Combined ultrasound and exome sequencing approach recognizes Opitz G/BBB syndrome in two malformed fetuses.

Orofacial clefts are the most common congenital craniofacial anomalies and can occur as an isolated defect or be associated with other anomalies such as posterior fossa anomalies as a part of several genetic syndromes. We report two consecutive voluntary pregnancy interruptions in a nonconsanguineous couple following the fetal ultrasound finding of cleft lip and palate and posterior fossa anomalies confirmed by means of post-termination examination on the second fetus. The quantitative fluorescent PCR, the karyotype, and the comparative genomic hybridization-array analysis after amniocentesis were normal. Exome sequencing on abortive material from both fetuses detected a missense mutation in MID1, resulting in a clinical diagnosis of Opitz G/BBB syndrome. The same mutation was found in the mother and in her brother, who both revealed cerebellar anomalies at an MRI examination. Our study supports the efficacy of exome sequencing in the presence of both a family history suggestive of an inherited disorder and well-documented ultrasound findings. It reveals the importance of a synergistic effort between gynecologists and geneticists aimed at the integration of the most sophisticated ultrasound techniques with the next-generation sequencing tools to provide a definite diagnosis essential to orient the final decision and to estimate a proper recurrence risk.

Bifid choroid plexus: always a normal fetal brain structure variant?

Choroid plexus, a fetal organ developing approximately from the sixth week of gestation, plays a fundamental role in developing fetal brain organization. As relatively little is known about the relationship between anomalies of choroid plexuses structure and their role in brain function, we examined cases of bifid choroid plexus (BCP) and discussed their potential association with lateral ventriculomegaly, other abnormal ultrasound findings, and their potential role as markers of fetal chromosomal abnormalities. In the present study, we described 23 cases of fetal BCP found in 2145 routine second trimester ultrasounds. For each patient 2D and 3D ultrasound volumes were acquired. BCP was defined as a choroid plexus whose body was divided into two portions (arms) differently located and oriented on the three spatial axes in correspondence to the lateral ventricle, in one or both sides. The entity of the separation and reciprocal orientation of the two arms was examined. The presence of BCP in a low-risk population of pregnant women undergoing routine second trimester ultrasound was showed. Lateral ventricles significantly increased in the presence of BCP. Malformations were found in four of 23 fetuses with BCP. Pregnancy outcome was favorable only in one of these four cases. We suggest that in the presence of mono or bilateral BCP without associated abnormal ultrasound findings, a closer look at fetal brain or extra-cranial structures is recommended. If no related abnormalities are found, serial prenatal and postnatal sonographic follow-up should be considered. In the presence of concomitant abnormal findings, genetic counseling, fetal karyotyping and magnetic resonance imaging, if possible by gestational age, are strongly advised.

Acrania-anencephaly associated with hypospadias. Prenatal ultrasound and MRI diagnosis and molecular folate metabolism pathway analysis.

Acrania may occur as a single isolated malformation or associated with extracranial defects. Hypospadias is one of the most common congenital abnormalities of the genitalia frequently missed on prenatal sonograms. Second trimester two- and three-dimensional ultrasound and MRI diagnosis with necropsy and folate metabolism pathway analysis. The mechanisms leading to closure of both neural and urethral tubes, are far from being demonstrated, and molecular studies of this very rare association are lacking although it might be based on a common genetic mechanism, leading to a disturbed development pathway at the molecular level.

Prenatal diagnosis of severe epignathus in a twin: case report and review of the literature.

A prenatal ultrasound diagnosis of epignathus in a dichorionic-diamniotic twin pregnancy is reported. A complex mass protruding from the fetal face was seen at week 19. Amniocentesis resulted in a 46,XX fetus with elevated alpha-fetoprotein (α-FP). An increase in tumor size and severe polyhydramnios ensued. Selective feticide performed at 22 weeks led to untreatable uterine contractions with iatrogenic abortion and early neonatal mortality of the healthy cotwin. Without development of polyhydramnios and tumor growth, weekly scan and transvaginal cervical assessment would have been carried out and cesarean section planned at around 32 weeks. Necroscopy and histology aided the ultrasound-based prenatal diagnosis.

4D vs 2D ultrasound-guided amniocentesis.

PURPOSE: The aim of this study was to assess the effectiveness of 4D sonography (US) to guide amniocentesis when compared with standard 2D US, and to evaluate the impact this new method may have on needle placement, the number of needle insertions performed, and duration of the procedure. METHODS: One hundred routine consecutive unselected amniocenteses were performed with 4D US-guided technique and compared with 100 standard 2D US-guided amniocenteses. All procedures were performed by trainees in maternal-fetal medicine under the supervision of expert sonographers. RESULTS: There were no significant statistical differences between 4D and 2D US-guided amniocenteses. The procedure time was longer with the 4D US guidance than with the 2D US guidance, but this difference was not statistically significant. A 2nd needle insertion was necessary in two cases with 4D US guidance and in three cases with 2D US guidance. A better visualization of the needle tip was observed in both techniques when a 20-gauge needle was used. CONCLUSION: The 4D US, which allows the needle tip to be displayed in real time in three orthogonal planes simultaneously, thus providing reassurance that no fetal parts are in the needle path, did not offer any advantage over 2D US in guiding routine midtrimester amniocentesis and this new modality has not yet proved effective in reducing the number of needle insertions.

Amniotic fluid urocortin, CRF, oestriol, dehydroepiandrosterone sulfate and cortisol concentrations at mid-trimester: putative relationship with preterm delivery.

OBJECTIVE: Stress-related peptide and steroid hormones are involved in the pathogenesis of preterm delivery, even though their clinical usefulness as predictive markers of preterm delivery remains unclear. The present study evaluated whether mid-trimester amniotic fluid concentrations of stress-related peptides, that is corticothophin-releasing factor (CRF) and urocortin (Ucn) and feto-placental steroids (oestriol, DHEA-S and cortisol) correlated with preterm delivery. STUDY DESIGN: It is a retrospective case-control study. Healthy women (n=130) undergoing amniocentesis at mid-gestation for genetic indications, of whom 15 had a preterm delivery (cases) and 115 delivered at term (controls). CRF, urocortin, cortisol, DHEA-S and oestriol concentrations were measured by specific and sensitive immunoenzymatic assays. RESULTS: Amniotic fluid urocortin concentrations in the cases (0.50+/-0.07 ng/ml) (M+/-SD) were significantly lower (P<0.0001) than in the control group (0.90+/-0.26 ng/ml), while CRF concentrations did not differ between the cases (1.52+/-0.39 ng/ml) and control group (1.64+/-0.68 ng/ml). Amniotic fluid cortisol (17.71+/-3.72 ng/ml vs. 17.32+/-3.17 ng/ml), DHEA-S (0.16+/-0.06 ng/ml vs. 0.17+/-0.09 ng/ml) and oestriol (4.68+/-1.95 ng/ml vs. 4.79+/-1.84 ng/ml) concentrations were similar in the two groups. CONCLUSIONS: The low amniotic fluid concentrations of urocortin at mid-trimester may be a signal of predisposition to preterm delivery, while the unchanged CRF and steroid hormones concentrations in women delivering preterm suggest that this mechanisms are not yet activated at mid-trimester.

First trimester three-dimensional transvaginal imaging of alobar holoprosencephaly associated with proboscis and hypotelorism (ethmocephaly) in a 46,XX fetus.

A 19-year-old woman was scanned at 10(+6) weeks gestation by 2D-3D ultrasound. The fetus had a crown-rump length of 40.9 mm, with the cephalic pole occupied by a single cystic cavity measuring 10.6 x 7.7 x 6.8 mm and severe hypotelorism associated with mid-facial hypoplasia. 3D ultrasound confirmed the malformations seen on the 2D scan and enabled the visualization of a proboscis and a low-set right ear. Fetal karyotyping was performed by chorionic villus sampling. Due to major fetal malformations of the fetus, the patient opted for termination of pregnancy. First trimester sonographic diagnosis of holoprosencephaly relies on bilateral visualization of choroid plexuses in what has been called the 'butterfly' sign. Differential diagnosis between holoprosencephaly and hydranencephaly may be difficult in the first trimester of pregnancy. However, midline structures such as falx cerebri, interhemispheric fissure and third ventricle are present in hydranencephaly and are absent in alobar holoprosencephaly, and thalami are never fused in hydranencephaly. 3D ultrasound has demonstrated an increased definition of anatomical abnormalities of malformations, compared with 2D ultrasound, and has proven to be crucial in the decision-making process of parents and in later prenatal counseling, especially in this case where necroscopy examination was refused by the parents. Images obtained by 3D ultrasound gave detailed insight into this ventral midline anomaly, depicting much of the disordered prosencephalic development.

Association between oxidative stress in pregnancy and preterm premature rupture of membranes.

BACKGROUND: Premature rupture of membranes (PROM) is caused by collagen damage in the chorioamniotic sac leading to tearing. Reactive oxygen species (ROS) may be the cause of collagen damage. Isoprostanes (F(2)-IP) are produced by ROS attack on polyunsaturated fatty acids and are sensitive and specific biomarkers of lipid-peroxidation in vivo. AIM: To verify whether oxidative stress occurs in pregnancies associated with preterm PROM. METHODS: F(2)-IPs were measured in amniotic fluid of 16 pregnancies with preterm PROM (Group II) and 97 without PROM (Group I). RESULTS: F(2)-IP concentrations (pg/mL) were significantly higher in group II than group I (p<0.0001). The ROC curve showed a sensitivity of 100% and a specificity of 84.5% at a cut-off of 124.4 pg/mL. CONCLUSIONS: An association exists between oxidative stress in pregnancy and preterm PROM. The detection of amniotic fluid F(2)-IP concentrations seems to be a reliable predictive index of risk of preterm PROM.

Three-dimensional first-trimester transvaginal diagnosis of alobar holoprosencephaly associated with omphalocele in a 46,XX fetus.

A three-dimensional (3D) transvaginal diagnosis of alobar holoprosencephaly (HPE) with associated omphalocele is reported at 12 weeks, 3 days gestation. Diagnosis of HPE was based on visualization of a single holoprosencephalic cavity with absent falx and basal ganglia and omphalocele by the presence of abdominal wall defect with mid-gut herniation. Chorionic villus sampling showed a normal 46,XX karyotype. 3D volumetric reconstruction allowed a more detailed definition of the anatomic landmarks of the lesion, including visualization of a thin rim of cortical mantel within the prosencephalic cavity, the dysmorphic face with flattened nose, and the abdominal eventration that looked like an abdominal air bag on 3D volumetric reconstruction.

Prenatal screening for fetal face and clefting in a prospective study on low-risk population: can 3- and 4-dimensional ultrasound enhance visualization and detection rate?

A study of 1856 second trimester low-risk pregnancies was conducted over a period of 12 months to evaluate the detection rate of cleft lip and palate by 3- and 4-dimensional (3D, 4D) ultrasonography. To image the fetal face and profile, a protocol regarding the use of external or internal hand stimulation or a repeated scan was followed, and the time taken to perform 3D scan was compared to that of a conventional 2D ultrasound. One case of unilateral right cleft lip and a cleft lip plus cleft palate were both identified, giving a prevalence of 1.1 per 1000 live births and a prenatal detection rate of 100%. The average imaging time for fetal face/profile view was significantly less with 3D when compared to 2D (5.33 vs 6.2 seconds, P < .001) and diagnosis at first scan without external or internal hand stimulation was feasible in 78% by 2D versus 87% by 3D technique (P < .0001). Cleft lip and palate were isolated prenatal findings and newborn karyotyping showed normal chromosomal maps in both cases. With the use of this standardized protocol, we were able to image the fetal face and profile view in all cases. We underline the critical role of sonographic expertise in screening for these anomalies and the great enhancement in imaging soft tissues and bone lesions by using 3D ultrasound. We advocate that screening for cleft lip and palate be included in future standard ultrasound examination in the second trimester of pregnancy.

Isoprostanes in amniotic fluid: a predictive marker for fetal growth restriction in pregnancy.

Isoprostanes are markers of free radical-catalyzed lipid peroxidation. Evidence suggests that oxidative stress occurs in pregnancies with fetal growth restriction (FGR). The aim of this study was to analyze F2-isoprostanes in amniotic fluid of FGR pregnancies. We tested the hypothesis that F2-isoprostanes are reliable markers to distinguish FGR pregnancies from normal ones and appropriate-for-gestational-age (AGA) from small-for-gestational-age (SGA) newborns. F2-isoprostanes levels were measured by colorimetric enzyme immunoassay in the amniotic fluid of 77 pregnancies with normal fetal growth (group I) and 37 with FGR (group II). Fetal biometry and Doppler measurements were obtained using an ATL HDI 3000 ultrasound system. Isoprostanes were higher in group II than group I. The ROC curve distinguished group I from group II, showing 100% sensitivity and 88.3% specificity at a cutoff of 94 pg/ml. There were no statistical differences in isoprostanes levels between AGA and SGA newborns in group II. The area under the ROC curve drawn to distinguish AGA and SGA newborns showed a sensitivity of 100% and a specificity of 72.3% at a cutoff of 94 pg/ml. The relative risk index indicated a 8.05 times higher risk of birth weight below the 3rd percentiles in group II than in group I. High isoprostanes concentrations can be detected in the amniotic fluid of FGR pregnancies and the assay of isoprostanes in amniotic fluid is a reliable assessment of fetal oxidative stress. Common use of this predictive marker in obstetrics will improve the ability of clinicians to identify those fetuses who will be born SGA or with a birth weight below the 25th percentile.

Re-evaluation of risk for Down syndrome by means of the combined test in pregnant women of 35 years or more.

OBJECTIVE: Evaluation of combined test in pregnant women 35 years of age and over to detect fetal Down syndrome. MATERIALS AND METHODS: The study population included 408 pregnant women of 35 years and over, who requested the combined test (nuchal translucency, PAPP-A, free beta hCG, maternal age, cut-off 1:250) before deciding whether to undergo amniocentesis. RESULTS: The test was positive in 66 women who then requested amniocentesis for fetal karyotype determination; the other women had a negative test and declined amniocentesis. False-positives increased with maternal age from 6.6% at 35 years to about 50% at 40 to 41 and 100% in women over 41. Six cases of Down syndrome and two cases of trisomy 18 were detected. Not a single case of Down syndrome or trisomy 18 was missed, and other chromosome abnormalities were detected as well. CONCLUSIONS: The application of the combined test reduced the need for invasive testing to only 14% of the studied pregnant population, without missing any of the fetuses with trisomy 21 or 18.