Sonographic large fetal head circumference and risk of cesarean delivery.

BACKGROUND: Persistently high rates of cesarean deliveries are cause for concern for physicians, patients, and health systems. Prelabor assessment might be refined by identifying factors that help predict an individual patient's risk of cesarean delivery. Such factors may contribute to patient safety and satisfaction as well as health system planning and resource allocation. In an earlier study, neonatal head circumference was shown to be more strongly associated with delivery mode and other outcome measures than neonatal birthweight. OBJECTIVE: In the present study we aimed to evaluate the association of sonographically measured fetal head circumference measured within 1 week of delivery with delivery mode. STUDY DESIGN: This was a multicenter electronic medical record-based study of birth outcomes of primiparous women with term (37-42 weeks) singleton fetuses presenting for ultrasound with fetal biometry within 1 week of delivery. Fetal head circumference and estimated fetal weight were correlated with maternal background, obstetric, and neonatal outcome parameters. Elective cesarean deliveries were excluded. Multinomial regression analysis provided adjusted odds ratios for instrumental delivery and unplanned cesarean delivery when the fetal head circumference was ≥35 cm or estimated fetal weight ≥3900 g, while controlling for possible confounders. RESULTS: In all, 11,500 cases were collected; 906 elective cesarean deliveries were excluded. A fetal head circumference ≥35 cm increased the risk for unplanned cesarean delivery: 174 fetuses with fetal head circumference ≥35 cm (32%) were delivered by cesarean, vs 1712 (17%) when fetal head circumference <35 cm (odds ratio, 2.49; 95% confidence interval, 2.04-3.03). A fetal head circumference ≥35 cm increased the risk of instrumental delivery (odds ratio, 1.48; 95% confidence interval, 1.16-1.88), while estimated fetal weight ≥3900 g tended to reduce it (nonsignificant). Multinomial regression analysis showed that fetal head circumference ≥35 cm increased the risk of unplanned cesarean delivery by an adjusted odds ratio of 1.75 (95% confidence interval, 1.4-2.18) controlling for gestational age, fetal gender, and epidural anesthesia. The rate of prolonged second stage of labor was significantly increased when either the fetal head circumference was ≥35 cm or the estimated fetal weight ≥3900 g, from 22.7% in the total cohort to 31.0%. A fetal head circumference ≥35 cm was associated with a higher rate of 5-minute Apgar score ≤7: 9 (1.7%) vs 63 (0.6%) of infants with fetal head circumference <35 cm (P = .01). The rate among fetuses with an estimated fetal weight ≥3900 g was not significantly increased. The rate of admission to the neonatal intensive care unit did not differ among the groups. CONCLUSION: Sonographic fetal head circumference ≥35 cm, measured within 1 week of delivery, is an independent risk factor for unplanned cesarean delivery but not instrumental delivery. Both fetal head circumference ≥35 cm and estimated fetal weight ≥3900 g significantly increased the risk of a prolonged second stage of labor. Fetal head circumference measurement in the last days before delivery may be an important adjunct to estimated fetal weight in labor management.

[ADVANCES IN FETAL THERAPY IN COMPLICATED MONOCHORIONIC PREGNANCIES AND IN SEVERE CONGENITAL DIAPHRAGMATIC HERNIA: FIVE YEARS EXPERIENCE].

INTRODUCTION: : Minimally invasive fetal therapeutic procedures reduce the morbidity and mortality in monochorionic (MC) twins and in fetuses with congenital diaphragmatic hernia (CDH). MC pregnancies share their blood systems due to communicating vessels over their single placenta and may develop specific complications: Twin-to-Twin transfusion syndrome (TTTS), Selective intrauterine growth restriction (sIUGR), Twin Anemia-Polycythemia Sequence (TAPS), Twin Reverse Arterial Perfusion Syndrome (TRAP) or anomalies in one. Half of complicated MC require intrauterine interventions. Severe CDH is linked to a high rate of neonatal death due to pulmonary hypoplasia. Fetoscopic tracheal occlusion (FETO) with a balloon improves postnatal outcome. AIMS: A fetal therapy center was established in the Hadassah Medical Centers, Jerusalem in 2011 for intrauterine interventions. We report our 5 years' experience. METHODS: This prospective cohort follows the outcome of MC pregnancies and cases of severe CDH which underwent therapeutic fetal procedures in Hadassah between the years 2011-16. RESULTS: Out of 114 procedures, 95 were in MC: 84 monochorionic diamniotic twins, 7 monochorionic monoamniotic twins, 2 dichorionic triamniotic triplets and 2 monochorionic triplets. We treated 65 TTTS cases with fetoscopy and laser ablation of communicating vessels. The survival rate of both twins was 58.5% and at least one survived in 81.5% of the cases. In 2nd/3rd trimesters selective termination of 15 cases the survival rate of the remaining twin was 87%. In 11 cases of TRAP sequence treated with laser ablation of the feeding vessel the survival of the remaining twin was 91%. In 19 fetoscopies in severe CDH, 12 were for balloon insertion and 7 for removal. Endotracheal balloon was successfully placed in 11 of 12 cases (10 left-sided, 1 right-sided CDH). Balloon removal was prenatally performed by elective fetoscopy (n=7) or by intrapartum urgent puncture. There were no intrauterine fetal deaths. In isolated left-sided CDH the survival was 57%, whereas none survived in non-isolated left-sided CDH and right sided CDH. CONCLUSIONS: In-utero procedures are safe for the mother and increase newborn survival in MC pregnancies, thus specialized clinics are life-saving. FETO is a therapeutic option for severe CDH. Our results meet similar achievements reported by other leading world centers.

Third- or Fourth-Degree Intrapartum Anal Sphincter Tears Are Associated With Levator Ani Avulsion in Primiparas.

OBJECTIVES: We evaluated primiparous women with clinically diagnosed third- and fourth-degree and anal sphincter tears, to evaluate the rate of levator ani muscle injury compared to primiparous women without sphincter tears. METHODS: Primiparous women delivering in our maternity ward with intrapartum diagnoses of third- or fourth-degree anal sphincter tears, repaired by the overlapping technique, were recruited to undergo 3-dimensional transperineal sonography of the pelvic floor anatomy, including the anterior and posterior compartments. Primiparas with uncomplicated vaginal deliveries were recruited as a comparison group. Patient files were examined, and maternal backgrounds and delivery and neonatal details were extracted for all patients. RESULTS: Ninety-four women with tears were recruited to the study group, and 464 women with normal vaginal deliveries constituted the comparison group. The groups differed significantly in the rates of levator ani defects: 38 of 94 women (40.4%) in the study group versus 75 of 464 (16.2%) in the comparison group (P < .001; odds ratio, 3.53; 95% confidence interval, 2.18­5.7). Neonatal head circumference differed significantly between the study and comparison groups: (mean ・} SD, 34.5 ・} 1.3 cm in the study group versus 33.9 ・} 1.3 cm in the comparison group; P= .005), as did birth weight (3322 ・} 430 g in the study group versus 3169 ・} 458 g in the comparison group; P= .007). The groups did not differ in maternal age, gestational age at delivery, length of second stage of labor, and rates of epidural anesthesia, episiotomy, and vacuum extraction. CONCLUSIONS: Third- and fourth-degree intrapartum sphincter tears are associated with levator ani avulsion. Knowledge of complex pelvic floor damage may allow for prompt referral to secondary preventive measures for pelvic floor disorders.

Third- or Fourth-Degree Intrapartum Anal Sphincter Tears Are Associated With Levator Ani Avulsion in Primiparas.

OBJECTIVES: We evaluated primiparous women with clinically diagnosed third- and fourth-degree and anal sphincter tears, to evaluate the rate of levator ani muscle injury compared to primiparous women without sphincter tears. METHODS: Primiparous women delivering in our maternity ward with intrapartum diagnoses of third- or fourth-degree anal sphincter tears, repaired by the overlapping technique, were recruited to undergo 3-dimensional transperineal sonography of the pelvic floor anatomy, including the anterior and posterior compartments. Primiparas with uncomplicated vaginal deliveries were recruited as a comparison group. Patient files were examined, and maternal backgrounds and delivery and neonatal details were extracted for all patients. RESULTS: Ninety-four women with tears were recruited to the study group, and 464 women with normal vaginal deliveries constituted the comparison group. The groups differed significantly in the rates of levator ani defects: 38 of 94 women (40.4%) in the study group versus 75 of 464 (16.2%) in the comparison group (P < .001; odds ratio, 3.53; 95% confidence interval, 2.18-5.7). Neonatal head circumference differed significantly between the study and comparison groups: (mean ± SD, 34.5 ± 1.3 cm in the study group versus 33.9 ± 1.3 cm in the comparison group; P= .005), as did birth weight (3322 ± 430 g in the study group versus 3169 ± 458 g in the comparison group; P = .007). The groups did not differ in maternal age, gestational age at delivery, length of second stage of labor, and rates of epidural anesthesia, episiotomy, and vacuum extraction. CONCLUSIONS: Third- and fourth-degree intrapartum sphincter tears are associated with levator ani avulsion. Knowledge of complex pelvic floor damage may allow for prompt referral to secondary preventive measures for pelvic floor disorders.

A large head circumference is more strongly associated with unplanned cesarean or instrumental delivery and neonatal complications than high birthweight.

OBJECTIVE: Fetal size impacts on perinatal outcomes. We queried whether the fetal head, as the fetal part interfacing with the birth canal, might impact on obstetric outcomes more than birthweight (BW). We examined associations between neonatal head circumference (HC) and delivery mode and risk of perinatal complications as compared to high BW. STUDY DESIGN: This was an electronic medical records-based study of term singleton births (37-42 weeks' gestation) from January 2010 through December 2012 (N = 24,780, 6343 primiparae). We assessed risks of unplanned cesarean or instrumental delivery and maternal and fetal complications in cases with HC or BW ≥95th centile (large HC, high BW) vs those with parameters <95th centile (normal). Newborns were stratified into 4 subgroups: normal HC/normal BW (reference, n = 22,548, primiparae 5862); normal HC/high BW (n = 817, P = 213); large HC/normal BW (n = 878, P = 265); and large HC/high BW (n = 537, P = 103). Multinomial multivariable regression provided adjusted odds ratio (aOR) while controlling for potential confounders. RESULTS: Infants with HC ≥95th centile (n = 1415) were delivered vaginally in 62% of cases, unplanned cesarean delivery 16%, and instrumental delivery 11.2%; 78.4% of infants with HC <95th centile were delivered vaginally, 7.8% unplanned cesarean, and 6.7% instrumental delivery. Odds ratio (OR) for unplanned cesarean was 2.58 (95% confidence interval [CI], 2.22-3.01) and for instrumental delivery OR was 2.13 (95% CI, 1.78-2.54). In contrast, in those with BW ≥95th centile (n = 1354) 80.3% delivered vaginally, 10.2% by unplanned cesarean (OR, 1.2; 95% CI, 1.01-1.44), and 3.4% instrumental delivery (OR, 0.46; 95% CI, 0.34-0.62) compared to infants with BW <95th centile: spontaneous vaginal delivery, 77.3%, unplanned cesarean 8.2%, instrumental 7.1%. Multinomial regression with normal HC/normal BW as reference group showed large HC/normal BW infants were more likely to be delivered by unplanned cesarean (aOR, 3.08; 95% CI, 2.52-3.75) and instrumental delivery (aOR, 3.03; 95% CI, 2.46-3.75). Associations were strengthened in primiparae. Normal HC/high BW was not associated with unplanned cesarean (aOR, 1.18; 95% CI, 0.91-1.54), while large HC/high BW was (aOR, 1.93; 95% CI, 1.47-2.52). Analysis of unplanned cesarean indications showed large HC infants had more failure to progress (27.7% vs 14.1%, P < .001), while smaller HC infants had more fetal distress (23.4% vs 16.9%, P < .05). CONCLUSION: A large HC is more strongly associated with unplanned cesarean and instrumental delivery than high BW. Prospective studies are needed to test fetal HC as a predictive parameter for prelabor counseling of women with "big babies."

Detailed transabdominal fetal anatomic scanning in the late first trimester versus the early second trimester of pregnancy.

OBJECTIVES: To compare visualization rates for early targeted organ scanning at gestational ages ranging from 11 weeks 3 days to 13 weeks 2 days versus 14 weeks 3 days to 16 weeks 2 days. METHODS: We conducted a prospective longitudinal study of patients who presented for nuchal translucency (NT) screening and targeted organ scanning. Extended targeted organ scanning, including the central nervous system, face and neck, chest, heart (including complete echocardiography), digestive system, abdominal wall, urinary system, skeleton, and umbilical cord with its insertion and placenta, was performed on gravidas in 2 age ranges. Uterine artery Doppler mapping was performed during the second scan. All cases were examined twice: once at NT screening (up to 13 weeks 2 days) and again in the early second trimester. RESULTS: A total of 408 women were recruited and scanned twice. Three abnormalities were diagnosed in the second scan that were not seen in the first: dysplastic long bones, tricuspid stenosis, and cleft lip (without palate involvement). None had chromosomal anomalies. Successful visualization rates in all organ systems exceeded 94% in the second trimester. At the first-trimester scan, some systems had high success rates, whereas others were very low; eg, in the brain, the cerebellum and posterior fossa were visualized successfully approximately 50% of the time and the upper lip only approximately 10%. On fetal echocardiography, the 4-chamber view and outflow tracts were imaged successfully approximately 40% of the time, and the kidneys approximately 35%. Uterine artery Doppler mapping was possible in all patients on at least one side. On third-trimester follow-up, we diagnosed 1 mild pulmonary stenosis, 1 autosomal recessive polycystic kidney disease, and 1 ventricular septal defect. CONCLUSIONS: The early second-trimester scan was much more productive than targeted organ scanning performed during the NT window. When counseling women regarding the optimal time for early transabdominal targeted organ scanning, successful visualization rates for various organ systems should be considered.

Exome sequencing for structurally normal fetuses-yields and ethical issues.

The yield of chromosomal microarray analysis (CMA) is well established in structurally normal fetuses (0.4-1.4%). We aimed to determine the incremental yield of exome sequencing (ES) in this population. From February 2017 to April 2022, 1,526 fetuses were subjected to ES; 482 of them were structurally normal (31.6%). Only pathogenic and likely pathogenic (P/LP) variants, per the American College of Medical Genetics and Genomics (ACMG) classification, were reported. Additionally, ACMG secondary findings relevant to childhood were reported. Four fetuses (4/482; 0.8%) had P/LP variants indicating a moderate to severe disease in ATP7B, NR2E3, SPRED1 and FGFR3, causing Wilson disease, Enhanced S-cone syndrome, Legius and Muenke syndromes, respectively. Two fetuses had secondary findings, in RET and DSP. Our data suggest that offering only CMA for structurally normal fetuses may provide false reassurance. Prenatal ES mandates restrictive analysis and careful management combined with pre and post-test genetic counseling.

Fetoscopic laser surgery for twin-to-twin transfusion syndrome after 26 weeks of gestation.

OBJECTIVE: To compare the outcomes of twin-to-twin transfusion syndrome (TTTS) cases treated with fetoscopic laser coagulation of vascular anastomoses before 25 + 6 weeks of gestation and between 26 and 28 weeks of gestation. MATERIAL AND METHODS: 28 consecutive cases of TTTS at Quintero stages II-IV treated with laser therapy between 26 + 0 and 28 + 6 weeks of gestation were compared with 324 cases treated between 15 + 0 and 25 + 6 weeks during a 3-year period in two centers. The following data were recorded and compared: duration of the fetoscopy, rate of complications (preterm labor before 28 weeks and before 32 weeks, chorioamnionitis, twin anemia-polycythemia syndrome and recurrent TTTS), gestational age at delivery and neonatal survival rate. RESULTS: The study groups were similar as regards Quintero staging and the frequency of anterior placental location (50.0 vs. 47.8%, p = 0.85 in late and conventional laser, respectively). There were no significant differences in the duration of surgery (29 vs. 30, p = 0.27, respectively) and in the rates of any of the complications evaluated. Gestational age at delivery (33 vs. 33.3 weeks, p = 0.69) and neonatal survival of at least one fetus (92.3 vs. 88.6%, p = 0.24) were also similar. CONCLUSION: Fetoscopic laser coagulation for TTTS performed between 26 + 0 and 28 + 6 weeks of gestation was associated with similar outcomes as those observed in cases treated before 26 weeks.

Sonographic examination of the fetal vermis: tricks for obtaining the narrow midline target with 3-dimensional volume contrast imaging in the C plane.

Prenatal imaging of the fetal cerebellar vermis is challenging even for experienced examiners. We found that by aiming the ultrasound beam through the mastoid fontanel and then rotating the data set in a multiplanar reconstruction and applying volume contrast imaging in the C plane, we were consistently able to obtain images of the vermis in the standard midsagittal plane. Images of the fetal vermis suitable for morphologic evaluation were obtained in 408 of 414 cases (98.5%) at gestational ages of 18 weeks to 31 weeks 6 days; the examination time was only minimally increased.

Twin-to-twin transfusion syndrome (TTTS).

Twin-to-twin transfusion syndrome (TTTS) is a severe complication of monochorionic (MC) twin pregnancies, characterized by the development of unbalanced chronic blood transfer from one twin, defined as donor twin, to the other, defined as recipient, through placental anastomoses. If left untreated, TTTS is associated with very high perinatal mortality and morbidity rates, due to a combination of fetal and/or obstetric complications. The reported prevalence is 10-15% of all MC twins, or about 1 in 2000 pregnancies. This consensus document reviews available evidence and offers practical guidance to clinicians by providing recommendations on various aspects concerning diagnosis and management of TTTS.

Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies.

Selective intrauterine growth restriction (sIUGR) occurs in 10 to 15% of monochorionic (MC) twins, and it is associated with a substantial increase in perinatal mortality and morbidity. Clinical evolution is largely influenced by the existence of intertwin placental anastomoses: pregnancies with similar degrees of fetal weight discordance are associated with remarkable differences in clinical behavior and outcome. We have proposed a classification of sIUGR into three types according to umbilical artery (UA) Doppler findings (I-normal, II-absent/reverse end-diastolic flow, III-intermittent absent/reverse end-diastolic flow), which correlates with distinct clinical behavior, placental features and may assist in counseling and management. In terms of prognosis, sIUGR can roughly be divided in two groups: type I cases, with a fairly good outcome, and types II and III, with a substantial risk for a poor outcome. Management of types II and III may consist in expectant management until deterioration of the IUGR fetus is observed, with the option of cord occlusion if this occurs before viability. Alternatively, active management can be considered electively, including cord occlusion or laser coagulation. Both therapies seem to increase the chances of intact survival of the larger fetus, while they entail, or increase the chances of, intrauterine demise of the IUGR fetus.

Application of 3-dimensional ultrasonography to imaging the fetal anal canal.

OBJECTIVE: Ultrasonography has been applied previously to the assessment of the fetal anal canal. We aimed to examine the potential of 3-dimensional ultrasonography (3DUS) in the evaluation of the fetal anal canal and to obtain normal fetal anal canal measurements. METHODS: Patients were recruited from an unselected population of gravidas with known gestational age (by dates or first-trimester ultrasonography) and without known fetal anomalies presenting for fetal evaluation in the ultrasound units of 2 tertiary care centers between 16 and 39 gestational weeks. In addition to the ordered scan, 3DUS imaging of the fetal anal canal was performed. Transverse and sagittal views and volumes were obtained. Measurements of the fetal anal canal anteroposterior diameter, lateral diameter, and length were performed in transverse and sagittal planes, respectively, and scatterplots of these dimensions were created. Measurements were performed and repeated on raw data sets by 2 independent observers, and the results were analyzed to estimate interobserver and intraobserver reliability. RESULTS: A total of 186 patients were examined for this study at 16 to 39 weeks' gestation (mean, 27.4 weeks). The anteroposterior diameter of the fetal anal canal in this study group ranged from 4 to 21 mm (mean, 11.2 mm; SD, +/-3.5 mm), whereas the lateral diameter ranged from 7 to 18 mm (mean, 9.1 mm; SD, +/-3.0 mm). The length of the fetal anal canal in this study group ranged from 3 to 24 mm (mean, 14.3 mm; SD, +/-3.8 mm). CONCLUSIONS: Ultrasonographic assessment of the fetal anal canal with 3DUS is feasible. Scatterplots were created for internal anal sphincter width and length measurements from 16 to 39 weeks' gestation. Larger studies are necessary to establish nomograms of these measurements and their application to the evaluation of pathologic cases. We speculate that 3DUS assessment of the fetal anal canal may improve detection rates of disorders involving this system.

Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women.

OBJECTIVE: We evaluated rate of levator ani muscle (LAM) avulsion among primiparae using 3-dimensional transperineal ultrasound to identify possible risk factors for such trauma. STUDY DESIGN: We conducted a prospective observational study. Three-dimensional transperineal ultrasound was performed on all subjects. Primiparae were evaluated 24-72 hours after vaginal delivery. In all, 32 nulliparous gravidae (35-41 weeks) and 15 elective cesarean delivery primiparae were evaluated as methodological controls. We compared newborn head circumference (HC), birthweight, second stage duration, maternal age, baby sex, episiotomy, and instrumental delivery. RESULTS: LAM trauma was observed in 39 of 210 (18.8%) patients and no controls. Odds ratio for LAM trauma when newborn HC >or= 35.5 cm was 3.343 (95% confidence interval, 1.33-8.42); when second stage duration >or= 110 minutes, odds ratio was 2.27 (95% confidence interval, 1.07-4.81). Logistic regression showed that HC >or= 35.5 and second stage duration >or= 110 minutes increased odds of LAM trauma by a factor of 5.32. CONCLUSION: Large HC and prolonged second stage duration are risk factors in LAM trauma. Elective cesarean delivery may prevent LAM trauma.

Three-dimensional and four-dimensional ultrasound applications in fetal medicine.

PURPOSE OF REVIEW: To describe the state of the science of three-dimensional/four-dimensional ultrasound (3D/4DUS) applications to fetal medicine. RECENT FINDINGS: 3D/4DUS applications are many and varied. Their use in fetal medicine varies with the nature of the tissue to be imaged and the challenges each organ system presents, versus the advantages of each ultrasound application. We will here describe the research and clinical use of 3D/4DUS applications in fetal medicine today, as they are applied to greatest benefit to various organ systems. SUMMARY: 3D/4DUS has been extensively applied to the study of the fetus. Fetal applications include all types of anatomical assessment, morphometry and volumetry, as well as functional assessment. 3D/4DUS provides many advantages in fetal imaging; however, its contribution to improving the accuracy of fetal scanning over rates achieved with 2DUS, remains to be established.

[Diagnosis of congenital uterine anomaly using three-dimensional ultrasound].

The prevalence of uterine malformation is about 3% to 4% in general population. Half of these women manifest no clinical symptoms and discovering the malformation is incidental. The other half having congenital or acquired uterine malformation suffers from fertility problems or obstetric complications such as preterm labor, intrauterine growth restriction and pathological lie or presentation. Since some of this malformation can be surgically corrected, pre-surgical pelvic imaging has a diagnostic and therapeutic value. One of the common imaging methods is the pelvic ultrasonography. A major disadvantage of two-dimensional pelvic ultrasonography is its inability to reconstruct the uterine coronal axis. Imaging of this axis has major significance in the diagnosis of uterine fundus malformation. In recent years further advances in ultrasonography have led to three-dimensional ultrasonography (3DUS). This method enables multiplanner three-dimensional reconstruction of the uterus. This review shows the advantages of the three-dimensional ultrasound as a diagnostic tool. Several works are reviewed comparing this imaging method to others. The authors also present several examples of uterine malformations from their own experience.

Three-dimensional power Doppler (3DPD) ultrasound in the diagnosis and follow-up of fetal vascular anomalies.

OBJECTIVE: This study was undertaken to examine the value of 3-dimensional power Doppler (3DPD) ultrasound imaging in diagnosis and follow-up of fetal vascular anomalies. STUDY DESIGN: In 174 women undergoing early second-trimester targeted organ scanning, followed by a midtrimester second scan in a university hospital setting, 3DPD was applied to the fetal intra-abdominal and intrathoracic vessels. RESULTS: In 137 of 174 fetuses (75%) in the earlier scan, and in 164 of 174 fetuses (95%) in the later scan, 3DPD ultrasound successfully visualized the fetal vessels. In an additional 9 cases, anomalous vascularity was identified: fetal intra-abdominal umbilical vein varix (2), persistent right umbilical vein (1), agenesis of ductus venosus (2), eventration of diaphragm (1), parenchymal and vascular lung anomaly (1), sacrococcygeal teratoma (1), and chorioangioma (1). 3DPD improved diagnostic precision, aided our understanding of anomalous structure, and added information on the vascular volume of lesions in some cases. CONCLUSION: 3DPD improved ultrasound visualization of the fetal vessels of the abdomen and thorax in normal and anomalous cases.

Selective intrauterine growth restriction in monochorionic twins: pathophysiology, diagnostic approach and management dilemmas.

Selective intrauterine growth restriction (sIUGR) in monochorionic twins is associated with a substantial increase in perinatal mortality and morbidity for both twins. Clinical evolution depends on the combination of the effects of placental insufficiency in the IUGR twin with inter-twin blood transfer through placental anastomoses. Classification of sIUGR into types according to the characteristics of umbilical artery diastolic flow in the IUGR twin permits the differentiation of clinical and prognostic groups. sIUGR type I has normal diastolic flow and relatively good outcome. Type II is defined by persistently absent/reverse end-diastolic flow and is associated with a high risk of intrauterine demise of the IUGR twin and/or very preterm delivery. Type III is defined by the presence of intermittent absent/reverse end-diastolic flow (iAREDF), and is associated with 10-20% risk of unexpected fetal demise of the smaller twin and 10-20% risk of neurological injury in the larger twin. The management strategy for sIUGR with abnormal umbilical artery Doppler (types II and III) remains a challenge, and may include elective fetal therapy or close surveillance with fetal therapy or elective delivery in the presence of severe fetal deterioration. Small clinical series reporting the use of cord occlusion or laser therapy in severe cases suggest that the outcome of the larger twin might be improved. There is probably no single optimal strategy, since decisions will ultimately be influenced by the severity of IUGR, gestational age, parents' wishes and technical issues.

Three-dimensional transperineal ultrasonography of the pelvic floor: improving visualization for new clinical applications and better functional assessment.

OBJECTIVE: With increasing awareness of the scope of pelvic floor disorders has come development and introduction into clinical practice of new imaging techniques, with increasing importance of ultrasonography. Complex pelvic floor anatomy, the conceptual difficulty in the basics of some pelvic floor disorders, and the uneven standardization of ultrasonographic techniques were the impetuses of this review. The purpose of this study was to review the basic anatomy of the pelvic floor and the transperineal ultrasonographic evaluation technique and to provide an overview of the current clinical use of 3-dimensional transperineal ultrasonography in the evaluation of the anterior and posterior pelvic floor compartments. METHODS: A literature review illustrated with index cases from our center was conducted. RESULTS: Ultrasonography has been widely applied to evaluation of the anterior and posterior compartments of the pelvic floor. Three-dimensional ultrasonography has a role in improving pelvic floor assessment. CONCLUSIONS: Three-dimensional transperineal ultrasonography has been applied to evaluation of normal and pathologic pelvic floor anatomy. Practical application, through well-designed and sufficiently powered clinical studies, will establish the association between the clinical presentations of dysfunction with ultrasonographic findings.