Mild gestational thrombocytopenia in primiparous women, does it affect risk of early postpartum hemorrhage? A retrospective cohort study.

PURPOSE: To assess whether women with mild gestational thrombocytopenia have a higher risk of postpartum hemorrhage. METHODS: A retrospective computerized database. Primiparous women that delivered at our center (2005-2019) were included; we excluded women with possible etiologies for thrombocytopenia such as systemic lupus or coagulation disorders, and hypertensive disorder of pregnancy. Demographics, obstetric characteristics, and maternal as well as neonatal data were compared between groups. The exposure measure of the study was mild thrombocytopenia (100,000-150,000) versus normal thrombocyte count (>150,000) at admission for labor. Postpartum hemorrhage (PPH) is defined as a clinical estimated blood loss of > 500 mL and/or a hemoglobin drop of ≥ 3 g/dl. RESULTS: Overall, 39,886 primiparous met the study's criteria, 5,209 (13.1%) had mild gestational thrombocytopenia (mean platelet count of 132.4 ± 13.2, study group) while 34,677 (86.9%) had normal platelet count at admission (mean of 221.6 ± 50.6, comparison group.) PPH occurred in 17.6% of the study group as opposed to 14% in the comparison group (p < .001). Similarly, all measures of increased bleeding were more common in the study group as compared to the comparison group, including rates of hemoglobin drop greater than 4 and 5 gram/dl, parenteral iron infusion, and blood products transfusion. On multivariable analysis, the aOR for PPH among women in the study group was 1.23 [1.11-1.36]. CONCLUSION: Primiparous women with mild gestational thrombocytopenia are at increased risk of peripartum hemorrhage, this should be considered a risk factor when assessing parturients' risk of PPH.

Outcomes of attempted vaginal births after previous recurrent operative vaginal deliveries: An individual cumulative risk analysis.

BACKGROUND: Data about the risk of recurrence of vacuum extraction (VE) in multiple consecutive deliveries are scarce. We aimed to evaluate the pattern and individual cumulative risk of recurrence of VE in consecutive term deliveries. STUDY DESIGN: A retrospective cohort study based on a validated electronic database at a single center between 2005 and 2019. For the purpose of the study, we focused on consecutive term deliveries of all primiparas (P1) that had a record of at least one additional delivery during the study period. We identified P1 VE deliveries (reference group) and calculated the individual cumulative risk of repeated VE for three consecutive deliveries. Multivariate analysis was conducted adjusting for potential confounders. RESULTS: We identified 35 113 primiparas that met inclusion criteria. The overall VE rate for P1 was 17.9% (6969 parturient). The cumulative rates of repeated VEs at the 2nd, 3rd, and 4th deliveries were 8.6%, 26.8%, and 25.0%, respectively. The risk of recurrent VE for each of the consecutive deliveries was confirmed after adjustment for confounders (aOR [95% CI]: 5.8 [4.76-7.04], 34.2 [18.59-62.81], and 113.9 [9.77-1328.69] for the 2nd, 3rd, and 4th consecutive deliveries, respectively). CONCLUSION: Women with VE at the first and second deliveries have a substantially increased risk of VE in their following deliveries; this finding may influence woman's preference when choosing future mode of delivery.

A unique sonographic presentation of prenatal volvulus associated with malrotation.

This is a unique case of prenatal diagnosis of bowel malrotation suspected by an abnormal course of the duodenum. Early detection of volvulus was enabled, leading to timely intervention and a favorable outcome.

To drain or not to drain: intraperitoneal closed-suction drainage placement during cesarean delivery.

INTRODUCTION: Intraperitoneal closed suction drains are occasionally placed during cesarean delivery. This study aims to ascertain the prevalence, associated factors, outcome, and risks of intraperitoneal closed-suction drain placed during cesarean delivery. MATERIAL AND METHODS: A retrospective cohort study of all women undergoing cesarean delivery in a single center from 2005 to 2015. We excluded cases of cesarean hysterectomy and women who had hollow viscus injury. Cesarean deliveries were categorized into two groups based on intraperitoneal drain use: drain + and drain-.The study aims were to describe: (1) drain use prevalence; (2) factors associated with drain use; (3) interval to relaparotomy due to intraperitoneal bleeding and outcome of drain use; and (4) unique drain-related adverse outcome. Statistics: univariate, multivariable, and inverse probability treatment weighting (IPTW) analysis. RESULTS: After applying the inclusion and exclusion criteria, 16 581 (99.3%) cesareans were included. An intraperitoneal drain was used in 1264 (7.6%) cesareans, ranging from 4.4 to 18.8% in women with no and four or more cesareans, respectively. Comparing the drain + and drain- groups, multivariable analysis revealed that the factors associated with the use of a drain included (OR, 95%CI) uterine rupture (5.14, 3.15-8.38), intrapartum fever (2.65, 1.87-3.75), previous cesareans (2.29, 2.00-2.68), second-stage cesarean (2.21, 1.64-2.74), preterm delivery (1.89, 1.63-2.19), spontaneous onset of labor (1.42, 1.24-1.63), and maternal age greater than 35 years (1.35, 1.19-1.54); p < .001 for all. Of the forty-four women (0.27%) who underwent relaparotomy for intraperitoneal bleeding, there were fourteen in the intraperitoneal drain group. Inverse probability treatment weighting analysis demonstrated that median (interquartile range) times (hours) to relaparotomy were significantly shorter in the drain + group [3.5 (3.3-10.0) versus 12.5 (7.9-15.6), p < .001] and that puerperal fever incidence was higher in the drain + group (2.2 vs. 1.4%, p < .001). The incidence of relaparotomy to remove a retained drain or drain fragment was 0.48% (6/1264). CONCLUSIONS: Drain use in our study resulted in a shorter time to relaparotomy for intraperitoneal hemorrhage. However, it was associated with a higher risk for puerperal fever and a 0.5% risk for relaparotomy for removal of the drain.KEY MESSAGEIntraperitoneal drain placed during cesarean is used more often in complicated surgeries and is associated with a shorter interval to relaparotomy.

A new prenatal sonographic sign of epidermolysis bullosa.

We report on the prenatal sonographic appearance of epidermolysis bullosa (EB). The third viable pregnancy of a consanguineous couple was found at 23 weeks to have dysplastic external ears and nose. The neonate was born at 33 weeks and was found to have junctional EB with pyloric atresia. On reviewing the 23-week ultrasound images, skin denudation was evident. This is a report of visualization of skin denudation in EB. When EB is suspected prenatally, special attention should be given to the visualization of skin surfaces.

Vacuum extraction in twin deliveries-maternal and neonatal consequences: a retrospective cohort study.

PURPOSE: To establish the frequency of vacuum extraction among parturients with twin pregnancies, identify the risk factors and perinatal outcomes. METHODS: A retrospective cohort database study was conducted between 2005-2018. Twin fetuses with vertex presentation >34 weeks gestation who achieved vaginal delivery were included. Outcomes were compared between neonates who were delivered by vacuum extraction and neonates delivered by spontaneous vaginal delivery (aORs; [95% CI]). RESULTS: A total of 1751 neonates of 905 parturients with twin pregnancies met inclusion criteria, of which 163 (18%) parturients had vacuum extraction and 225 (12.8%) neonates were delivered by vacuum extraction. The most significant risk factors for vacuum extraction were primiparity (6.79 [4.77-9.66]), previous cesarean delivery (5.59 [3.13-9.97]), and epidural analgesia (4.34 [1.83-10.31]). Vacuum extractions were associated with a spectrum of adverse maternal outcomes (2.60 [1.61-4.19]), particularly postpartum hemorrhage and its associated morbidities. From the neonatal aspect, vacuum extraction deliveries were associated with a composite of birth trauma injuries (21.81 [6.43-73.91]). CONCLUSION: Vacuum extractions among twin pregnancies were found to be associated with significantly higher rates of postpartum hemorrhage, blood transfusion, and perinatal birth trauma. These findings should be presented to women when counseling on mode of delivery and considered individually against cesarean delivery disadvantages.

Duration of first vaginal birth following cesarean: Is stage of labor at previous cesarean a factor?

OBJECTIVE: Parturients in second delivery undergoing vaginal birth after cesarean (VBAC) are divided to those who had their cesarean delivery (CD) while in labor as opposed to those who had an elective CD. We aimed to study if the stage of labor that was present during the primary CD is associated with the duration of subsequent spontaneous VBAC. METHODS: A retrospective study (2006-2014). Multiparas in second delivery with a history of a CD (P2-VBAC) were sub-grouped based on stage of labor at which the CD was performed in the first delivery; elective, latent, first or second stage of labor, Duration of labor was compared between P2-VBAC (as one group and further as the sub-groups) to primiparas (P1), multiparas in second (P2) and third (P3) vaginal delivery (VD). A Cox regression analysis was performed including maternal age, preterm-delivery, regional anesthesia, oxytocin augmentation, birthweight and neonatal gender. RESULTS: A total of 58,028 parturients were included in the study. Mean duration of labor was significantly longer in parturients with a first VD (P1 and P2-VBAC) compared to repeat VD (P2 and P3), 6.0 versus 2.5 h, respectively, (P < 0.001). Analyzing duration of labor by the sub-groups of P2-VBAC revealed that spontaneous VD following a second-stage CD was associated with shorter duration of labor when compared with spontaneous VD following elective, latent and active first stage CD 4.2 versus 6.3, 7.0, 6.9 h respectively, p<0.001. CONCLUSION: Second stage CD shortens duration of the following VBAC compared to those who underwent cesarean in earlier stages of labor.

Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications.

BACKGROUND: Repeat cesarean delivery (CD) accounts for approximately 15% of all annual deliveries in the US with an estimated 656,250 operations per year. We aimed to study whether prolonged operative time (OT; skin incision to closure) is a risk marker for post-operative maternal complications among women undergoing repeat CD. METHODS: We conducted a cross-sectional retrospective study in a single tertiary center including all women who underwent repeat CD but excluding those with cesarean hysterectomy. Prolonged OT was defined as duration of CD longer than the 90th percentile duration on record for each specific surgeon in order to correct for technique differences between surgeons. Bi-variate analysis was used to study the association of prolonged OT with each one of the following maternal complications: post-operative blood transfusion, prolonged maternal hospitalization (defined as hospitalization duration longer than 1 week post-CD), infection necessitating antibiotics, re-laparotomy within 7 days post-CD, and re-admission within 42 days post-CD. A multivariate regression analysis was performed controlling for maternal age, ethnicity, parity, number of fetus, gestational age at delivery, trial of labor after cesarean, anesthesia, and number of previous CDs. The adjusted odd ratio was calculated for each complication independently and for a composite adverse maternal outcome defined as any one of the above. RESULTS: A total of 6507 repeat CDs were included; prolonged OT was highly associated (P value < 0.000) with: post-operative blood transfusion (4.4% vs. 1.5%), prolonged hospitalization (8.4% vs. 4.0%), infection necessitating antibiotics (2% vs. 1%), and readmission (1.8% vs. 0.8%) when compared to control. The composite adverse maternal outcome was also associated with prolonged OT (20.2% vs. 11.2%, p < 0.000). These correlations remained statistically significant in the multivariate regression analysis when controlling for confounders. CONCLUSIONS: Among women undergoing repeat CD, prolonged OT (reflecting CD duration greater than 90th percentile for the specific surgeon) is a risk marker for post-operative maternal complications.

First trimester expression of anorectal malformation: Case report and review of the literature.

A 26-years-old woman, underwent an ultrasound examination at 13.4 weeks. A cystic structure was identified in the right lower abdomen. Gradually, the cystic mass was replaced by echogenic content and eventually attained the appearance of hyperechoic bowel. At 21.2 weeks, the anal sphincter could not be demonstrated which was consistent with the diagnosis of isolated anal agenesis. Amniocentesis revealed 46XY karyotype with normal comparative genomic hybridization. After termination of pregnancy at 23 weeks, an autopsy revealed an isolated high type anorectal malformation (ARM) without fistula. We reviewed all 14 cases reported in the literature of first trimester sonographic expression of ARM.

Sliding Sign for Intra-abdominal Adhesion Prediction Before Repeat Cesarean Delivery.

BACKGROUND: The sliding sign (the relative motion between the abdominal and uterine wall as assessed by ultrasonography) may help identify severe intra-abdominal adhesions before repeat cesarean delivery. METHODS: We conducted a prospective observational study of scheduled repeat cesarean deliveries. Using transabdominal ultrasonography, while the parturient breathed deeply, the ultrasonographer recorded a video clip in a sagittal plane lateral to the umbilicus. These clips were assessed for the presence (sliding-positive) or absence (sliding-negative) of relative movement between the maternal abdominal and uterine wall. Surgeons blinded to ultrasonography results graded the severity of intraperitoneal adhesions intraoperatively. Study outcomes were the accuracy of the preoperative sliding sign for prediction of severe adhesions and its association with surgical times and bleeding. EXPERIENCE: We recruited 370 women. A negative sliding sign was associated with severe adhesions (sensitivity 56%, 95% CI 35-76; specificity 95%, 95% CI 93-97). A similar accuracy (sensitivity 64%, 95% CI 43-82; specificity 94%, 95% CI 92-97) was achieved by combining the sliding sign with a history of adhesions in the previous surgery. In multivariable models, a negative sliding sign was significantly correlated with a longer interval from skin incision to delivery and increased risk for bleeding. CONCLUSION: A negative sliding sign predicts severe intra-abdominal adhesions encountered during repeat cesarean delivery, longer time to delivery, and a higher chance of bleeding.

Delivering elsewhere between the first and second deliveries is a risk marker for obstetric complications in the second delivery.

PURPOSE: We speculate that parturients who deliver elsewhere between the first and second deliveries compose a unique clinical group, characterized by higher rates of cesarean section (CS) both in the first and second deliveries, compared with parturients who deliver both deliveries at the same hospital. METHODS: A retrospective study conducted at Shaare Zedek Medical Center in a tertiary university-affiliated hospital. The cohort included all women in the second delivery, aged ≤24 years with a singleton pregnancy who delivered their second child in our medical center during 2010-2012. Parturients who delivered both the first and second children in our medical center ("stayers") were compared with parturients who delivered their first child in a different hospital ("switchers"). Groups were compared in regard to history of CS in the first delivery and obstetric complications in the second delivery, including CS, instrumental vaginal delivery (IVD), preterm delivery (PTD), and postpartum hemorrhage (PPH). Logistic regressions were constructed to study if delivering elsewhere between the first and second deliveries was a risk for adverse pregnancy outcome, followed by multivariate analysis controlling for confounders. RESULTS: In all, 4166 parturients were included: "stayers" = 3163 and "switchers" = 1003. History of CS in the first delivery was approximately twice as prevalent in "switchers" (12 versus 6.3 %, p < 0.000). "Switchers" experienced higher rates of CS: OR = 1.8 (95 % CI 1.2-2.3); IVD: OR = 1.3 (95 % CI 0.8-2.1); and PTD (<37w): OR = 1.4 (95 % CI 1.0-1.9). CONCLUSIONS: Parturients who deliver elsewhere between the first and second childbirth are at increased risk for CS and PTD in the second delivery; hence, the decision to deliver elsewhere after the first delivery should be considered as a risk marker for obstetric complication.

Loss of function of PCDH12 underlies recessive microcephaly mimicking intrauterine infection.

OBJECTIVE: To identify the genetic basis of a recessive syndrome characterized by prenatal hyperechogenic brain foci, congenital microcephaly, hypothalamic midbrain dysplasia, epilepsy, and profound global developmental disability. METHODS: Identification of the responsible gene by whole exome sequencing and homozygosity mapping. RESULTS: Ten patients from 4 consanguineous Palestinian families manifested in utero with hyperechogenic brain foci, microcephaly, and intrauterine growth retardation. Postnatally, patients had progressive severe microcephaly, neonatal seizures, and virtually no developmental milestones. Brain imaging revealed dysplastic elongated masses in the midbrain-hypothalamus-optic tract area. Whole exome sequencing of one affected child revealed only PCDH12 c.2515C>T, p.R839X, to be homozygous in the proband and to cosegregate with the condition in her family. The allele frequency of PCDH12 p.R839X is <0.00001 worldwide. Genotyping PCDH12 p.R839X in 3 other families with affected children yielded perfect cosegregation with the phenotype (probability by chance is 2.0 × 10(-12)). Homozygosity mapping revealed that PCDH12 p.R839X lies in the largest homozygous region (11.7 MB) shared by all affected patients. The mutation reduces transcript expression by 84% (p < 2.4 × 10(-13)). PCDH12 is a vascular endothelial protocadherin that promotes cellular adhesion. Endothelial adhesion disruptions due to mutations in OCLN or JAM3 also cause congenital microcephaly, intracranial calcifications, and profound psychomotor disability. CONCLUSIONS: Loss of function of PCDH12 leads to recessive congenital microcephaly with profound developmental disability. The phenotype resembles Aicardi-Goutières syndrome and in utero infections. In cases with similar manifestations but no evidence of infection, our results suggest consideration of an additional, albeit rare, cause of congenital microcephaly.

Fetal Biometry in the Israeli Population: New Reference Charts.

BACKGROUND: Selection of appropriate reference charts for fetal biometry is mandatory to ensure an accurate diagnosis. Most hospitals and clinics in Israel use growth curves from the United States. Charts developed in different populations do not perform well in the Israeli population. OBJECTIVES: To construct new reference charts for fetal biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), using a large sample of fetuses examined at 14-42 weeks gestational age in a medical center and a community ultrasound unit located in two different regions of Israel. METHODS: Data from the medical center and the community clinic were pooled. The mean and standard error of each measure for each week was calculated. Based on these, reference charts were calculated using quantiles of the normal distribution. The performance of the reference charts was assessed by comparing the new values to empiric quantiles. RESULTS: Biometric measurements were obtained for 79,328 fetuses. Growth charts were established based on these measurements. The overall performance of the curves was very good, with only a few exceptions among the higher quantiles in the third trimester in the medical center subsample. CONCLUSIONS: We present new local reference charts for fetal biometry, derived from a large and minimally selected Israeli population. We suggest using these new charts in routine daily obstetric practice.

Impact of surgeon annual volume on short-term maternal outcome in cesarean delivery.

BACKGROUND: The annual procedure volume is an accepted marker for quality of care and has been documented in various medical fields. Surgeon volume has been shown to correlate with morbidity and mortality rates in surgical and high-risk medical procedures. Although cesarean delivery is 1 of the most common surgical procedures in the United States, the link between a surgeon's annual cesarean delivery volume and maternal outcome has never been tested. OBJECTIVE: The purpose of this study was to evaluate the impact of a surgeon's annual volume on short-term maternal outcome in cesarean deliveries. STUDY DESIGN: We performed a retrospective cohort study in a single tertiary center between 2006 and 2013. Cesarean deliveries were categorized into 2 groups based on the annual volume of cesarean delivery of the attending obstetrician. The "low" group included obstetricians with a low annual volume, whose annual volume of cesarean delivery was lower than median. The "high" group comprised obstetricians with a high annual volume whose annual volume was at median and above. Further analyses were done for quartiles and for 4 clinical relevant groups according to the annual number of cesarean deliveries that were performed/supervised by the attending obstetrician (≤20, 21-60, 61-120, and >120). The primary outcome was a composite adverse maternal outcome that included ≥1 of the following outcomes: urinary or gastrointestinal tract injuries, hemoglobin drop >3 g/dL, blood transfusion, relaparotomy, puerperal fever, prolonged maternal hospitalization, and readmission. Secondary outcomes were operative times (skin incision to delivery and overall). RESULTS: A total of 11,954 cesarean deliveries were included; the median annual number of cesarean deliveries that were performed/supervised by 1 obstetrician was 48. Unadjusted analysis suggested that the patients in the high group had fewer urinary and gastrointestinal injuries (18/9278 [0.2%] vs 16/2676 [0.6%] injuries; P < .001), less blood loss as measured by hemoglobin drop >3 g/dL (1053/9278 [11.5%] vs 366/2676 [13.8%]; P < .001), and fewer cases of prolonged maternal hospitalization (80/9278 [0.9%] vs 39/2676 [1.5%]; P = .006). The rate of blood transfusion, relaparotomy, puerperal febrile morbidity, and readmission to hospital did not differ between groups. Multivariable regression analysis showed that cesarean delivery performed/supervised by the high group resulted in a significantly lower composite adverse maternal outcome (15.8% vs 18.9%; odds ratio, 0.86; 95% confidence interval, 0.78-0.95; P = .004). This was related primarily to a decreased frequency of urinary and gastrointestinal injuries, lower likelihood of hemoglobin drop >3 g/dL, and lower incidence of prolonged maternal hospitalization. Operative times were significantly shorter for the high group. Composite adverse maternal outcome ranged from 21.8% in the lowest quartile to 17.9% in quartile 2, to 17.4% in quartile 3, and 15.6% in quartile 4. quartile 4 served as the reference; quartile 3 had an odds ratio of 1.14 (95% confidence interval, 1.01-1.29; P = .029); quartile 2 had an odds ratio of 1.18 (95% confidence interval, 1.02-1.36; P = .021, and quartile 1 had an odds ratio of 1.51 (95% confidence interval, 1.14-1.99; P = .004) for composite adverse maternal outcome. Composite adverse maternal outcome ranged from 21.5% in clinical group 1 to 17.5% in clinical group 2, to 17.9% in clinical group 3, and 15.2% in clinical group 4 (P = .001). Cesarean delivery performed/supervised by clinical groups 2, 3, and 4 in comparison with clinical group 1 were associated with a statistically significant risk reduction, (23%, 25%, and 34% respectively). CONCLUSION: Maternal composite morbidity is decreased as the volume of cesarean deliveries that are performed or supervised by obstetricians increases.

A comparison of methods for construction of fetal reference charts.

Reference charts for fetal measures are used for early detection of pregnancies that should be monitored closely. Construction of reference charts corresponds to estimation of quantiles of a distribution as a function of gestational age. Existing methods have been developed under various modeling assumptions, typically by fitting a polynomial regression to certain functionals of the distributions (e.g., mean, standard deviation, and quantiles). We use a large dataset to compare various existing methods for construction of reference charts. We also relax the assumptions of a parametric polynomial link between the distribution parameters and age and consider cubic splines and discretization of age in order to compare charts based on more flexible and simpler models, respectively. We compare the different methods using various tools and demonstrate the importance of considering performance measures calculated from age-stratified data. We also examine the question of sample size. We compare our charts to similar charts that have been recently published and emphasize that the source of an apparent heterogeneity should be investigated. We conclude that the choice of which method to use for construction of reference charts should take the following into account: available sample size, validity of normality assumption, and results of various performance measures.

Intrapartum fetal heart rate patterns of trisomy 21 fetuses: A case-control study.

BACKGROUND/AIM: To determine whether there are specific characteristic intrapartum heart rate patterns for fetuses with trisomy 21(T21). BACKGROUND STUDY DESIGN/PATIENTS: Intrapartum fetal heart rate (FHR) tracings of T21 fetuses were compared to those of euploid fetuses in a retrospective, observational, matched, case-control study. The study group consisted of 42 fetuses with T21 and 42 matched euploid controls. Matching was designed to accommodate possible confounders. The sign test and McNemar's test were used for categorical variables. The paired t test was used for comparison between quantitative variables. RESULTS: Intrapartum baseline FHR of fetuses with T21 was found to be slightly decreased compared to controls (122.5 vs 129.05 beats per minute, p=0.028). No differences were detected in the presence of periodic changes, or FHR variability between the groups. CONCLUSION: When evaluating intrapartum FHR of fetuses with T21, decreased baseline FHR can be expected.

Evaluating Spatiotemporal Image Correlation Technology as a Tool for Training Nonexpert Sonographers to Perform Examinations of the Fetal Heart.

OBJECTIVES: We aimed to evaluate the use of spatiotemporal image correlation (STIC) as a tool for training nonexpert examiners to perform screening examinations of the fetal heart by acquiring and examining STIC volumes according to a standardized questionnaire based on the 5 transverse planes of the fetal heart. METHODS: We conducted a prospective study at 2 tertiary care centers. Two sonographers without formal training in fetal echocardiography received theoretical instruction on the 5 fetal echocardiographic transverse planes, as well as STIC technology. Only women with conditions allowing 4-dimensional STIC volume acquisitions (grayscale and Doppler) were included in the study. Acquired volumes were evaluated offline according to a standardized protocol that required the trainee to mark 30 specified structures on 5 required axial planes. Volumes were then reviewed by an expert examiner for quality of acquisition and correct identification of specified structures. RESULTS: Ninety-six of 112 pregnant women examined entered the study. Patients had singleton pregnancies between 20 and 32 weeks' gestation. After an initial learning curve of 20 examinations, trainees succeeded in identifying 97% to 98% of structures, with a highly significant degree of agreement with the expert's analysis (P < .001). A median of 2 STIC volumes for each examination was necessary for maximal structure identification. Acquisition quality scores were high (8.6-8.7 of a maximal score of 10) and were found to correlate with identification rates (P = .017). CONCLUSIONS: After an initial learning curve and under expert guidance, STIC is an excellent tool for trainees to master extended screening examinations of the fetal heart.