, 52 BSA cases presented some kind of spinal dysraphism (SPDYS) and were classified as BSA/SPDYS, most of these cases did not show structural limb anomalies, except for three cases and were classified as LBWC/SPDYS. CONCLUSION: This morphology-based classification represents a useful tool for clinical diagnosis, it helps to quantify and to evaluate CBWA in a precise, objective manner.

Predictive possibility of the transverse cerebellar diameter to abdominal circumference ratio for small-for-gestational-age fetus suspected as a cause of maternal placental syndromes: a retrospective cohort study.

Objective: To examine whether fetal transverse cerebellar diameter (TCD) to abdominal circumference (AC) ratio can predict small-for-gestational age suspected as a cause of maternal placental syndromes (SGA-MPS).Methods: We evaluated 473 women who underwent ultrasound examinations at 24-28 weeks of gestation. A receiver operating characteristic curve was used to determine the TCD/AC ratio thresholds to predict SGA-MPS. We used multivariable logistic regression analysis to examine the association.Results: TCD/AC ratio>14.37 was associated with SGA-MPS.Conclusions: Accurate risk stratification using the TCD/AC ratio could assist in managing patients with small-for-gestational-age fetuses at risk of developing MPS-associated adverse outcomes.

Tissue mechanical properties modulate cell extrusion in the Drosophila abdominal epidermis.

The replacement of cells is a common strategy during animal development. In the Drosophila pupal abdomen, larval epidermal cells (LECs) are replaced by adult progenitor cells (histoblasts). Previous work showed that interactions between histoblasts and LECs result in apoptotic extrusion of LECs during early pupal development. Extrusion of cells is closely preceded by caspase activation and is executed by contraction of a cortical actomyosin cable. Here, we identify a population of LECs that extrudes independently of the presence of histoblasts during late pupal development. Extrusion of these LECs is not closely preceded by caspase activation, involves a pulsatile medial actomyosin network, and correlates with a developmental time period when mechanical tension and E-cadherin turnover at adherens junctions is particularly high. Our work reveals a developmental switch in the cell extrusion mechanism that correlates with changes in tissue mechanical properties.

Prenatal sonographic features can accurately determine parental origin in triploid pregnancies.

OBJECTIVE: To describe the prenatal sonographic features and maternal biochemical markers in triploid pregnancies and to assess whether prenatal phenotype can determine genetic origin. METHODS: We performed a retrospective multicenter cohort study that included all triploid pregnancies diagnosed between 2000 and 2018 in two Fetal Medicine Units in Amsterdam. Fetal growth, presence of structural anomalies, extra-fetal anomalies, and maternal biochemical markers were retrieved. Asymmetrical intrauterine growth restriction was diagnosed when the head-to-abdominal circumference (HC/AC) ratio was >95th centile. Parental origin was analyzed via molecular genotyping in 46 cases (38.3%). RESULTS: One hundred and twenty triploid pregnancies were identified, of which 86 cases (71.6%) were detected before 18 weeks of gestation. Triploidy of maternal origin was found in 32 cases (69.6%) and was associated with asymmetrical growth restriction, a thin placenta, and low pregnancy-associated plasma protein A and free beta-human chorionic gonadotrophin (ß-hCG) levels. Triploidy of paternal origin was found in 14 cases (30.4%) and was associated with an increased nuchal translucency, placental molar changes, and a high free ß-hCG. Prospective prediction of the parental origin of the triploidy was made in 30 of the 46 cases based on phenotypical ultrasound presentation, and it was correct in all cases. CONCLUSION: Asymmetrical growth restriction with severe HC/AC discrepancy is pathognomonic of maternal triploidy. Placental molar changes indicate a paternal triploidy. Moreover, triploidy can present with an abnormal first trimester combined test, with serum levels on the extreme end. When available results of maternal serum markers can support the diagnosis of parental origin of the triploidy, an accurate assessment of the parental origin based on prenatal sonographic features is possible, making DNA analysis redundant.

Vermiform Appendix During the Repackaging Process from Umbilical Herniation to Fixation onto the Right Posterior Abdomen: A Study of Human Fetal Horizontal Sections.

The anatomical position of the vermiform appendix varies among adults, and these variations are responsible for differences in the symptoms of appendicitis. However, to date no study has examined how and when these variations occur during fetal development. The present study examined horizontal sections of 27 midterm fetuses (crown rump length [CRL] 38-97 mm, gestational age approximately 8-15 weeks). There were 10 fetuses (CRL 56 mm or more) in which the cecum and appendix were in a posterosuperior site near the right kidney (postmigration phase), and 12 fetuses (CRL 39-72 mm) in which the ileocecal junction and appendix remained on the visceral surface of the liver in the anterior or anterolateral abdominal cavity (migration phase, after physiological umbilical herniation). Analysis of the 12 fetuses in the migration phase indicated that the appendix extended inferiorly in eight fetuses and superiorly in four fetuses. Likewise, a "preileal" appendix (a morphology in which the distal part of the appendix was in front of the terminal ileum) was present in eight of these fetuses. Extension of the appendix superiorly or inferiorly during the migration phase seems unrelated to the topographical relationship of the appendix with the terminal ileum at the postmigration phase in fetuses and in adults. Conversely, it seems likely that a retroileal appendix leads to a coiled appendix behind the ileocecal junction. "Guidance" by the liver surface seemed to be important for posterior migration, which ended with the ascent of the liver. Clin. Anat., 33:667-677, 2020. © 2019 Wiley Periodicals, Inc.

Role of Doppler ultrasound at time of diagnosis of late-onset fetal growth restriction in predicting adverse perinatal outcome: prospective cohort study.

OBJECTIVE: Pregnancies complicated by late-onset fetal growth restriction (FGR) are at increased risk of short- and long-term morbidities. Despite this, identification of cases at higher risk of adverse perinatal outcome, at the time of FGR diagnosis, is challenging. The aims of this study were to elucidate the strength of association between fetoplacental Doppler indices at the time of diagnosis of late-onset FGR and adverse perinatal outcome, and to determine their predictive accuracy. METHODS: This was a prospective study of consecutive singleton pregnancies complicated by late-onset FGR. Late-onset FGR was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 3rd centile, or EFW or AC < 10th centile and umbilical artery (UA) pulsatility index (PI) > 95th centile or cerebroplacental ratio (CPR) < 5th centile, diagnosed after 32 weeks. EFW, uterine artery PI, UA-PI, fetal middle cerebral artery (MCA) PI, CPR and umbilical vein blood flow normalized for fetal abdominal circumference (UVBF/AC) were recorded at the time of the diagnosis of FGR. Doppler variables were expressed as Z-scores for gestational age. Composite adverse perinatal outcome was defined as the occurrence of at least one of emergency Cesarean section for fetal distress, 5-min Apgar score < 7, umbilical artery pH < 7.10 and neonatal admission to the special care unit. Logistic regression analysis was used to elucidate the strength of association between different ultrasound parameters and composite adverse perinatal outcome, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive accuracy. RESULTS: In total, 243 consecutive singleton pregnancies complicated by late-onset FGR were included. Composite adverse perinatal outcome occurred in 32.5% (95% CI, 26.7-38.8%) of cases. In pregnancies with composite adverse perinatal outcome, compared with those without, mean uterine artery PI Z-score (2.23 ± 1.34 vs 1.88 ± 0.89, P = 0.02) was higher, while Z-scores of UVBF/AC (-1.93 ± 0.88 vs -0.89 ± 0.94, P ≤ 0.0001), MCA-PI (-1.56 ± 0.93 vs -1.22 ± 0.84, P = 0.004) and CPR (-1.89 ± 1.12 vs -1.44 ± 1.02, P = 0.002) were lower. On multivariable logistic regression analysis, Z-scores of mean uterine artery PI (P = 0.04), CPR (P = 0.002) and UVBF/AC (P = 0.001) were associated independently with composite adverse perinatal outcome. UVBF/AC Z-score had an area under the ROC curve (AUC) of 0.723 (95% CI, 0.64-0.80) for composite adverse perinatal outcome, demonstrating better accuracy than that of mean uterine artery PI Z-score (AUC, 0.593; 95% CI, 0.50-0.69) and CPR Z-score (AUC, 0.615; 95% CI, 0.52-0.71). A multiparametric prediction model including Z-scores of MCA-PI, uterine artery PI and UVBF/AC had an AUC of 0.745 (95% CI, 0.66-0.83) for the prediction of composite adverse perinatal outcome. CONCLUSION: While CPR and uterine artery PI assessed at the time of diagnosis are associated independently with composite adverse perinatal outcome in pregnancies complicated by late-onset FGR, their diagnostic performance for composite adverse perinatal outcome is low. UVBF/AC showed better accuracy for prediction of composite adverse perinatal outcome, although its usefulness in clinical practice as a standalone predictor of adverse pregnancy outcome requires further research. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Papel de la ecografía Doppler en el momento del diagnóstico de la restricción del crecimiento fetal de aparición tardía para la predicción de resultados perinatales adversos: estudio prospectivo de cohortes OBJETIVO: Los embarazos complicados por la restricción del crecimiento fetal (RCF) de aparición tardía tienen un mayor riesgo de morbilidad a corto y largo plazo. A pesar de ello, es difícil identificar los casos con mayor riesgo de resultados perinatales adversos en el momento del diagnóstico de RCF. Los objetivos de este estudio fueron dilucidar la fortaleza de la asociación entre los índices Doppler fetoplacentarios en el momento del diagnóstico de la RCF de aparición tardía y el resultado perinatal adverso, y determinar su precisión predictiva. MÉTODOS: Este fue un estudio prospectivo de embarazos consecutivos con feto único complicados por una RCF de aparición tardía. La aparición tardía de la RCF se definió como peso estimado del feto (PEF) o circunferencia abdominal (CA) <3er percentil, o PEF o CA <10o percentil junto con índice de pulsatilidad (IP) de la arteria umbilical (AU) >95o percentil, o una relación cerebroplacentaria (RCP) <5o percentil, diagnosticado después de las 32 semanas. El PEF, el IP de la arteria uterina (IP-AU), el IP de la arteria cerebral media fetal (ACM), la RCP y el flujo sanguíneo de la vena umbilical normalizado para la circunferencia abdominal fetal (UVBF/AC, por sus siglas en inglés) se registraron en el momento del diagnóstico de RCF. Las variables Doppler se expresaron como puntuaciones Z para la edad gestacional. El resultado perinatal adverso compuesto se definió como la ocurrencia de al menos una cesárea de emergencia por sufrimiento fetal, test de Apgar a los 5 minutos <7, pH de la arteria umbilical <7,10 y el ingreso a la unidad de cuidados especiales de recién nacidos. Se utilizó el análisis de regresión logística para dilucidar la fortaleza de la asociación entre los diferentes parámetros de la ecografía y el resultado perinatal adverso compuesto, y se empleó el análisis de la curva de características operativas del receptor (ROC, por sus siglas en inglés) para determinar su precisión predictiva. RESULTADOS: En total, se incluyeron 243 embarazos con feto único consecutivos complicados por RCF de aparición tardía. El resultado perinatal adverso compuesto se produjo en el 32,5% (IC 95%, 26,7-38,8%) de los casos. En los embarazos con resultados perinatales adversos compuestos, en comparación con los que no los tuvieron, la puntuación Z del IP de la arteria uterina media (2,23±1,34 vs 1,88±0,89, P=0,02) fue mayor, mientras que las puntuaciones Z de UVBF/AC (-1,93±0,88 vs -0,89±0,94, P≤0,0001), IP-ACM (-1,56±0,93 vs -1,22±0,84, P=0,004) y RCP (-1,89±1,12 vs -1,44±1,02, P=0,002) fueron más bajas. En el análisis de regresión logística multivariable, las puntuaciones Z del IP de la arteria uterina media (P=0,04), RCP (P=0,002) y UVBF/AC (P=0,001) estuvieron asociadas de forma independiente con el resultado perinatal adverso compuesto. La puntuación Z del UVBF/AC tuvo un área bajo la curva (ABC) ROC de 0,723 (IC 95%, 0,64-0,80) para el resultado perinatal adverso compuesto, demostrando una mejor precisión que la de la puntuación Z del IP de la arteria uterina media (ABC, 0,593; IC 95%, 0,50-0,69) y la de la puntuación Z de la RCP (ABC, 0,615; IC 95%, 0,52-0,71). Un modelo de predicción multiparamétrico que incluía las puntuaciones Z del IP-ACM, el IP de la arteria uterina y el UVBF/AC resultó en un ABC de 0,745 (IC 95%, 0,66-0,83) para la predicción de un resultado perinatal adverso compuesto. CONCLUSIÓN: Aunque la RCP y el IP de la arteria uterina evaluados en el momento del diagnóstico están asociados de forma independiente con un resultado perinatal adverso compuesto en embarazos complicados por una RCF de aparición tardía, la eficacia del diagnóstico para el resultado perinatal adverso compuesto es baja. El UVBF/AC mostró una mayor precisión para la predicción de un resultado perinatal adverso compuesto, aunque su utilidad en la práctica clínica como parámetro indicativo independiente del resultado adverso del embarazo requiere más investigación. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Expected-value bias in routine third-trimester growth scans.

OBJECTIVES: Operators performing fetal growth scans are usually aware of the gestational age of the pregnancy, which may lead to expected-value bias when performing biometric measurements. We aimed to evaluate the incidence of expected-value bias in routine fetal growth scans and assess its impact on standard biometric measurements. METHODS: We collected prospectively full-length video recordings of routine ultrasound growth scans coupled with operator eye tracking. Expected value was defined as the gestational age at the time of the scan, based on the estimated due date that was established at the dating scan. Expected-value bias was defined as occurring when the operator looked at the measurement box on the screen during the process of caliper adjustment before saving a measurement. We studied the three standard biometric planes on which measurements of head circumference (HC), abdominal circumference (AC) and femur length (FL) are obtained. We evaluated the incidence of expected-value bias and quantified the impact of biased measurements. RESULTS: We analyzed 272 third-trimester growth scans, performed by 16 operators, during which a total of 1409 measurements (354 HC, 703 AC and 352 FL; including repeat measurements) were obtained. Expected-value bias occurred in 91.4% of the saved standard biometric plane measurements (85.0% for HC, 92.9% for AC and 94.9% for FL). The operators were more likely to adjust the measurements towards the expected value than away from it (47.7% vs 19.7% of measurements; P < 0.001). On average, measurements were corrected by 2.3 ± 5.6, 2.4 ± 10.4 and 3.2 ± 10.4 days of gestation towards the expected gestational age for the HC, AC, and FL measurements, respectively. Additionally, we noted a statistically significant reduction in measurement variance once the operator was biased (P = 0.026). Comparing the lowest and highest possible estimated fetal weight (using the smallest and largest biased HC, AC and FL measurements), we noted that the discordance, in percentage terms, was 10.1% ± 6.5%, and that in 17% (95% CI, 12-21%) of the scans, the fetus could be considered as small-for-gestational age or appropriate-for-gestational age if using the smallest or largest possible measurements, respectively. Similarly, in 13% (95% CI, 9-16%) of scans, the fetus could be considered as large-for-gestational age or appropriate-for-gestational age if using the largest or smallest possible measurements, respectively. CONCLUSIONS: During routine third-trimester growth scans, expected-value bias frequently occurs and significantly changes standard biometric measurements obtained. © 2019 the Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Impact of biometric measurement error on identification of small- and large-for-gestational-age fetuses.

OBJECTIVES: First, to obtain measurement-error models for biometric measurements of fetal abdominal circumference (AC), head circumference (HC) and femur length (FL), and, second, to examine the impact of biometric measurement error on sonographic estimated fetal weight (EFW) and its effect on the prediction of small- (SGA) and large- (LGA) for-gestational-age fetuses with EFW < 10th and > 90th percentile, respectively. METHODS: Measurement error standard deviations for fetal AC, HC and FL were obtained from a previous large study on fetal biometry utilizing a standardized measurement protocol and both qualitative and quantitative quality-control monitoring. Typical combinations of AC, HC and FL that gave EFW on the 10th and 90th percentiles were determined. A Monte-Carlo simulation study was carried out to examine the effect of measurement error on the classification of fetuses as having EFW above or below the 10th and 90th percentiles. RESULTS: Errors were assumed to follow a Gaussian distribution with a mean of 0 mm and SDs, obtained from a previous well-conducted study, of 6.93 mm for AC, 5.15 mm for HC and 1.38 mm for FL. Assuming errors according to such distributions, when the 10th and 90th percentiles are used to screen for SGA and LGA fetuses, respectively, the detection rates would be 78.0% at false-positive rates of 4.7%. If the cut-offs were relaxed to the 30th and 70th percentiles, the detection rates would increase to 98.2%, but at false-positive rates of 24.2%. Assuming half of the spread in the error distribution, using the 10th and 90th percentiles to screen for SGA and LGA fetuses, respectively, the detection rates would be 86.6% at false-positive rates of 2.3%. If the cut-offs were relaxed to the 15th and 85th percentiles, respectively, the detection rates would increase to 97.0% and the false-positive rates would increase to 6.3%. CONCLUSIONS: Measurement error in fetal biometry causes substantial error in EFW, resulting in misclassification of SGA and LGA fetuses. The extent to which improvement can be achieved through effective quality assurance remains to be seen but, as a first step, it is important for practitioners to understand how biometric measurement error impacts the prediction of SGA and LGA fetuses. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound markers for prediction of complex gastroschisis and adverse outcome: longitudinal prospective nationwide cohort study.

OBJECTIVES: To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value. METHODS: This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome. RESULTS: Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02-2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%). CONCLUSIONS: This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Management of delivery of a fetus with autosomal recessive polycystic kidney disease: a case report of abdominal dystocia and review of the literature.

BACKGROUND: Autosomal recessive renal polycystic kidney disease occurs in 1 in 20,000 live births. It is caused by mutations in both alleles of the PKHD1 gene. Management of delivery in cases of suspected autosomal recessive renal polycystic kidney disease is rarely discussed, and literature concerning abdominal dystocia is extremely scarce. We present a case of a patient with autosomal recessive renal polycystic kidney disease whose delivery was complicated by abdominal dystocia, and we discuss the factors that determined the route and timing of delivery. CASE PRESENTATION: A 23-year-old Caucasian woman, G2 P0, with a prior unremarkable pregnancy was referred to our tertiary center at 31 weeks of gestation because of severe oligoamnios (amniotic fluid index = 2) and hyperechogenic, dedifferentiated, and enlarged fetal kidneys. She had no other genitourinary anomaly. Fetal magnetic resonance imaging showed enlarged, hypersignal kidneys and severe pulmonary hypoplasia. We had a high suspicion of autosomal recessive renal polycystic kidney disease, and after discussion with our multidisciplinary team, the parents opted for conservative care. Ultrasound performed at 35 weeks of gestation showed a fetal estimated weight of 3550 g and an abdominal circumference of 377 mm, both above the 90th percentile. Because of the very rapid kidney growth and suspected risk of abdominal dystocia, we proposed induction of labor at 36 weeks of gestation after corticosteroid administration for fetal lung maturation. Vaginal delivery was complicated by abdominal dystocia, which resolved by continuing expulsive efforts and gentle fetal traction. A 3300-g (P50-90) male infant was born with Apgar scores of 1-7-7 at 1, 5, and 10 minutes, respectively, and arterial and venous umbilical cord pH values of 7.23-7.33. Continuous peritoneal dialysis was started at day 2 of life because of anuria. Currently, the infant is 1 year old and is waiting for kidney transplant that should be performed once he reaches 10 kg. Molecular analysis of PKHD1 performed on deoxyribonucleic acid (DNA) from the umbilical cord confirmed autosomal recessive renal polycystic kidney disease. CONCLUSIONS: Management of delivery in cases of suspected autosomal recessive renal polycystic kidney disease needs to be discussed because of the risk of abdominal dystocia. The route and timing of delivery depend on the size of the fetal abdominal circumference and the gestational age. The rate of kidney growth must also be taken into account.

Adherence to Swedish national pregnancy dating guidelines and management of discrepancies between pregnancy dating methods: a survey study.

BACKGROUND: Swedish national guidelines for pregnancy dating were published in 2010. Follow-up is needed to assess adherence and to identify whether any clinical topics are not covered in the guidelines. METHODS: All units in Sweden that performed ultrasound-based pregnancy dating were asked to complete a web-based questionnaire comprising multiple-response questions and commentary fields. Information was collected regarding baseline information, current and previous clinical practice, and management of discrepancies between last-menstrual-period- and ultrasound-based methods for pregnancy dating. RESULTS: The response rate was 79%. Half of the units offered first-trimester ultrasound to all pregnant women. However, contrary to the guidelines, the crown-rump length was not used for ultrasound-based pregnancy dating in most units. Instead, ultrasound-based pregnancy dating was performed only if the biparietal diameter was between 21 and 55 mm. Management of discrepancies between methods for pregnancy dating varied widely. CONCLUSIONS: The units reported high adherence to national guidelines, except for early pregnancy dating, for which many units followed unwritten or informal guidelines. The management of discrepancies between last-menstrual-period-based and ultrasound-based estimated day of delivery varied widely. These findings emphasize the need for regular updating of national written guidelines and efforts to improve their implementation in all units.

Extraction of foetal ECG from abdominal ECG by nonlinear transformation and estimations.

BACKGROUND AND OBJECTIVE: This paper proposes a simple yet effective method for the extraction of foetal ECG from abdominal ECG which is necessary due to similar spatial and temporal content of mother and foetal ECG. METHODS: The proposed algorithm for extraction of foetal ECG (fECG) from abdominal signal uses single channel. Pre-processing of abdominal ECG (abdECG) has been done to eliminate noise and condition the signal. The maternal ECG R-peaks have been detected based on thresholding, first order Gaussian differentiation and zero cross detection on pre-processed signal. Having identified R-peaks and pre-processed signal as base, using Maximum Likelihood Estimation, one beat including QRS complex morphology of maternal ECG (mECG) has been constructed. Extraction of maternal ECG from abdECG is done based on the constructed beat, R-peak locations and its corresponding QRS complex of abdECG. Extracted mECG has been cancelled from abdECG. This results in foetal ECG with residual noise. The noise has been reduced by Polynomial Approximation and Total Variation (PATV) to improve SNR. This approach ensures no loss of partially or completely overlapped fECG signals due to mECG removal. The algorithm is tested on three database namely daISy (DBI), Physiobank challenge 2013 (DBII) and abdominal and direct foetal ECG database (adfecgdb) of Physiobank (DBIII). RESULTS: The algorithm detected no false positives or false negatives with certain channel for DBI, DBII and DBIII which shows that the proposed algorithm can achieve good performance. Overall accuracy and sensitivity of the system is 98.53% and 100% for DBI. Best accuracy and sensitivity of 97.77% and 98.63% are obtained for DBII. Best accuracy of 92.41% and sensitivity of 93.8% are obtained for DBIII. Correlation coefficient between actual foetal heart rate (fHR) and estimated fHR of 0.66 for DBII and 0.59 for DBIII is obtained. The method has obtained overall F1 score of 99.25% for DBI, 96.04% for DBII and 94.25% for DBIII. It has obtained a best MSE of fHR and overall MSE of R-R interval which is 10.8bpm2 and 2.2 ms for DBII, 12bpm2 and 2.14 ms for DBIII. CONCLUSION: The results for different public databases show that the proposed method is capable of providing good results. The foetal QRS, R-peaks and R-R intervals have also been obtained in this method. Thus, it gives a significant contribution in the required area of research.