Placental Location in Maternal-Fetal Surgery for Myelomeningocele.

INTRODUCTION: Uterine incision based on the placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regard to maternal or fetal outcomes. OBJECTIVE: The aim of this study was to investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for fetal myelomeningocele (fMMC) closure. METHODS: Data from the international multicenter prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, December 15, 2010-June 31, 2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS: The placental location for 623 patients was evenly distributed between anterior (51%) and posterior (49%) locations. Intraoperative fetal bradycardia (8.3% vs. 3.0%, p = 0.005) and performance of fetal resuscitation (3.6% vs. 1.0%, p = 0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the 2 groups. However, thinning of the hysterotomy site (27.7% vs. 17.7%, p = 0.008) occurred more frequently in cases of an anterior placenta. Gestational age (GA) at delivery (p = 0.583) and length of stay in the neonatal intensive care unit (p = 0.655) were similar between the 2 groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with the placental location. CONCLUSIONS: An anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied, but the aggregate data from the fMMC Consortium did not show a significant impact on the GA at delivery or maternal or fetal clinical outcomes.

Can the Enhanced Transtheoretical Model Intervention (ETMI) Impact the Attitudes and Beliefs Regarding Low Back Pain of Family Medicine Residents.

BACKGROUND: Low back pain has been the leading cause for disability worldwide for several decades, and clinical guidelines for its management clearly emphasize a multifactorial approach. Yet, current guidelines are still not well implemented by clinicians. OBJECTIVES: To explore the attitudes of family medicine residents regarding low back pain and to determine whether they positively correlate with their treatment approaches. To test if these attitudes can be affected by the Enhanced Transtheoretical Model Intervention (ETMI), a guideline-based workshop. METHODS: Participants completed an online questionnaire regarding their attitudes toward low back pain and clinical habits, after which they attended an online ETMI educational workshop. One month later all participants were asked to complete the questionnaire a second time. Statistical analysis was conducted to explore the attitudes of the residents and clinical approaches, as well as any associations between them, as well as possible differences pre- and post-intervention. RESULTS: The participants exhibited highly psychologically oriented attitudes. Correlations between the attitudes and treatment did not show consistent coherency. Results regarding the participants clinical approaches were revealed to have two distinct and opposed inclinations: biomedically and biopsychosocially. Last, results for the re-activation subscale were significantly higher post-intervention. CONCLUSIONS: Family medicine residents seem to be highly psychologically oriented regarding low back pain; however, they do not necessarily treat their patients accordingly. Their clinical choices seem to follow two different approaches: guideline-consistent and non-guideline-consistent. An ETMI guideline-based workshop may sway their attitudes toward re-activation of patients. Further research is needed to determine whether similar results would arise in larger physician populations.

Ultrasound characteristics of early-stage high-grade serous ovarian cancer.

BACKGROUND: Survival from ovarian cancer is strongly dependent on the stage at diagnosis. Therefore, when confronted with a woman with an isolated adnexal mass, clinicians worry about missing the opportunity to detect cancer at an early stage. High-grade serous ovarian cancers account for 80% of ovarian cancer deaths, largely because of their tendency to be diagnosed at a late stage. Among adnexal masses, large size and the presence of solid areas on ultrasound examination have been found to be associated with cancer, but it is unclear whether these characteristics identify early-stage cases. OBJECTIVE: This study aimed to evaluate the ultrasound findings associated with clinically detected early-stage high-grade serous ovarian cancer. STUDY DESIGN: This was a retrospective cohort study of women diagnosed with stage I or II high-grade serous ovarian or fallopian tube cancer measuring at least 1 cm at pathology from 2007 to 2017. Preoperative ultrasound examinations were independently reviewed by 3 radiologists. Adnexal masses were scored for size and volume; overall appearance; presence, thickness, and vascularity of septations; morphology and vascularity of other solid components; and degree of ascites. Characteristics were compared between masses of <5 cm and larger masses and between stage I and stage II cases. Interobserver variability was assessed. RESULTS: Among 111 women identified, 4 had bilateral ovarian involvement, for a total of 115 adnexal masses characterized by ultrasound examination. The mean age at diagnosis was 61.8 years (range, 42-91 years). The median mass size was 9.6 cm (range, 2.2-23.6 cm) with 87% of cases having a mass size of ≥5 cm. A mixed cystic and solid appearance was most common (77.4%), but a completely solid appearance was more frequently seen for tumors of <5 cm compared with larger tumors (26.7% vs 13.0%). Solid components other than septations were seen in 97.4% of cases. The characteristics of stage I and II cases were similar other than ascites, which was more commonly seen in stage II cases (18.0% vs 3.1%, respectively). Interobserver concordance was high for size and volume measurements (correlation coefficients, 0.96-0.99), with moderate agreement observed across the other ultrasound characteristics (Fleiss kappa, 0.45-0.58). CONCLUSION: In this community-based cohort, early-stage high-grade serous cancers rarely presented as masses of <5 cm or masses without solid components other than septations. Our findings provide additional support for the observation of small masses without solid areas on ultrasound examination.

Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele.

BACKGROUND: Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. OBJECTIVE: The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. STUDY DESIGN: An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. RESULTS: From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). CONCLUSION: The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.

Fetal Congenital Pulmonary Airway Malformation: The Role of an Objective Measurement of Cardiomediastinal Shift.

OBJECTIVE: To examine the relationship between cardiomediastinal shift angle (CMSA) and adverse perinatal outcomes and hydrops in cases of congenital pulmonary airway malformation (CPAM). STUDY DESIGN: This retrospective study evaluated CPAM cases referred to our institution from 2008 to 2015. The primary outcome was a composite score for adverse perinatal outcome. CMSA was measured for each case and evaluated for its association with the primary outcome. The prediction accuracy of CMSA for adverse perinatal outcome was assessed using receiver operator characteristic (ROC) curves. RESULTS: Eighteen (21.2%) of the 85 cases experienced an adverse perinatal outcome. Increases in CMSA were associated with adverse perinatal outcomes and hydrops in bivariate analyses. Adjusted analyses found each 10-degree increase in CMSA to be associated with increased odds of an adverse perinatal outcome (adjusted odds ratio [aOR] 2.2, 95% confidence interval [CI]: 1.4-3.3) and hydrops (aOR 3.0, 95% CI: 1.5-6.1). CMSA performed well and was comparable to CPAM volume ratio in predicting adverse perinatal outcomes (area under the curve 0.81 and 0.84, respectively). CONCLUSION: We describe a novel measurement of mediastinal shift in cases of CPAM and its relationship with adverse perinatal outcomes and hydrops. These findings may shape the evaluation and management of CPAMs, improve our understanding of their prognosis, and influence patient counseling.

Uterine artery pseudoaneurysm in the setting of deep endometriosis: an uncommon cause of hemoperitoneum in pregnancy.

Uterine, ovarian, and placental pathologies are among the differential considerations for a pregnant woman presenting with abdominal and pelvic pain. Imaging plays a key role in the initial work-up of these patients. Sonography is often the first line test; however, evaluation of pelvic pathology can be limited in the gravid state, especially in mid- or late-term pregnancy. We present a case of a pregnant woman who came to the emergency room at 25 weeks with acute abdominal and pelvic pain. Both ultrasound and MR imaging findings revealed intraperitoneal hemorrhage, initially of unknown origin, as well as endometriomas and deep endometriosis. Only postpartum imaging confirmed a uterine artery pseudoaneurysm (PSA) presumably due to decidual reaction in deep endometriosis. We speculate the intraperitoneal hemorrhage was subsequently due to the PSA. This case demonstrates that if hemorrhage is not recognized promptly, it can lead to hemodynamic instability, as well as premature labor and delivery.

Ultrasonography versus computed tomography for suspected nephrolithiasis.

BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).

Feasibility of Antegrade Contrast-enhanced US Nephrostograms to Evaluate Ureteral Patency.

Purpose To demonstrate the feasibility of contrast material-enhanced ulrasonographic (US) nephrostograms to assess ureteral patency after percutaneous nephrolithotomy (PCNL) in this proof-of-concept study. Materials and Methods For this HIPAA-compliant, institutional review board-approved prospective blinded pilot study, patients undergoing PCNL provided consent to undergo contrast-enhanced US and fluoroscopic nephrostograms on postoperative day 1. For contrast-enhanced US, 1.5 mL of Optison (GE Healthcare, Oslo, Norway) microbubble contrast agent solution (perflutren protein-type A microspheres) was injected via the nephrostomy tube. Unobstructed antegrade ureteral flow was defined by the presence of contrast material in the bladder. Contrast-enhanced US results were compared against those of fluoroscopic nephrostograms for concordance. Results Ten studies were performed in nine patients (four women, five men). Contrast-enhanced US demonstrated ureteral patency in eight studies and obstruction in two. One patient underwent two studies, one showing obstruction and the second showing patency. Concordance between US and fluoroscopic assessments of ureteral patency was evaluated by using a Clopper-Pearson exact binomial test. These results were perfectly concordant with fluoroscopic nephrostogram results, with a 95% confidence interval of 69.2% and 100%. No complications or adverse events related to contrast-enhanced US occurred. Conclusion Contrast-enhanced US nephrostograms are simple to perform and are capable of demonstrating both patency and obstruction of the ureter. The perfect concordance with fluoroscopic results across 10 studies demonstrated here is not sufficient to establish diagnostic accuracy of this technique, but motivates further, larger scale investigation. If subsequent larger studies confirm these preliminary results, contrast-enhanced US may provide a safer, more convenient way to evaluate ureteral patency than fluoroscopy. © RSNA, 2016 Online supplemental material is available for this article.

Distal Forearm Fracture Open Reduction-Internal Fixation: Sonographic Detection of Hardware Malalignment and Associated Tendon Injuries Missed by Radiography.

Tendon injury is a known complication of distal radius fracture plate and screw fixation. Targeted musculoskeletal sonography is uniquely capable of assessing both tendon integrity and hardware abnormalities not recognized on radiographs. Each of the 3 patients described presented with pain after an open reduction-internal fixation following a distal forearm fracture. In each patient, radiographic findings, specifically the hardware position, were interpreted as normal. Important radiographically occult observations were subsequently made with sonography, including 3 proud screws and tendon injuries, all of which required surgical treatment. This case series demonstrates the clinical utility of musculoskeletal sonography in symptomatic patients after distal radius open reduction-internal fixation with negative radiographic findings. In our practice, sonography has been the most useful modality for precluding missing or delaying the diagnosis and treatment of these hardware complications. We advocate its use as an adjunct in any department performing musculoskeletal imaging.

Sonographic Findings in Necrotizing Fasciitis: Two Ends of the Spectrum.

Necrotizing fasciitis is a rare but serious disease, and early diagnosis is essential to reducing its substantial morbidity and mortality. The 2 cases presented show that the key clinical and radiographic features of necrotizing fasciitis exist along a continuum of severity at initial presentation; thus, this diagnosis should not be prematurely ruled out in cases that do not show the dramatic features familiar to most clinicians. Although computed tomography and magnetic resonance imaging are considered the most effective imaging modalities, the cases described here illustrate how sonography should be recommended as an initial imaging test to make a rapid diagnosis and initiate therapy.

Amalgamated Histories: Tracing Quicksilver's Legacy Through Environmental and Political Bodies in Andean and Amazonian Gold Mining.

This article argues that the centuries-long history of mercury-gold amalgamation is crucial to contemporary debates surrounding global mercury pollution from artisanal and small-scale gold mining. Drawing on historical findings that examine Spanish colonial and Indigenous metallurgical knowledge as well as ethnographic and scientific research, we resituate the history of mercury amalgamation in Latin America, focusing on the Colombian Andes and the Peruvian Amazon - two regions where mercury pollution from artisanal and small-scale gold mining provokes international concern. We identify the policy pitfalls caused by overlooking the untold histories of the amalgamation process along with the European contribution to global mercury emissions rooted in these histories. By critically examining the curation of presentist narratives in UNESCO's memorialisation of Almadén's mercury mines as a World Heritage Site, narratives that also underpin initiatives by the United Nations to bring about a "mercury-free world," we demonstrate how such ahistorical framings contribute to the criminalisation of artisanal and small-scale gold miners, not only in Perú and Colombia but also worldwide. Our findings present an important first step in highlighting the histories of mercury and gold in the hands of artisanal and small-scale gold miners in Latin America.

Patient's evaluations and expectations of primary care medicine in Israel revisited after two decades - Health Service Research.

BACKGROUND: The European Task Force on Patient Evaluations of General Practice's (EUROPEP) internationally-validated questionnaire measures patients' satisfaction with their primary care physicians. A study published in 1999 showed positive evaluations of primary care among patients across Europe and included 1603 Israeli patients. Major changes have taken place during the past 20 years, in Israel's society, in the healthcare system, and particularly in primary care clinics. OBJECTIVES: The study aims to reevaluate patients' satisfaction with their primary care physicians and care clinics in Israel and compares the results to the 1999 survey. METHODS: A survey based on the EUROPEP questionnaire was conducted among 1617 people. Data collection was carried out by an internet panel for the Hebrew speaking population and by a phone questionnaire for the Arabic speaking population. RESULTS: The study's results show a significant reduction in satisfaction. Notably, patients' satisfaction with physicians' support relating to emotional problems and physicians' explanations about referrals and workup plans have dramatically deteriorated. CONCLUSIONS: The decrease in patients' satisfaction with primary care physicians and clinics found in the current study is concerning and requires recognition and further exploration. PRACTICE IMPLICATIONS: The results may be used as a baseline for future assessments of trends in patients' satisfaction.

Cerebellar hemorrhage on magnetic resonance imaging in preterm newborns associated with abnormal neurologic outcome.

OBJECTIVE: To investigate the relationship between cerebellar hemorrhage in preterm infants seen on magnetic resonance imaging (MRI), but not on ultrasonography, and neurodevelopmental outcome. STUDY DESIGN: Images from a cohort study of MRI in preterm newborns were reviewed for cerebellar hemorrhage. The children were assessed at a mean age of 4.8 years with neurologic examination and developmental testing using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition. RESULTS: Cerebellar hemorrhage was detected on both ultrasonography and MRI in 3 of the 131 preterm newborns evaluated, whereas smaller hemorrhages were seen only on MRI in 10 newborns (total incidence, 10%). Adjusting for gestational age at birth, intraventricular hemorrhage, and white matter injury, cerebellar hemorrhage detectable solely by MRI was associated with a 5-fold increased odds of abnormal neurologic examination compared with newborns without cerebellar hemorrhage (outcome data in 74%). No association with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition score was found. CONCLUSIONS: Cerebellar hemorrhage is not uncommon in preterm newborns. Although associated with neurologic abnormalities, hemorrhage seen only on MRI is associated with much more optimistic outcomes than that visible on ultrasonography.

Pseudo gallbladder sign in biliary atresia--an imaging pitfall.

BACKGROUND: Ultrasound (US) is used to identify causes of neonatal cholestasis. We describe a potential sonographic pitfall, the "pseudo gallbladder," in biliary atresia (BA). OBJECTIVE: To describe the Pseudo Gallbladder sign (PsGB sign). MATERIALS AND METHODS: Sonograms/clinical records of 20 confirmed BA infants and 20 non-BA cases were reviewed retrospectively. For the BA group, preoperative sonography and surgical and pathological findings were examined. For the non-BA group, sonographic features and pathological findings were examined. The PsGB sign is defined as a fluid-filled structure, located in the expected region of the gallbladder, measuring ≤ 15 mm in length but without a well-defined or normal-appearing gallbladder wall. RESULTS: A recognizable gallbladder and normal gallbladder wall were present in all non-BA infants. However, none of the BA infants had a sonographically normal gallbladder. Seventy-three percent of BA patients had a PsGB, and in 27% no gallbladder or gallbladder-like structure was detected. CONCLUSION: A gallbladder-like structure in BA is common and can be misinterpreted as a normal gallbladder, delaying diagnosis and therapy. Recognition of this imaging pitfall, described here as the pseudo gallbladder sign, will help avoid this error.

Placental thickness correlates with placenta accreta spectrum (PAS) disorder in women with placenta previa.

OBJECTIVE: To evaluate the association of placental thickness with placenta accreta spectrum disorder in placenta previa. METHODS: In this IRB-approved, retrospective study, ultrasound (US) reports were retrospectively queried for keyword previa. US performed closest to mid-gestation were included. Three measurements were performed at the thickest portion of the placenta on longitudinal transabdominal images. Operative reports and surgical pathology were used as the reference standard. Statistical analysis was performed using unpaired T-tests and receiver operating curve (ROC) analysis. RESULTS: Sixty-five patients with placenta previa were included: 38 with PAS disorder and 27 without PAS disorder, clinically or pathologically. 38/38 (100%) patients of PAS group and 16/27 (59.3%) patients of non-PAS group had history of prior cesarean section. The average placental thickness was 4.3 cm (range 1.8 cm to 7.8 cm) for PAS group and 3.0 cm (range 0.6 cm to 5.3 cm) for non-PAS group (p < 0.001). Placental thickness in patients without PAS disorder and history of prior cesarean section was 3.1 (± 1.1) cm. This was statistically different from patients who had history of prior cesarean section with PAS diagnosis (4.3 cm, P<0.01). Using ROC analysis, a threshold measurement of 4.5 cm leads to sensitivity of 50% and specificity of 96%. CONCLUSION: Our results demonstrate that among women with placenta previa, increased placental thickness at lower uterine segment correlates with placenta accreta spectrum disorder. A threshold of 4.5 cm can be useful for screening patients with placenta previa and risks factors for PAS.

Prenatal intraabdominal bowel dilation is associated with postnatal gastrointestinal complications in fetuses with gastroschisis.

OBJECTIVE: The purpose of this study was to determine whether prenatal intraabdominal bowel dilation (IBD) is associated with increased postnatal complications in fetuses with gastroschisis. STUDY DESIGN: A retrospective review was performed on all maternal-fetus pairs with prenatally diagnosed gastroschisis that was treated at the University of California San Francisco from 2002-2008. Postnatal outcomes were compared between fetuses with and without IBD. RESULTS: Forty-three of 61 maternal-fetal pairs met the criteria for inclusion. Sixteen fetuses (37%) had evidence of IBD. Fetuses with IBD were significantly more likely to have postnatal bowel complications (38% vs 7%; P = .037). The presence of multiple loops of IBD (n = 6) as opposed to a single loop (n = 10) was associated highly with bowel complications and increased time to full enteral feeding and length of hospital stay (100% vs 0% [P = .001]; 44 vs 23 days [P = .034]; 69 vs 27 days [P = .001], respectively). CONCLUSION: IBD is associated with increased postnatal complications in infants with prenatally diagnosed gastroschisis; however, this association seems to be limited to those with multiple loops of dilated intraabdominal bowel.

Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis.

STUDY OBJECTIVE: Ectopic pregnancy is a common concern in emergency departments (EDs) and remains the leading cause of first-trimester mortality. Pelvic ultrasonography by emergency physicians has been investigated as a diagnostic test for ectopic pregnancy. We present a meta-analysis of the use of emergency physician ultrasonography in the evaluation of patients at risk of ectopic pregnancy. METHODS: A structured search was performed of both MEDLINE and EMBASE. Inclusion criteria were that (1) the study reported original research on ED patients at risk for ectopic pregnancy; (2) an emergency physician performed and interpreted the initial pelvic ultrasonography; and (3) follow-up was conducted on all patients. Sensitivity was defined as the proportion of patients with ectopic pregnancy for which ED ultrasonography demonstrated no intrauterine pregnancy. A random-effects model was used to obtain summary test characteristics. RESULTS: The initial search showed 576 publications, abstract review yielded 60 with potential relevance, and 10 studies were included. There was a total of 2,057 patients, of whom 152 (7.5%) had ectopic pregnancy. The pooled sensitivity estimate was 99.3% (95% confidence interval [CI] 96.6% to 100%), negative predictive value was 99.96% (95% CI 99.6% to 100%), and negative likelihood ratio was 0.08 (95% CI 0.025 to 0.25), all without significant heterogeneity. CONCLUSION: The results of this meta-analysis suggest that in a wide variety of clinical settings, the use of bedside ultrasonography performed by emergency physicians as a diagnostic test for ectopic pregnancy provides excellent sensitivity and negative predictive value. Visualization of an intrauterine pregnancy by an emergency physician is generally sufficient to rule out ectopic pregnancy.

Supratentorial abnormalities in the Chiari II malformation, IV: the too-far-back ventricle.

OBJECTIVE: The sonographic diagnosis of fetal myelomeningocele (MMC) has improved mainly because the diagnostic focus has shifted from observation of the spinal abnormality to observation of cranial abnormalities. We describe an abnormality in the position of the occipital horn in fetuses with MMC. The occipital horn appears to be too posterior in location when compared to healthy fetuses. METHODS: We searched for all cases in which fetal MMC was sonographically detected from 1999 to 2009. Random controls from normal pregnancies were identified. We then measured the shortest distance of the edge of the occipital horn to the occipital bone in fetuses with MMC compared to healthy fetuses. Only fetuses with MMC who had normal-size ventricles were included. RESULTS: A total of 91 fetuses with MMC were identified. Twenty-six fetuses had a normal ventricle size. The gestational age range in this cohort was 18 weeks 5 days to 30 weeks 0 days. The comparison group of 39 healthy fetuses all had normal ventricles and had a gestational age range of 18 weeks 3 days to 35 weeks 2 days. After adjusting for gestational age, the statistical analysis showed that fetuses with MMC had significantly shorter measured distances from the posterior edge of the occipital horn to the occipital bone than healthy fetuses (P = .003). CONCLUSIONS: The occipital horn both appears to be and measures closer to the occipital bone in fetuses with MMC compared to healthy fetuses.