Placental and umbilical cord anomalies detected by ultrasound as clinical risk factors of adverse perinatal outcome: Case series review of selected conditions. Part 1: Placental abnormalities.

BACKGROUND: The aim of this extended review of multicenter case series is to describe the prenatal ultrasound features and pathogenetic mechanisms underlying placental and umbilical cord anomalies and their relationship with adverse perinatal outcome. From an educational point of view, the case series has been divided in three parts; Part 1 is dedicated to placental abnormalities. METHODS: Multicenter case series of women undergoing routine and extended prenatal ultrasound and perinatal obstetric care. RESULTS: Prenatal ultrasound findings, perinatal care, and pathology documentation in cases of placental pathology are presented. CONCLUSIONS: Our case series review and that of the medical literature confirms the ethiopathogenetic role and involvement of placenta abnormalities in a wide variety of obstetrics diseases that may jeopardize the fetal well-being. Some of these specific pathologies are strongly associated with a high risk of poor perinatal outcome.

Clinical Presentations and Diagnostic Imaging of VACTERL Association.

Background: VACTERL association consists of Vertebral, Anorectal, Cardiac, Tracheo-Esophageal, Renal, and Limb defects. The diagnosis depends on the presence of at least three of these structural abnormalities. Methods: The clinical presentation and diagnostic prenatal imaging of VACTERL association are comprehensively reviewed. Results: The most common feature is a vertebral anomaly, found in 60-80% of cases. Tracheo-esophageal fistula is seen in 50-80% of cases and renal malformations in 30% of patients. Limb defects including thumb aplasia/hypoplasia, polydactyly, and radial agenesis/hypoplasia are present in 40-50% of cases. Anorectal defects, like imperforate anus/anal atresia, are challenging to detect prenatally. Conclusion: The diagnosis of VACTERL association mostly relies on imaging techniques such as ultrasound, computed tomography, and magnetic resonance. Differential diagnosis should exclude similar diseases such as CHARGE and Townes-Brocks syndromes and Fanconi anemia. New insights into genetic etiology have led to recommendations of chromosomal breakage investigation for optimal diagnosis and counseling.

Oral-facial-digital syndrome type VI: is C5orf42 really the major gene?

Oral-facial-digital type VI syndrome (OFDVI) is a rare phenotype of Joubert syndrome (JS). Recently, C5orf42 was suggested as the major OFDVI gene, being mutated in 9 of 11 families (82 %). We sequenced C5orf42 in 313 JS probands and identified mutations in 28 (8.9 %), most with a phenotype of pure JS. Only 2 out of 17 OFDVI patients (11.7 %) were mutated. A comparison of mutated vs. non-mutated OFDVI patients showed that preaxial and mesoaxial polydactyly, hypothalamic hamartoma and other congenital defects may predict C5orf42 mutations, while tongue hamartomas are more common in negative patients.

First trimester diagnosis of cervico-thoracic diastematomyelia and diplomyelia using three-dimensional ultrasound.

BACKGROUND: Diastematomyelia and diplomyelia are rare form of spinal cord malformations (SCM) characterized by sagittal cleft in the spinal cord, conus medullaris, and/or filum terminale with splaying of the posterior vertebral elements and duplication of the spinal cord into two twin cords. Prenatal diagnosis of these diseases by two-dimensional ultrasound has been reported usually late in pregnancy and only recently in the first trimester. OBJECTIVE: We describe the first case of cervico-thoracic diastematomyelia and diplomyelia diagnosed early in pregnancy using three-dimensional ultrasound.

Bifid uvula and familial Stickler syndrome diagnosed prenatally before the sonographic "equals sign" landmark.

PURPOSE: The prenatal ultrasound visualization of the soft palate and especially the uvula may be technically difficult due to its anatomy and presence of surrounding structures. A cleft involving the soft palate and the uvula is one of the clinical features of Stickler syndrome, a rare connective tissue disorder. MATERIALS AND METHODS: Third trimester scan performed at 30 weeks' gestation in a pregnant woman with a familial history of Stickler syndrome using conventional 2D ultrasound. RESULTS: Transabdominal scan performed with the fetal head in oblique plane and following fetal swallowing movements enabled a previously unrecognized median cleft at the level of the uvula. Molecular biology analysis allowed a precise prenatal diagnosis of Stickler syndrome and excluded overlapping syndrome. CONCLUSIONS: The prenatal ultrasound diagnosis was achieved time before the "equals signs" was proposed as a useful sonographic marker of a normal uvula. The identification of a bifid uvula by conventional 2D ultrasound led to a prenatal diagnosis of Stickler syndrome in this affected Family and allowed the neonatologist team to be available at the time of birth. Moreover, postnatal multispecialist follow up could be timely planned for targeted organ examination and appropriate management.

Craniosynostosis with wormian bone, bowing of the long bones, unilateral short femur, and focal fibula deficiency: a prenatal diagnostic dilemma.

The prenatal detection in the second trimester of pregnancy of a fetus with craniosynostosis, wide metopic suture, and wormian bone associated with bowing of the long bones, unilateral short femur, and focal fibula deficiency is reported. These ultrasonographic findings when not supported by a diagnostic molecular biology result represent a prenatal dilemma in term of both parent's counseling and management of potential overlapping skeletal diseases.

Umbilical Cord Diseases Affecting Obstetric and Perinatal Outcomes.

BACKGROUND: (1) The aim of this article is to describe the physiopathology underlying umbilical cord diseases and their relationship with obstetric and perinatal outcomes. (2) Methods: Multicenter case series of umbilical cord diseases with illustrations from contributing institutions are presented. (3) Results: Clinical presentations of prenatal ultrasound findings, clinical prenatal features and postnatal outcomes are described. (4) Conclusions: Analysis of our series presents and discusses how umbilical cord diseases are associated with a wide variety of obstetric complications leading to a higher risk of poor perinatal outcomes in pregnancies. Knowing the physiopathology, prenatal clinical presentations and outcomes related to umbilical diseases allow for better prenatal counseling and management to potentially avoid severe obstetric and perinatal complications.

OmniView algorithm: a novel 3-dimensional sonographic technique in the study of the fetal hard and soft palates.

The purpose of this pictorial essay is to report on the application of OmniView (GE Healthcare, Zipf, Austria), new 3-dimensional sonographic software, and its application in the prenatal sonographic study of the fetal hard and soft palates. We will show that this novel technique is easy and feasible, requires a limited learning curve, and provides correct volume interrogation of the region of interest. The OmniView algorithm may be useful in training programs, and volume data sets can be interpreted by experts in remote sites. Future prospective studies with consecutive patients will be necessary to evaluate whether the routine application of OmniView will increase the prenatal diagnosis of facial clefting, especially those with isolated palate defects.

Placental and Umbilical Cord Anomalies Diagnosed by Two- and Three-Dimensional Ultrasound.

The aim of this review is to present a wide spectrum of placental and umbilical cord pathologies affecting the pregnancy. Placental and umbilical cord anomalies are highly associated with high-risk pregnancies and may jeopardize fetal well-being in utero as well as causing a predisposition towards poor perinatal outcome with increased fetal and neonatal mortality and morbidity. The permanent, computerized perinatology databases of different international centers have been searched and investigated to fulfil the aim of this manuscript. An extended gallery of prenatal imaging with autopsy correlation in specific cases will help to provide readers with a useful iconographic tool and will assist with the understanding and definition of this critical obstetrical and perinatological issue.

Prenatal ultrasound and histological diagnosis of fetal nasal glioma (heterotopic central nervous system tissue): report of a new case and review of the literature.

INTRODUCTION: Nasal glioma is a rare, benign congenital midline facial lesion. MATERIALS AND METHODS: Prenatal ultrasound diagnosis performed at 2nd trimester of pregnancy revealed a right-sided mass at the level of the fetal face extending from the right internal canthus to the nasal bridge. CONCLUSION: Differential diagnosis of facial mass in the fetus represents a critical issue because is essential in guiding the prenatal counselling of the couple and in guiding the prenatal and/or postnatal management. Alternative diagnoses such as dacryocystocele, dermoid cyst, retinoblastoma or teratoma, hemangioma, and encephalocele that can not completely be excluded prenatally are discussed. Embryology, pathology, prenatal ultrasound diagnostic clusters of the lesion as well as MR imaging findings are discussed together with review of the literature.

Craniosynostosis: prenatal diagnosis by means of ultrasound and SSSE-MRI. Family series with report of neurodevelopmental outcome and review of the literature.

INTRODUCTION: Craniosynostosis is a condition characterized by a premature closure of one or more skull sutures and refers to a wide spectrum of cranial malformation with an estimated birth of 1:2,000-1:4,000 live births. Four receptors (FGFR 1, FGFR 2, FGFR 3, FGFR 4) involving mutation in the fibroblast growth factor have been identified. MATERIALS AND METHODS: Two cases occurred in the same family and diagnosed prenatally by means of ultrasound, and antenatal and postnatal MR imaging are reported. Molecular biology regarding identification of craniosynostosis type has been analyzed. A revision of the medical literature is also provided. CONCLUSION: The premature closure of sagittal suture is characterized by a disproportionately large occipito-frontal and short biparietal diameter (scaphocephaly). The prenatal ultrasound diagnosis of craniosynostosis in utero may be difficult and be suspected when the cephalic index, the cranial shape or the fetal face shape are abnormal. Fetal karyotype is recommended and DNA testing plays a critical role in achieving an appropriate diagnosis, when possible. The prognosis of craniosynostosis is primarily dependent on the presence of associated anomalies as craniosynostosis are correlated with three to fivefold increased risk for cognitive disabilities.

Multipotent mesenchymal stromal cells from amniotic fluid: solid perspectives for clinical application.

BACKGROUND: Mesenchymal stromal cells are multipotent cells considered to be of great promise for use in regenerative medicine. However, the cell dose may be a critical factor in many clinical conditions and the yield resulting from the ex vivo expansion of mesenchymal stromal cells derived from bone marrow may be insufficient. Thus, alternative sources of mesenchymal stromal cells need to be explored. In this study, mesenchymal stromal cells were successfully isolated from second trimester amniotic fluid and analyzed for chromosomal stability to validate their safety for potential utilization as a cell therapy product. DESIGN AND METHODS: Mesenchymal stromal cells were expanded up to the sixth passage starting from amniotic fluid using different culture conditions to optimize large-scale production. RESULTS: The highest number of mesenchymal stromal cells derived from amniotic fluid was reached at a low plating density; in these conditions the expansion of mesenchymal stromal cells from amniotic fluid was significantly greater than that of adult bone marrow-derived mesenchymal stromal cells. Mesenchymal stromal cells from amniotic fluid represent a relatively homogeneous population of immature cells with immunosuppressive properties and extensive proliferative potential. Despite their high proliferative capacity in culture, we did not observe any karyotypic abnormalities or transformation potential in vitro nor any tumorigenic effect in vivo. CONCLUSIONS: Fetal mesenchymal stromal cells can be extensively expanded from amniotic fluid, showing no karyotypic abnormalities or transformation potential in vitro and no tumorigenic effect in vivo. They represent a relatively homogeneous population of immature mesenchymal stromal cells with long telomeres, immunosuppressive properties and extensive proliferative potential. Our results indicate that amniotic fluid represents a rich source of mesenchymal stromal cells suitable for banking to be used when large amounts of cells are required.

Systemic endotoxin administration results in increased S100B protein blood levels and periventricular brain white matter injury in the preterm fetal sheep.

OBJECTIVE: Intrauterine infection is suggested to cause perinatal brain white matter injury. The aim of the present study was to clarify, whether intravenous application of endotoxin results in neuropathological findings and increased blood levels of the S100B protein, which is a consolidated marker of brain injury. METHODS: Twenty-one fetal sheep were chronically catheterized at a mean gestational age of 107+/-1 days (0.7 of gestation). Three days after surgery fetuses received either 100 (n = 9), 500 (n = 5) or 2500 ng (n = 1) lipopolysaccharide (LPS; E. coli; O127:B8, Sigma-Aldrich) or 2 ml 0.9% saline (n = 6) i.v. S100B protein blood levels were assessed before during and after LPS or placebo administration. Brain damage was evaluated by light microscopy. Selected areas of the periventricular white matter were also examined by electron microscopy. RESULTS: Histopathological screening revealed no evidence for cortical neuronal cell damage in both groups. However, LPS treatment resulted in inflammatory infiltrates in all animals and cystic lesions in the periventricular brain white matter in two fetuses. On electron micrographs, infiltrate forming cells appeared to be activated microglia. S100B protein blood levels were significantly higher in the LPS group at 1h (p < 0.01) after LPS injection, peaking at 3h (p < 0.001) and returning to baseline between 12 and 72 h. CONCLUSION: Intravenous application of endotoxin caused focal periventricular brain white matter injury, inflammation and an increase in S100B protein release. It is suggested that longitudinal investigations of S100B protein blood levels offer a tool for the early detection of white matter injury.

Three-dimensional ultrasonography by means of HDlive rendering in the first trimester of pregnancy: A pictorial review.

Our objective was to describe early embryo/fetus anatomy and abnormalities provided by three and four-dimensional (3D/4D) ultrasound using HDlive rendering technology in the first trimester of pregnancy. Normal and pathologic embryonic and fetal volume data set with postprocessing using HDlive rendering mode. Virtual fetoscopic imaging of the normal and pathologic fetus even at early stage of development with increasing maternal-fetal bonding process. HDlive represents a novel and valuable lightening system for 3D/4D ultrasound application that may aid the prenatal interpretation of early congenital malformations although limitations and cautions are still needed for inclusion in obstetric clinical practice.

Skeletal dysplasia with bowing long bones: Proposed flowchart for prenatal diagnosis with case demonstration.

OBJECTIVE: Skeletal dysplasia with bowing long bones is a rare group of multiple characterized congenital anomalies. MATERIALS AND METHODS: We introduce a simple, practical diagnostic flowchart that may be helpful in identifying the appropriate pathway of obstetrical management. RESULTS: Herein, we describe four fetal cases of bent bony dysplasia that focus on ultrasound findings, phenotype, molecular tests, distinctive X-ray features, and chondral growth plate histology. The first case was a typical campomelic dysplasia resulting from a de novo mutation in the SOX9 gene. The second fetus was affected by osteogenesis imperfecta Type II carrying a mutation in the COLA1 gene. The third case was a rare presentation of campomelic dysplasia, Cumming type, in which SOX9 examination was normal. Subsequently, a femoral hypoplasia unusual facies syndrome is also discussed. CONCLUSION: Targeted molecular tests and genetic counseling are required for supplementing ultrasound imaging in order to diagnose the correct skeletal disorders.

Amniotic fluid S100B protein in mid-gestation and intrauterine fetal death.

Fetal death in the mid-trimester of pregnancy is unexplained and no reliable markers are available to identify at-risk women. We aimed to assess use of alpha fetoprotein and S100B concentrations in amniotic fluid as markers. We did a case-control study in 758 healthy women undergoing amniocentesis at mid-gestation, of whom 12 had a spontaneous intrauterine fetal death before 28 weeks, and 746 matched controls. Concentrations were corrected for gestational age by conversion to multiples of median (MoM) of healthy controls of the same gestational age. Concentrations of S100B, but not alpha fetoprotein, were significantly higher (p<0.0001) in women who later had spontaneous fetal death (median 4.431 MoM [95%CI 3.605-6.197]) than in controls (1.000 MoM [1.062-1.121]). Sensitivity, specificity, and positive and negative predictive values of S100B as a diagnostic test were 100%, suggesting that measurement of this protein at amniocentesis could be useful to identify at-risk women.

S100B protein levels in saliva: correlation with gestational age in normal term and preterm newborns.

OBJECTIVES: S100B is an acidic calcium-binding protein of the EF-hand family present in the central nervous system, where it is concentrated in glial cells. It has been suggested to act as a cytokine with neurotrophic effects at physiological concentrations. DESIGN AND METHODS: S100B concentration was assessed in saliva by western blot analysis and an immunoluminometric assay. A reference curve of the protein was established in 216 preterm and term newborns. RESULTS: S100B levels were significantly higher in saliva taken from the preterm group, and the highest S100B levels were found in newborns who were delivered in the earlier weeks of gestation, exhibiting a progressive decrease nearer to term. S100B concentration in saliva was correlated with gestational age (r = -0.69; P < 0.001). CONCLUSIONS: The present study offers data consistent with the putative neurotrophic role of S100B and suggests the usefulness of saliva in the clinical monitoring of S100B levels.

Measurement of urinary S100B protein concentrations for the early identification of brain damage in asphyxiated full-term infants.

BACKGROUND: Perinatal asphyxia is a major cause of mortality and morbidity. To date there are no reliable methods to detect which infants will develop brain damage after asphyxia insult. We investigated whether measurements of urine levels of S100B in asphyxiated full-term newborns may be a useful tool for early detection of postasphyxia brain damage. METHODS: A prospective study of 38 infants with perinatal asphyxia and 96 control subjects, recruited at 3 tertiary departments of neonatology between April 1, 1999, and July 31, 2001. Routine laboratory variables, neurologic patterns, and urine concentrations of S100B protein were determined at 4 predetermined time points (first urination and 12, 24, and 72 hours after birth). The concentrations of S100B protein in urine were measured using an immunoluminometric assay. The results were correlated with the presence or absence of neurologic abnormalities at age 12 months. RESULTS: S100B protein levels were significantly higher in samples collected at all monitoring times from new-borns with abnormal neurologic findings on follow-up (first urination, 1.92 +/- 0.33 micro g/L; 12 hours, 2.78 +/- 1.71 micro g/L; 24 hours, 4.75 +/- 4.08 micro g/L; 72 hours, 5.93 +/- 1.63 micro g/L) than in samples from those without (first urination, 0.24 +/- 0.06 micro g/L; 12 hours, 0.13 +/- 0.06 micro g/L; 24 hours, 0.21 +/- 0.07 micro g/L; 72 hours, 0.12 +/- 0.04 micro g/L) or from healthy infants (first urination, 0.11 +/- 0.01 micro g/L; 12 hours, 0.12 +/- 0.03 micro g/L; 24 hours, 0.12 +/- 0.02 micro g/L; 72 hours, 0.12 +/- 0.02 micro g/L) (P<.001 for all). An S100B concentration cutoff of 0.28 micro g/L at first urination had a sensitivity of 100% and a specificity of 87.3% for predicting the development of abnormal neurologic findings on follow-up. The sensitivity and specificity of measurements obtained between 12 and 72 hours were up to 100% and 98.2%, respectively. CONCLUSION: Longitudinal S100B protein measurements in urine soon after birth are a useful tool to identify which asphyxiated infants are at risk of long-term neurologic sequelae.

Adrenomedullin increases in term asphyxiated newborns developing intraventricular hemorrhage.

OBJECTIVES: Adrenomedullin (AM) is a newly discovered vasodilator peptide that participates in the regulation of cerebral blood flow. The aim of this study was to investigate whether circulating AM was increased in infants with prenatal asphyxia who developed intraventricular hemorrhage (IVH). DESIGN AND METHOD: : A case-control study was performed on 40 full-term asphyxiated newborns: 20 developed IVH (group A) and 20 did not (group B). Forty term healthy newborns represented the control group. Biochemical laboratory parameters, neurological patterns, cerebral ultrasound scanning, and Doppler velocimetry were assessed at 12 and 72 h from birth. Plasma AM concentration was measured at 12 h from birth by means of a specific RIA. RESULTS: AM levels were significantly higher in group A (20.2 +/- 5.2 fmol/ml) than in group B (8.4 +/- 2.1 fmol/ml) or controls (9.3 +/- 2.6 fmol/ml). In asphyxiated newborns, AM concentration was correlated with middle cerebral artery PI value only in group B. CONCLUSIONS: Increased concentration of AM at 12 h from birth in asphyxiated newborns who later developed IVH suggests that this peptide may participate in the loss of cerebral vascular autoregulation in response to hypoxia and could be useful to discriminate, among newborns at risk, those with an adverse neurological outcome.

Amniotic fluid levels of S100B protein in normal and trisomy-21 foetuses.

BACKGROUND: The human chromosome 21 has been shown to contain the gene for the beta subunit of the S100B protein. The present case-control study was aimed at investigating whether overproduction of S100B protein is detectable in the amniotic fluid of foetuses with trisomy-21. METHODS: Measurements of S100B in amniotic fluid samples from 14 pregnant women with trisomy-21 foetuses were compared with those obtained from 182 physiological pregnancies. S100B was measured in the samples using an immunoluminometric assay (LIA-mat Sangtec 100). RESULTS: Our results showed that S100B protein amniotic fluid levels were significantly higher in trisomy-21 foetuses (0.83+/-0.21 microg/l) than in controls (0.51+/-0.22 microg/l) (p<0.05). CONCLUSION: The present finding supports the notion that the expression of S100B is increased in trisomy-21 foetuses; it also constitutes a prerequisite basis for a possible involvement of the protein in pathogenic processes associated with trisomy-21, and/or for its potential employment as a diagnostic tool.