[Chart for estimation of fetal weight 2014 by the French College of Fetal Sonography (CFEF)]. / Courbe d'estimation de poids fœtal 2014 par le Collège français d'échographie fœtale (CFEF).

OBJECTIVE: To establish a reference chart for estimated fetal weight (EFW) using the Hadlock formula based on recent biometric data (2012-2013). MATERIAL AND METHODS: A prospective multicentric longitudinal study was carried out. Biometric parameters as the head circumference (HC), abdominal circumference (AC) and the femur length were measured in multiple areas of France from January 2012 until December 2013. EFW was calculated using the predictive formula of Hadlock using three parameters. The accurate gestational age was the main inclusion criteria calculated in weeks of gestation (WG). A polynomial regression approach was used to calculate the mean and standard deviation for every WG adjusted to raw data. Centiles of EFW were calculated from the z score that corresponds to the -1.88, -1.28, 0, +1.28, +1.88 respectively for the 3rd, 10th, 50th, 90th, et 97th percentile in order to establish a new chart of EFW. RESULTS: Measurements were obtained for 33,143 fetus between 17 et 38 WG. Reference charts with the 3rd, 10th, 50th, 90th et 97th percentiles were presented. CONCLUSION: The reference Chart 2014 is an in utero chart for EFW based on ultrasound measurements data reliable and homogenous from a sample of 33,143 fetus of a general population. It offers a tool to use in routine ultrasound examination for the survey of the fetal growth and to diagnose fetus that are small for gestational age or presenting a restriction in growth.

Neurodevelopmental outcome following prenatal diagnosis of an isolated anomaly of the corpus callosum.

OBJECTIVES: To assess the ability of prenatal ultrasound and magnetic resonance imaging (MRI) to diagnose isolated anomalies of the corpus callosum (ACC) and to further document the long-term prognosis following diagnosis. METHODS: This was a prospective case-control study carried out between 1999 and 2004. Diagnosis was made by a combination of ultrasound and MRI. All infants were examined by a neuropediatrician and parents consented to answer questionnaires (CDI, Ireton's Child Developmental Inventory) in 22 cases, which were matched with 44 control infants. The CDI was used to assess neurodevelopmental outcome in cases and controls. Mean DQ-CDI (development quotient calculated from CDI) values and frequencies of abnormal results were compared between groups, and a meta-analysis of previous studies was performed. RESULTS: The diagnosis of ACC was made prenatally and confirmed postnatally in 175 cases. The diagnosis was thought to be isolated ACC in 88/175 (50%) cases. Sixty of these 88 cases (68%) underwent termination of pregnancy and one died in utero. Twenty-seven were liveborn, of which 26 were followed up for a median of 50 (range, 30-74) months. Additional anomalies were diagnosed postnatally in four (15%) of these 26 neonates. The control group was significantly better (P < 0.05) compared with the cases diagnosed prenatally with isolated ACC with respect to gross motor, fine motor, language comprehension, numbers and general development, and it was marginally better for letters (P = 0.066). Seven of 26 (27%) (95% CI, 13-46%) infants with ACC over the age of 30 months had neurodevelopmental delay, compared with only one case with borderline developmental delay among the 44 controls (P = 0.006). CONCLUSION: Prenatal diagnosis of ACC by a combination of ultrasound and MRI is reliable. However, the isolated nature of the anomaly could only be assessed in 85% of our cases. Since counseling is provided at the time of prenatal diagnosis, our population of isolated ACC included the cases that were missed prenatally as being ACC with associated anomalies. A meta-analysis of nine studies suggests that the development of children diagnosed prenatally with isolated ACC is normal in up to 70% (CI 95%, 56-83%) of cases. This means that the prospective risk of neurodevelopmental delay for a fetus with ACC described as isolated prenatally is 27%, compared with 15% for an infant whose diagnosis of isolated ACC is confirmed postnatally.

Ultrasonography of the fetal brainstem: a biometric and anatomical, multioperator, cross-sectional study of 913 fetuses of 21-36 weeks of gestation.

OBJECTIVES: To establish the ultrasonographic fetal growth charts of the pons and the vermis/pons ratio on a multioperator basis in low-risk pregnancies and provide a detailed description of the anatomical and ultrasonographic criteria of normal brainstem growth. METHODS: A prospective, multicenter, multioperator, ultrasonographic study was conducted on 913 fetuses aged 21-36 weeks. The anteroposterior diameter of the pons and the greatest vermal height were measured to establish a growth chart, using a mid-sagittal plane with a posterior transfontanellar approach. The LMS semiparametric statistical method was used to construct the growth charts. Three morphological structures were also examined: the pons arch and its echostructure, the bulbo-protuberential sulcus and the primary vermal fissure. RESULTS: The anteroposterior diameter of the pons and the greatest vermal height were measured in 96.7% of cases. The anteroposterior diameter of the pons and vermis increased linearly with gestational age. The vermis/pons ratio was stable during pregnancy. CONCLUSION: We have drawn the growth charts for the pons and vermis during pregnancy and described the normal ultrasound morphology of the brainstem. Knowledge of these morphological and biometric data could facilitate early screening for pontocerebellar hypoplasia.

[Ultrasonography of fetal esophagus: healthy appearance and prenatal diagnosis of a case of esophagus atresia with esotracheal fistula]. / Echographie de l'oesophage foetal: aspect physiologique et application au dépistage anténatal d'une atrésie oesophagienne.

The thoracic part of a fetal esophagus is generally overlooked by usual prenatal ultrasonography. However, screening it might improve the detection rate of esophageal malformations for which prenatal diagnosis remains far from accurate. In this article, we describe the technique which makes it possible to get a precise image of a fetal thoracic esophagus in its more sensitive part: between the trachea and the aorta. After describing the appearance of a healthy thoracic esophagus, we will show how this technique can be used for prenatal detection of esophagus malformations. For this purpose, we provide the case report of a prenatal diagnosis of esophagus atresia with esotracheal fistula.

French fetal biometry: reference equations and comparison with other charts.

OBJECTIVES: To construct new reference charts and equations for fetal biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), using a large sample of fetuses examined at 15-40 weeks in France, and to compare them with previous references. METHODS: The study data were obtained over a continuous 1-year period from a population of pregnant women undergoing ultrasound examination. Excluded were those with a known abnormal karyotype or congenital malformation, multiple pregnancies, and those with no first-trimester dating based on crown-rump length. No fetuses were excluded on the basis of abnormal biometry or birth weight. For each measurement, separate regression models were fitted to estimate both the mean and the SD at each gestational age. RESULTS: Full biometric measurements were obtained for 19 647 fetuses. New charts and reference equations are reported for BPD, HC, AC and FL. Prediction intervals for the new reference charts were similar to those of previous ones, whereas there were some differences in predicted centiles. CONCLUSION: We present new French reference charts and equations for fetal biometry. They can be used easily to compute centiles and Z-scores to control the quality of biometric assessments and to evaluate their performance relative to other references.

Feasibility and reproducibility of an image-scoring method for quality control of fetal biometry in the second trimester.

OBJECTIVES: The need for training programs and certification processes in fetal ultrasound has become obvious. The purpose of this study was to evaluate the feasibility of a score-based quality control system for fetal biometry in the second trimester. METHODS: Standard measurements of biparietal diameter and head circumference, abdominal circumference, and femur length at 20-24 weeks had been made by four operators using the same ultrasound machine. Twenty-five of each of the cephalic, abdominal and femoral images with the calipers in place were selected arbitrarily from each operator's ultrasound database and anonymized. These 300 images were analyzed by three experienced reviewers blinded to the operator's identity. Each image was first evaluated subjectively and then scored according to six criteria for abdominal and cephalic measurements and four criteria for femur length making a six-point score for abdominal and cephalic biometry and a four-point score for femur length. For subjective evaluation, inter-reviewer differences were analyzed using percentage agreement and adjusted kappa. For objective evaluation, a difference in scoring of one point or less among reviewers was considered good agreement. Intrareviewer variability was assessed using 40 images of each type of examination selected arbitrarily. RESULTS: The distribution of scores was similar between reviewers. One operator obtained significantly lower scores whereas the other three had good and comparable results. There was no statistical difference in the mean score attributed by each reviewer and agreement was good in 84-90% of the cases. Intrareviewer agreement was good in 90-100% of the cases, with similar scores for each reviewer. CONCLUSION: A quality control policy based on image scoring is feasible and allows for fair to good inter- and intrareviewer reproducibility. The potential contribution of this approach to assess the quality of routine ultrasound examinations should be tested on a larger scale.

Predicting late-onset growth abnormalities using growth velocity between trimesters.

OBJECTIVES: To determine whether growth velocity parameters derived from routine prenatal ultrasound measurements at first, second and third trimester can identify normal growth at term as well as late-onset growth abnormalities. MATERIAL AND METHODS: Longitudinal study of fetal growth in normal singleton pregnancies with three normal ultrasound examinations and delivered at term. Fetuses were classified into 3 groups (<10th percentile, 10-90th percentile, >90th percentile) based on birth weight. Multiple regression on birth weight classification was used to build up a prediction equation of fetal growth potential (FGP) based on fetal biometry and fetal growth velocity parameters between ultrasound examinations. Best cut-off value for FGP predicting growth restriction and macrosomia were defined. RESULTS: 356 pregnancies were included. Fetal biometry growth velocities between examinations were calculated for all measurements. Using best cut-off values, the estimated sensitivity, specificity and odds ratio were: 60% [44;74], 91% [89;92] and 14.55 [6.30;33.98] and 53% [36;69], 89% [88;91] and 10 [4.27;23.49] for the prediction of growth restriction and macrosomia, respectively. DISCUSSION: Fetal growth potential can be derived and calculated from standard ultrasound measurements. It can improve identification of these fetuses at risk for late-onset growth abnormalities and their related morbidity.

Growth discrepancy in twins in the first trimester of pregnancy.

OBJECTIVE: The prevalence and significance of intertwin growth discrepancy in the first trimester of pregnancy are controversial. The aim of this study was to refine the incidence and outcome of this discrepancy in relation to dating of the pregnancy and other biometric parameters. METHODS: This prospective study of twin pregnancies initially evaluated at 11-14 weeks' gestation was conducted between 2001 and 2004. Differences in crown-rump length (CRL) and estimated gestational age (GA) were calculated for each twin pair and their distribution was analyzed according to chorionicity and mode of conception (spontaneous or following assisted reproductive technologies). CRL-based GA and actual GA were compared. Other biometric parameters were also compared for each twin pair. The distribution of discrepancies was analyzed according to pregnancy outcome. RESULTS: A total of 182 twin pregnancies was included. The mean+/-SD discrepancy in CRL was 3.4+/-3.18 mm or 5.1+/-4.69% and the 95th centile was 9.8 mm or 14.3%. There was no influence of chorionicity (P=0.44), mode of conception (P=0.18) and no relation with outcome (P=0.54). In conceptions resulting from assisted technology, the measured CRL of the smaller twin was closer to the actual GA. Cephalic and abdominal biometric measurements were significantly greater in the twin with the smaller CRL (P<0.05). The two cases with a discrepancy>15 mm were affected by trisomy 18 and triploidy, respectively. CONCLUSIONS: CRL discrepancy in twin pregnancies in the first trimester is a frequent finding. Discrepancy>95th centile indicates major growth delay of one twin, which could indicate the presence of aneuploidy. For milder degrees of discordance the CRL of the smaller fetus is a more accurate estimate of the actual GA.

[Linear insertion of the atrioventricular valves without defect]. / Insertion linéaire des valves atrioventriculaires sans défect. A propos d'une nouvelle série anatomique de 213 coeurs de foetus trisomiques 21.

On a first anatomical series of 52 hearts of trisomic 21 fetuses, published in June 2002, we described a new minor cardiac anomaly, belonging to the atrioventricular septal defect, with a linear insertion of the atrioventricular valves without defect. We want to confirm these data, on a larger series of 213 new hearts of trisomic 21 fetuses by adding a complementary section to the standard examination; 100% of controls have shown a normal insertion with an offsetting of the atrioventricular valves. On 113 out of these 213 hearts of trisomic 21 fetuses, with a so called "normal" heart at the standard examination showing no defect, the complementary section has shown that only 37.2% of these hearts have a normal insertion, whereas 62.83% show a linear insertion, without offsetting and without any septal defect. This linear insertion has been observed in all the different types of atrioventricular septal defect as a good hallmark for trisomy 21; but, since then, they have always been described associated with a septal defect, atrial or ventricular. Our hypothesis is that the linear insertion of the atrioventricular valves without defect is the minor form of the atrioventricular septal defect spectrum, taking place between the prior described partial types of atrioventricular septal defect, in which there is always a defect (ostium primum type atrial septal defect or inflow type ventricular septal defect), and the real normal heart. A precise description of the level of the complementary section and of the anatomic peculiarities of the linear insertion of the atrioventricular valves without defect would help its screening in fetal ultrasonography.

The impact of choice of reference charts and equations on the assessment of fetal biometry.

OBJECTIVES: The assessment of fetal biometry is usually based on the comparison of measured values with predicted values derived from reference charts or equations in a normal population. This study was undertaken to assess the impact of the choice of reference charts and to develop a Z-score-based tool that could help sonographers to choose the reference charts that best fit their practice. METHODS: Fetal biparietal diameter, head circumference, abdominal circumference and femur diaphysis length measurements were made at 20-24 and 30-34 weeks' gestation by four experienced sonographers. All measurements were transformed into Z-scores calculated according to three prediction equations (Snijders and Nicolaides, 1994; Chitty et al., 1994 and Kurmanavicius et al., 1999). Distributions of Z-scores were compared to the expected standard normal distribution based on mean, SD and Kolmogorov-Smirnov test. Simulations were made to assess sensitivity (Se), specificity (Sp) and Youden's index (Se + Sp - 1) of each reference equation, reflecting their ability to identify fetuses with abnormal biometry in our population. The reference that best fitted our practice was determined based on these results. RESULTS: The Z-scores of all biometric parameters were significantly different (P < 0.001) when using any of the three reference equations, and none of the Z-score distributions could be considered similar to the standard normal distribution. The number of measurements that would be considered as abnormal according to these references ranged from 2.6% to 23.6%. Se and Sp ranged from 39.59% to 67.12% and 90.14% to 99.69%, respectively. CONCLUSION: Assessment of fetal biometry is largely dependent on the choice of reference charts. We suggest that the choice of reference charts for fetal biometry could be controlled using Z-scores in each institution and that this could be the first step towards any quality assessment policy. The method we describe for the choice of the most appropriate fetal biometry reference chart might be used for all size charts.

Fetal lung volumetry using two- and three-dimensional ultrasound.

OBJECTIVES: To compare methods of measuring fetal pulmonary volume and to establish nomograms of fetal pulmonary volume according to gestational age for the accurate diagnosis of pulmonary hypoplasia. METHODS: Three methods of measuring fetal pulmonary volume in 39 normal fetuses were compared: two-dimensional (2D) ultrasound measurement assuming that the lung is a geometrical pyramid, three-dimensional (3D) ultrasound using the VOCAL rotational method, and the conventional multiplanar 3D mode. Linear regression was used to construct an equation for 3D volume calculation from 2D measurements (the re-evaluated pulmonary volume equation (RPVE)). Lung volume measurements were recorded from 622 singleton fetuses in order to construct nomograms. RESULTS: There was no statistically significant difference between the lung volume values obtained using the two 3D modes. However, in comparison with the 2D measurements the volumes obtained were larger (mean difference = 11.99, P < 0.1 x 10(-6)). The relationship between the 2D and 3D volumes was determined using a statistical linear regression method: RPVE (mL) = 4.24 + (1.53 x 2DGPV), where 2DGPV (2D geometric pulmonary volume) = (surface area right lung base (cm2) + surface area left lung base (cm2)) x 1/3 height right lung (cm). Two nomograms were constructed, one for use with 2D and one for 3D technology. CONCLUSION: 2D pulmonary volume assessment can be used in clinical situations where fetal prognosis depends on lung volume and its growth potential. It is routinely available and easy to perform particularly when repeat measurements are required in evaluation of lung growth. We therefore propose this method as an alternative to magnetic resonance imaging or 3D ultrasound.

[First-line radiosurgery of brain metastases. Interest and results of reduced dose]. / Irradiation stéréotaxique de première intention des métastases cérébrales. Intérêt et résultats d'une réduction de la dose délivrée.

BACKGROUND: The minimal radiosurgical dose required to control cerebral metastases remains unknown. The aim of this study was to test whether a lower peripheral dose than usually delivered could effectively control these lesions or not. PATIENTS AND METHODS: One hundred and eighty patients presenting 356 lesions were give first-line radiosurgery between 1995 and 2001 in Pitié-Salpêtrière hospital using a 10 MV LINAC. Mean age was 59 years, sex-ratio was 1.65, mean KI was 70. The lung was the most frequent primary site (n=85), followed by melanoma (n=29), kidney (n=21), digestive tract (n=14), breast (n=11), and others (n=20). Seventy-six percent of the patients presented 1 or 2 lesions. Mean tumor Volume was 5.5 cm3. Mean peripheral dose was 14.8Gy, mean isocenter dose was 21.6Gy. RESULTS: Median survival was 7.6 months, local control rate was 90% at 6 months, 76% at 1 Year and 70% at 2 years. Median "neurological disease free" survival was 15 months. Multivariate analysis demonstrated the influence of two parameters on survival: number of lesions (p=0.001) and KI (p=0.04). The only parameter significantly correlated with disease-free survival was the number of isocenters (p=0.005). Morbidity (grade 2 RTOG) was 7.2% with no perimortality. CONCLUSIONS: Low peripheral doses delivered by radiosurgery may control brain metastases with the same efficacy and fewer side-effects as the doses usually reported in the literature.

Revisiting first-trimester fetal biometry.

INTRODUCTION: Although advances in ultrasound have facilitated the diagnosis of fetal abnormalities in the first trimester, fetal biometry at this stage of pregnancy remains underused in prenatal diagnosis. We hypothesized that charts which directly correlate measurements to crown-rump length (CRL) could be more accurate than those based on gestational age (GA) derived from CRL measurement. The aim of this study was to construct CRL-based biometric charts. METHODS: Measurements of biparietal diameter (BPD), head circumference (HC) and abdominal circumference (AC) were prospectively collected from 939 normal singleton fetuses. Charts and predictive equations were constructed from data obtained from pregnancies in which the CRL was between 45 and 84 mm and for which the outcome was normal. RESULTS: Measurements of BPD, HC and AC from 880 fetuses who met the criteria were correlated with CRL and used to construct charts and predictive equations. The standard error of estimates using CRL was significantly lower than that using GA in all cases. DISCUSSION: First-trimester growth charts and predictive equations based on CRL instead of GA are more accurate. They might have a role in quality control of first-trimester ultrasound examination and may help in the diagnosis of fetal conditions that involve early growth abnormalities.

Periventricular leukomalacia and mode of delivery in twins under 1500 g.

BACKGROUND: The optimal mode of delivery in twin gestations remains undefined, particularly for twins weighing less than 1500 g. OBJECTIVE: To evaluate the impact of the mode of delivery on neonatal outcome in twins below 1500 g. MATERIALS AND METHODS: In this multicenter cohort study during 1999, 66 sets of twins born in hospital and weighing below 1500 g formed our study group. Antenatal and neonatal parameters and their relationship to mode of delivery were studied, based on a factor analysis. Analysis of covariance was used to assess the effect of the mode of delivery on postnatal factors, with antenatal parameters used as covariates. RESULTS: Statistical analysis showed that infants delivered vaginally had significantly more periventricular leukomalacia than those children delivered by Cesarean section (p = 0.03). The estimated odds for leukomalacia were higher in the vaginal than in the Cesarean group when adjusted for covariates (OR = 4.7; 95% CI = 1.0, 25.15). CONCLUSION: Routine Cesarean section should be recommended in twin gestations with infants weighing less than 1500 g, regardless of gestational age or fetal presentation.

Linear insertion of atrioventricular valves without septal defect: a new anatomical landmark for Down's syndrome?

Our objective was to explore whether minor anatomical abnormalities of the septal insertion of tricuspid and mitral valves could be a feature of trisomy 21 in fetuses with an otherwise normal heart. Postmortem examinations were performed in 41 fetuses affected by Down's syndrome and in 52 controls. Adjoining the standard postmortem procedure, an apex-to-base section of the crux of the heart was made on a plane corresponding to the sonographic four-chamber view. This allowed gross and histological examination of the hinge points of tricuspid and mitral leaflets, showing the usual apical displacement of the tricuspid valve in all controls. Of 41 fetuses affected by Down's syndrome, 18 had a structural heart defect. Of the 23 Down syndrome fetuses without a patent heart defect, 16 (i.e., 69% of those considered as having 'normal hearts') had nevertheless a linear insertion of atrioventricular valves at autopsy. Prospective clinical studies are required to evaluate if these postmortem findings can be transposed to the clinical setting of 2nd-trimester sonographic screening.

Teaching ultrasound-guided invasive procedures in fetal medicine: learning curves with and without an electronic guidance system.

OBJECTIVE: To compare the learning curves of inexperienced junior obstetrics/gynecology registrars for ultrasound-guided invasive procedures on a training model, with and without an electronic guidance system. STUDY DESIGN: Four junior registrars performed their first 100 procedures on a training model with a new electronic guidance system, and four other junior registrars performed their first 100 procedures on the same training model without using the guidance system. All procedures were performed using a free-hand technique. We evaluated the quality of the procedure, which we defined as the time spent with the entire needle clearly visualized on the screen over the total duration of the procedure. We constructed learning curves for the eight junior registrars for comparative analysis. RESULTS: Quality of the procedure increased over time for all trainees. The learning curves were significantly steeper for trainees using the electronic guidance system. Trainees using the electronic guidance system performed better in the middle of their learning curve (procedures 25-75). All trainees reached the same level of quality by the end of their 100 procedures. CONCLUSIONS: The automated electronic guidance system helps faster learning but, after 100 procedures on a training model, both groups reached the same level of quality.

Measurement of the corpus callosum using magnetic resonance imaging: analyses of methods and techniques.

Since the first postmortem report of sex-related differences in the size of the human corpus callosum, a number of studies on sex differences have been published, but results conflicted. The aim of this review was not to assess the possible existence and magnitude of sex variations in the size of the corpus callosum but to analyze methodological differences in several studies using Magnetic Resonance Imaging to investigate the sexual dimorphism in the size of the corpus callosum. Methodological problems arise at several steps of the method: sampling, imagery techniques, and measurements. Moreover, the means of callosal areas obtained by the nine reported studies are significantly different. The hypothesis that methodoiogical differences could explain these differences is supported by statistical results. A common method for investigating sex-related differences in callosal morphology appears necessary to resolve the question of a real sexual dimorphism of the corpus callosum and its subregions.

Relationship between discrimination tasks of the cantab and the corpus callosum morphology in Alzheimer's disease.

The relationship between performances on a simple discrimination task of the Attentional Set Shifting of the Cambridge Neuropsychological Test Auto mated Battery (CANTAB) and morphometry of the corpus callosum is examined in patients with Alzheimer's disease. Analysis showed patients with probable Alzheimer's disease are heterogeneous for the relationship between performances in the attentional test of the CANTAB and the anterior callosal atrophies. Interest in these results for clinical diagnosis of this mental disease is discussed.

Carotid artery stenosis: prospective comparison of CT, three-dimensional gadolinium-enhanced MR, and conventional angiography.

PURPOSE: To prospectively compare gadolinium-enhanced magnetic resonance (MR) angiography and computed tomographic (CT) angiography with digital subtraction angiography (DSA) for use in detecting atheromatous stenosis and plaque morphology at the carotid bifurcation. MATERIALS AND METHODS: Forty-four carotid arteries (in 22 patients) were analyzed by using CT angiography, enhanced MR angiography, and DSA. CT and enhanced MR angiograms were reconstructed with maximum intensity projection and multiplanar volume reconstruction. The following four features were analyzed: degree of stenosis on the basis of North American Symptomatic Carotid Endarterectomy Trial criteria, length of stenosis, luminal surface, and presence of ulcers. RESULTS: There was significant correlation between CT angiography, enhanced MR angiography, and DSA for degree and length of stenosis. With enhanced MR angiography and CT angiography, degree of stenosis was underestimated in two of 44 cases. No case of overestimation with CT angiography was found. Severe internal carotid artery stenoses were detected with high sensitivity and specificity: 100% and 100%, respectively, with CT angiography; 93% and 100%, respectively, with enhanced MR angiography. Luminal surface irregularities were most frequently seen at CT angiography. With CT angiography and enhanced MR angiography, more ulceration was detected than with DSA. CONCLUSION: There was a significant correlation between CT angiography, enhanced MR angiography, and DSA in evaluation of carotid artery stenosis. Enhanced MR angiography or CT angiography can be used to adequately evaluate carotid stenosis.