The role of pediatric oncologist in prenatal diagnosis: A 10-year retrospective study at Assistance Publique Hôpitaux de Marseille (AP-HM).

Solid tumors or predisposition syndromes are increasingly suspected before birth. However optimal management and outcomes remain unclear. We have performed a ten-year retrospective study of oncologic indications of prenatal diagnosis in public hospitals in Marseille. Data were obtained from prenatal diagnosis center and hospital imaging databases and pediatric oncology department files. Fifty-one cases were identified, 40 with mass: adrenal 17, sacrococcygeal 9, cardiac 7, abdominal 4, ovarian 1, cervical 2; 8 with developmental abnormalities (omphalocele 4, macroglossia 4), 3 WITH familial predisposition syndromes (familial rhabdoid 2, Li-Fraumeni 1). Median detection time was 30 week. Termination of pregnancy was decided for 9 fetuses (4 cardiac lesions and suspected tuberous sclerosis, 2 sacrococcygeal tumors, 1 Beckwith-Wiedemann Syndrome, 2 SMARCB1 mutations. Preterm birth occurred in 8 cases. Eleven newborns (26,1%) required intensive care (8 for mechanical complications). Of of 17 adrenal mass ES, 4 disappeared before birth and 5 before one year. Seventeen newborns underwent surgery: 13 masses (teratoma 7, myelomeningocele 2, cystic nephroma 1, neuroblastoma 2), 4 omphaloceles, one biopsy. Surgery performed after one year for incomplete regression identified 1 neuroblastoma, 2 bronchogenic cysts and 2 nonmalignant masses. Three newborns received chemotherapy. Except one patient with BWS who died of obstructive apnea, all children are alive disease free with a median follow-up of 60 months [9-131 months]. Twelve have sequelae. Various solid tumors and cancer predisposition syndromes can be detected before birth. A multidisciplinary collaboration is strongly recommended for optimal management before and after birth.

The introduction of a universal transvaginal cervical length screening program is associated with a reduced preterm birth rate.

BACKGROUND: Midtrimester sonographic short cervix is a good predictor of preterm birth in singleton pregnancies. OBJECTIVE: This study aimed to assess the impact of implementing a universal transvaginal cervical length screening program on preterm birth rate. STUDY DESIGN: This study consisted of 2 parts: a before-and-after multicenter study and a study on the ECHOCOL ("echo"="ultrasound" and "col"="cervix" in French) prospective cohort. We compared the rate of preterm birth before and after the introduction of universal cervical length screening at the time of midtrimester anatomy ultrasound. The multicenter before-and-after regional study included all women with a singleton pregnancy who gave birth after 24 weeks' gestation in the South East of France from January 1, 2012 to April 30, 2018. In parallel, the ECHOCOL cohort study was prospectively conducted from May 2015 to July 2018, including 17 maternity hospitals in the South East region of France. In case of asymptomatic short cervix <25 mm, treatments offered included 200 mg of vaginal progesterone, or cerclage, or a pessary until 34 weeks' gestation. RESULTS: We observed a significant decrease rate of preterm birth between periods A and B after multivariate analysis. (respectively, 5.8% vs 5.6%; adjusted odds ratio, 0.92; 95% confidence interval, 0.89-0.95; P<.0001). In parallel, the percentage of cervical length screening significantly increased from 28.9% in period A to 52.9% in period B (odds ratio, 2.76; 95% confidence interval, 2.71-2.80; P<.0001). Among the 3468 patients of the ECHOCOL prospective cohort, 38 (1.1%) asymptomatic short cervices were detected, and 192 patients gave birth prematurely (11 with an asymptomatic short cervix and 181 without). In the ECHOCOL cohort, a marked but statistically insignificant tendency toward a reduced rate of preterm birth before 37 weeks of gestation was observed (from 5.8% to 5.5%; adjusted odds ratio, 0.72; 95% confidence interval, 0.51-1.03; P=.068). CONCLUSION: This study showed a significantly lower rate of preterm birth after the implementation of a universal cervical length screening and treating policy during the second trimester of pregnancy. The clinical trial was registered under NCT02598323.

Is failure of fetal head engagement during previous delivery a contraindication for trial of labor: A French retrospective study.

OBJECTIVE: To study whether history of cesarean delivery for arrest of descent (failure of fetal head engagement or unsuccessful instrumental delivery), is a factor of unsuccessful vaginal birth after cesarean delivery. METHODS: Multicenter prospective study of patients undergoing TOL after previous caesarean delivery between May 2012 and May 2013 in 6 maternities. Univariate statistical analysis was performed depending of previous cesarean delivery indication. Multivariate analysis was used to determine independent association between these factors and TOLAC success. RESULTS: Four hundred and eighty women with previous cesarean delivery were included and separated into two groups: the study group was composed of patients with history of CD for arrest of descent (failure of fetal head engagement or unsuccessful instrumental delivery) (n=31); control group included all other indications for CD (n=449). Overall, of the 480 women included in the study, 71.2 % underwent a TOL for a subsequent delivery (n=342): 68 % in the study group (n=21) vs 71.5 % in the control group (n=321). Vaginal birth after cesarean (VBAC) was obtained in 66.6 % vs 61% in the study and control group respectively (p=0.656). Univariate analysis of factors that may influence the success rate of (VBAC) did not show any difference between the two groups. Multivariate analysis showed that VBAC was only significantly associated with history of vaginal delivery subsequent to prior CD for arrest of descent. CONCLUSION: This study reassures us in our clinical practice allowing TOL in cases of history of CD for fetal head engagement failure or instrumental delivery failure in the second stage of labor.

Development of a nomogram for individual preterm birth risk evaluation.

OBJECTIVE: This study aimed to develop a new tool for personalised preterm birth risk evaluation in high-risk population. STUDY DESIGN: 813 high-risk asymptomatic pregnant women included in a French multicentric prospective study were analysed. Clinical and paraclinical variables, including screening for bacterial vaginosis with molecular biology, cervical length, have been used to create the nomogram, based on the logistic regression model. The validity was checked by bootstrap. A downloadable calculator was build. RESULTS: Nine risk factors were included in this model: history of late miscarriage and/or preterm delivery, active smoking, ultrasound cervical length, term of pregnancy at screening, bacterial vaginosis, premature rupture of membranes, daily travel more than 30min. Discrimination and calibration of the nomogram revealed good predictive abilities. The area under the receiver operating characteristic curve was 0.77 (95% CI; 0.72-0.81). The mean absolute error was 0.018, which showed proper calibration. The optimal risk threshold was 23.2% with a sensitivity of 74%, a specificity of 72.7% and a predictive negative value of 90.6%. CONCLUSION: The nomogram can help to better define individual preterm birth risk in high-risk pregnancies.

Preterm premature rupture of membranes at 22-25 weeks' gestation: perinatal and 2-year outcomes within a national population-based study (EPIPAGE-2).

BACKGROUND: Most clinical guidelines state that with early preterm premature rupture of membranes, obstetric and pediatric teams must share a realistic and individualized appraisal of neonatal outcomes with parents and consider their wishes for all decisions. However, we currently lack reliable and relevant data, according to gestational age at rupture of membranes, to adequately counsel parents during pregnancy and to reflect on our policies of care at these extreme gestational ages. OBJECTIVE: We sought to describe both perinatal and 2-year outcomes of preterm infants born after preterm premature rupture of membranes at 22-25 weeks' gestation. STUDY DESIGN: EPIPAGE-2 is a French national prospective population-based cohort of preterm infants born in 546 maternity units in 2011. Inclusion criteria in this analysis were women diagnosed with preterm premature rupture of membranes at 22-25 weeks' gestation and singleton or twin gestations with fetus(es) alive at rupture of membranes. Latency duration, antenatal management, and outcomes (survival at discharge, survival at discharge without severe morbidity, and survival at 2 years' corrected age without cerebral palsy) were described and compared by gestational age at preterm premature rupture of membranes. RESULTS: Among the 1435 women with a diagnosis of preterm premature rupture of membranes, 379 were at 22-25 weeks' gestation, with 427 fetuses (331 singletons and 96 twins). Median gestational age at preterm premature rupture of membranes and at birth were 24 (interquartile range 23-25) and 25 (24-27) weeks, respectively. For each gestational age at preterm premature rupture of membranes, nearly half of the fetuses were born within the week after the rupture of membranes. Among the 427 fetuses, 51.7% were survivors at discharge (14.1%, 39.5%, 66.8%, and 75.8% with preterm premature rupture of membranes at 22, 23, 24, and 25 weeks, respectively), 38.8% were survivors at discharge without severe morbidity, and 46.4% were survivors at 2 years without cerebral palsy, with wide variations by gestational age at preterm premature rupture of membranes. Survival at 2 years without cerebral palsy was low with preterm premature rupture of membranes at 22 and 23 weeks but reached approximately 60% and 70% with preterm premature rupture of membranes at 24 and 25 weeks. CONCLUSION: Preterm premature rupture of membranes at 22-25 weeks is associated with high incidence of mortality and morbidity, with wide variations by gestational age at preterm premature rupture of membranes. However, a nonnegligible proportion of children survive without severe morbidity both at discharge and at 2 years' corrected age.

Antenatal prognostic factor of fetal echogenic bowel.

OBJECTIVE: The aim of this study was to identify antenatal prognostic factors of neonatal outcomes in cases of fetal echogenic bowel (FEB). STUDY DESIGN: A retrospective study in three tertiary referral centers including fetal echogenic bowel over a 10-year period (from January 2003 to December 2013). The echogenicity of the fetal bowel was graded from 1 to 3, according to Slotnick's definition. Associated echographic findings such as bowel dilations, gallbladder abnormalities, calcifications, extra-abdominal abnormalities, intrauterine growth restriction (IUGR) and a decrease in amniotic fluid volume, if present were also recorded. This was followed by the FEB's sonographic evolution. The sonographic evolution was considered favorable if it was stable or decreasing and unfavorable if the echogenicity of the bowel increased or if additional sonographic findings appeared. Neonates had a pediatric examination in the delivery room and upon discharge from the maternity hospital. An outcome was considered good in the case of on-term delivery of a newborn with normal clinical examination and meconium elimination. RESULTS: Complete pregnancy outcome data were available for 409 pregnancies. 338 newborns had uneventful outcomes (82.6%). Antenatal exploration diagnosed 4 cases of aneuploidy (1 case of trisomy 13, 1 case of trisomy 18 and 2 cases of triploidies), 16 cases of congenital infections, 9 cases of cystic fibrosis and 11 cases of bowel abnormalities. After a multivariate analysis, we discovered the sonographic grade of the echogenic bowel was not a prognostic factor of neonatal outcome. The isolated fetal echogenic bowel had a 6.6-fold increase chance of uneventful outcomes (adjusted odd ratio (aOR) 6.6, 95% CI 3-14.4). Notably, favorable sonographic evolution (aOR 8.1, 95% CI 4.1-16) and late gestational age at the time of the diagnosis (aOR 1.17, 95% CI 1.07-1.27) are independent, good prognostic factors of good neonatal outcomes. None of the 180 fetuses with isolated fetal echogenic bowel and favorable sonographic evolution had adverse outcomes. Among these, 4 cases (0.98%) of aneuploïdy, 17 cases (4.2%) of congenital infections and 9 cases (2.2%) of cystic fibroses were also diagnosed. No cases of Down syndrome (DS) were reported. CONCLUSION: Our study shows that the grade should not be considered a prognostic factor of neonatal outcomes. Our data suggests the need to reevaluate the concept of systematic amniocentesis. Sonographic evolution of fetal bowel is an independent, strong prognostic factor for good neonatal outcomes. It also better defines the FEB prognostic.

Survival and morbidity of preterm children born at 22 through 34 weeks' gestation in France in 2011: results of the EPIPAGE-2 cohort study.

IMPORTANCE: Up-to-date estimates of the health outcomes of preterm children are needed for assessing perinatal care, informing parents, making decisions about care, and providing evidence for clinical guidelines. OBJECTIVES: To determine survival and neonatal morbidity of infants born from 22 through 34 completed weeks' gestation in France in 2011 and compare these outcomes with a comparable cohort in 1997. DESIGN, SETTING, AND PARTICIPANTS: The EPIPAGE-2 study is a national, prospective, population-based cohort study conducted in all maternity and neonatal units in France in 2011. A total of 2205 births (stillbirths and live births) and terminations of pregnancy at 22 through 26 weeks' gestation, 3257 at 27 through 31 weeks, and 1234 at 32 through 34 weeks were studied. Cohort data were collected from January 1 through December 31, 1997, and from March 28 through December 31, 2011. Analyses for 1997 were run for the entire year and then separately for April to December; the rates for survival and morbidities did not differ. Data are therefore presented for the whole year in 1997 and the 8-month and 6-month periods in 2011. MAIN OUTCOMES AND MEASURES: Survival to discharge and survival without any of the following adverse outcomes: grade III or IV intraventricular hemorrhage, cystic periventricular leukomalacia, severe bronchopulmonary dysplasia, retinopathy of prematurity (stage 3 or higher), or necrotizing enterocolitis (stages 2-3). RESULTS: A total of 0.7% of infants born before 24 weeks' gestation survived to discharge: 31.2% of those born at 24 weeks, 59.1% at 25 weeks, and 75.3% at 26 weeks. Survival rates were 93.6% at 27 through 31 weeks and 98.9% at 32 through 34 weeks. Infants discharged home without severe neonatal morbidity represented 0% at 23 weeks, 11.6% at 24 weeks, 30.0% at 25 weeks, 47.5% at 26 weeks, 81.3% at 27 through 31 weeks, and 96.8% at 32 through 34 weeks. Compared with 1997, the proportion of infants surviving without severe morbidity in 2011 increased by 14.4% (P < .001) at 25 through 29 weeks and 6% (P < .001) at 30 through 31 weeks but did not change appreciably for those born at less than 25 weeks. The rates of antenatal corticosteroid use, induced preterm deliveries, cesarean deliveries, and surfactant use increased significantly in all gestational-age groups, except at 22 through 23 weeks. CONCLUSIONS AND RELEVANCE: The substantial improvement in survival in France for newborns born at 25 through 31 weeks' gestation was accompanied by an important reduction in severe morbidity, but survival remained rare before 25 weeks. Although improvement in survival at extremely low gestational age may be possible, its effect on long-term outcomes requires further studies. The long-term results of the EPIPAGE-2 study will be informative in this regard.

Perceptions of lethal fetal abnormality among perinatal professionals and the challenges of neonatal palliative care.

BACKGROUND: After prenatal diagnosis of lethal fetal abnormality (LFA), some couples choose to continue the pregnancy rather than opt for termination of the pregnancy. This may result in the requirement for neonatal palliative care, which in France is prescribed by the Leonetti Law. These rare situations raise various questions about when and how palliative care is provided in cases of LFA. OBJECTIVE: The main goal of the study was to clarify the place given to the concept of perinatal palliative care within the antenatal information provided by perinatal professionals. This work was specifically aimed at revealing caregivers' perceptions of and attitudes toward LFA, how it is managed, and procedures for decision making and providing information. METHODS: This is a qualitative study using focus groups from two French Multidisciplinary Centers for Prenatal Diagnosis. All verbal production (individual statements, verbal exchanges, etc.) produced during the two focus groups was fully transcribed and the content analyzed. RESULTS: Content analysis revealed four main themes: (1) defining LFA; (2) the source and nature of information about LFA and how it is communicated; (3) therapeutic options and decisions in the management of LFA; and (4) palliative care (limits and criteria) in the context of LFA. CONCLUSIONS: Consistency as regards the perceived intention of care among all members of the health care team is essential to support parents facing a possible fatal outcome. Attitudes and practices at Multidisciplinary Centers for Prenatal Diagnosis need to be shaped on a national basis.

Fetal megacystis: etiologies, management, and outcome according to the trimester.

OBJECTIVE: To describe the diagnostic criteria and outcome of fetal megacystis according to the gestational age at diagnosis. METHODS: A 7-year retrospective study was carried out from 2004 to 2011, including cases of megacystis referred to 2 prenatal fetal medicine units. The following data were collected and analyzed: maternal age, term at diagnosis (gestational weeks), ultrasonographic and magnetic resonance imaging data, karyotype, decision of the multidisciplinary prenatal team, fetopathology in cases of termination of pregnancy or fetal death, final diagnosis at birth after ultrasonography and voiding cystourethrography, and medical and surgical follow-up. RESULTS: Of the 69 fetuses included in this study, 82.6% were males; 26 were diagnosed during the first trimester, 21 during the second, and 22 during the third. During the first trimester, the main etiologies were urethral occlusions and prune-belly syndrome with poor fetal prognosis. Nineteen pregnancies (69%) were terminated for medical reasons including the association with other malformations, poor evolution, or miscarriage. Only 4 children were born alive. The main etiologies of megacystis discovered during the second and third trimesters were vesicoureteral reflux and urethral occlusion. Twenty of 22 fetuses (91%) were born alive when the fetal megacystis was discovered after 27 weeks of gestation. CONCLUSION: Antenatal discovery of megacystis is a complex and challenging prognostic situation. The prognosis depends on the gestational age at discovery. Megacystis is not always associated with obstruction. In a newborn with megacystis, bladder outlet obstruction has to be excluded. Optimal counseling of the involved parents requires a multidisciplinary approach.

Short and medium-term outcomes of live-born twins after fetoscopic laser therapy for twin-twin transfusion syndrome.

OBJECTIVE: To evaluate short and medium term outcomes of children born of monochorionic pregnancies complicated by twin-twin transfusion syndrome treated by fetoscopic laser surgery. METHODS: This was a retrospective observational study performed between May 2007 and 2012. Neonatal data was from 45 patients under 5 years of age. The prospective observational study was of the neurologic outcome of these children using the Ages and Stages Questionnaire (ASQ), 2nd edition, French version, at up to 5 years of age. RESULTS: Neurologic assessment at discharge from maternity unit was normal for 41 infants (93.2%). Logistic regression suggested that the risk of neurosensory sequelae was significantly related to the status of donor [odds ratio=4.62 (1.18; 18.0)] and significantly preterm birth <32 weeks of gestation [odds ratio=5.50 (1.38; 21.9)]. Eleven questionnaires were considered abnormal (31.1%). Two children presented a severe neurologic abnormality (5.7%). There was no significant correlation between any area of the questionnaire and status at birth (donor or recipient). CONCLUSIONS: The data from our cohort, particularly as regards neurologic outcome, were satisfactory and concordant with previously published results. The use of the ASQ as a screening tool for neurologic outcome in children is original, which allowed in our cohort to highlight early neurological disorders.

Esophageal atresia, small omphalocele and ileal prolapse through a patent omphalomesenteric duct: a methimazole embryopathy? [Corrected].

Newborns prenatally exposed to methimazole (active metabolite of carbamizole) for maternal hyperthyroidism may present some disorders in common, but the phenotype is not well defined. Choanal atresia is the most frequent, and other anomalies such as esophageal atresia and aplasia cutis were described with this embryopathy. Additionally, patent omphalomesenteric duct or Meckel's diverticulum in similar association was reported in some patients. The predisposed genetic background has to be considered. We report the case of a newborn exposed to carbamizole during the first 4 weeks of pregnancy and define an association related to prenatal methamizole exposure consisting of esophageal atresia, small omphalocele, and ileal prolapse through a patent omphalomesenteric duct.

How to optimize excisional procedures for the treatment of CIN? The role of colposcopy.

PURPOSE: To evaluate the value of colposcopy during excisional treatment of cervical intraepithelial neoplasia (CIN). METHODS: Data from 469 women who underwent excisional treatment for CIN in three different hospitals between January 2005 and December 2009 were reviewed. Margins status and surgical specimen dimensions were analyzed according to the use of colposcopy during procedure. RESULTS: The rate of negative margins was not significantly different between women who had excision performed without colposcopic examination, with colposcopy immediately before excision and with direct colposcopic vision (DCV): 74 (62.2%), 186 (72.9%) and 25 (67.6%), respectively (p = 0.107). DCV allowed for significantly higher probability to achieve both negative margins and depth of specimen of less than 10 mm: 22 (18.5%) versus 70 (27.5%) versus 14 (37.8%), respectively (p = 0.039). In multivariate analysis, compared to women who had excision without any use of colposcopy, DCV allowed for significant and independent reduction in both depth (ß: -2.46; 95%CI: -4.45 to -0.47; p = 0.015) and diameter (ß: -4.80; 95%CI: -7.14 to -2.47; p < 0.001) of the surgical specimen. Compared to the use of colposcopy immediately before excision, DCV allowed for a significant and independent reduction in diameter of the surgical specimen (ß: -6.57; 95%CI: -8.78 to -4.35; p < 0.001) without significantly changing its depth (ß: -1.10; 95%CI: -3.01 to -0.80; p = 0.255). CONCLUSIONS: Use of colposcopy, and particularly of DCV during excisional procedures for CIN, allows for smaller surgical specimen without jeopardizing the margins status.

Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.

Foetal magnetic resonance imaging and echogenic bowel.

OBJECTIVES: To evaluate how foetal magnetic resonance imaging (MRI) may change the diagnosis in cases of ultrasound (U/S) findings of echogenic bowel (EB). METHODS: Seventeen foetuses with EB underwent serial U/S examinations, foetal MRI, cystic fibrosis screening and maternal viral serologic tests. MRI protocol included T2-weighted half-Fourier acquired single-shot turbo spin-echo (HASTE) sequence and gradient echo (GE) T1-weighted images. Foetal abdominal MRI analyzed patterns were size and signal of small bowel, colon and rectum, ascites and abdominal mass. All neonates had complete clinical examination, abdominal sonography, and a 6 months clinical follow-up. RESULTS: Eleven foetuses with isolated EB had normal MRI and normal outcome. In comparison, all the 6 foetuses whose U/S patterns showed associated signs had abnormal MRI (p < 0.001). Five had proven pathology (83.3%: 5/6) and only 1 (16.7%: 1/6) had no proven pathology and normal postnatal outcome (p = 0.001). For those five, foetal MRI showed bowel abnormalities with one case of bowel duplication and four cases of bowel obstruction. Two out of the four cases of bowel obstruction were genetically diagnosed as cystic fibrosis. The two remaining cases were diagnosed as ileal atresia. CONCLUSION: MRI could provide additive information in cases of EB associated with bowel dilatation.

Prenatally detected cystic adrenal mass associated with Beckwith-Wiedemann syndrome.

We report a case of a right-sided cystic adrenal mass, detected after the 21st week of gestation, associated with fetal macrosomia. The diagnosis of Beckwith-Wiedemann syndrome was evoked. Prenatal sonography and magnetic resonance imaging did not allow establishing the origin of the suprarenal mass. The differential diagnosis of cystic neuroblastoma, pseudocystic adrenal haemorrhage, and adrenocortical macrocysts was discussed. A laparotomy was performed 2 weeks after birth due to the increasing size of the tumour and due to its possible malignant origin. Histological findings were haemorrhagic lesions without evidence of malignancy and adrenal cortical cytomegaly. The diagnosis of an adrenocortical macrocyst component of Beckwith-Wiedemann syndrome was established.

Prenatal screening: invasive diagnostic approaches.

INTRODUCTION: Fetal invasive procedures provide ovular samples that are helpful in establishing diagnosis, etiology, and prognosis when ultrasonography and MRI show a central nervous system (CNS) anomaly or when the fetus is at high risk of such pathology. PROCEDURES: Invasive procedure techniques are amniocentesis, fetal blood sampling (FBS), and chorionic villous sampling (CVS). They provide material for fetal DNA, biochemical analysis, or identification of various infectious agents. COMPLICATIONS: The main complications are miscarriage and premature delivery. Counseling the parents about the risks and benefits of these procedures is therefore mandatory. DISCUSSION: Amniocentesis may be performed as early as 15 weeks' gestation and is the most widely used invasive technique. FBS is performed after 18 to 20 weeks of pregnancy and CVS may be carried out after 11 weeks. Indications for invasive techniques include DNA and cytogenetic analysis, diagnosis of neural tube defects, identification of infectious agents (toxoplasmosis, cytomegalovirus, rubella, and varicella), and etiology of intracerebral hemorrhage (fetal platelets and coagulation factors).

MR imaging of acquired fetal brain disorders.

INTRODUCTION: Acquired fetal brain disorders represent the third indication of fetal brain MRI, after ventricular dilatation and malformations of the central nervous system. DISCUSSION: MRI is an adequate imaging technique for evaluating fetal brain damage. Fetal brain response to brain injury may be acute, chronic or a combination of acute and chronic. An acute response is not as common in the fetal brain as in the postnatal period. A chronic response or the combination of chronic and acute response are the most common responses of the fetal brain to injury, whatever its origin. MRI also provides the natural history of acquired fetal brain lesions with regard to the stage of development.