Crash sign: new first-trimester sonographic marker of spina bifida.

OBJECTIVES: To describe a new first-trimester sonographic sign, the 'crash sign', associated with fetal open spina bifida, and to evaluate its clinical usefulness in the first-trimester diagnosis of spina bifida. METHODS: This was a retrospective review of patients referred to three fetal medicine centers in the first trimester (11 + 0 to 13 + 6 weeks) with suspected spina bifida. Spina bifida was confirmed by direct visualization of the spinal defect on ultrasound by two experts and, when possible, by fetal postmortem examination. Ultrasound images were reviewed for the presence of the crash sign, which is the posterior displacement of the mesencephalon and deformation against the occipital bone in the axial view. The first-trimester ultrasound images of a mixed group of 10 cases and 40 control fetuses without spina bifida were assessed for the presence of the crash sign by two assessors blinded to the diagnosis. RESULTS: The crash sign was present in 48 out of 53 confirmed cases of spina bifida. Of these, 27 had isolated spina bifida and 21 had an associated anomaly. Of the five cases without the crash sign, one had isolated spina bifida and four had an associated anomaly. The crash sign was not reported in any of the control fetuses. CONCLUSIONS: We have described a new first-trimester sonographic marker for the diagnosis of spina bifida. Our results suggest that the crash sign may be a useful tool in the first-trimester detection of spina bifida. Prospective evaluation of the crash sign would be beneficial, ideally in a routine clinical screening ultrasound setting. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

A rare occurrence of three consecutive autosomal trisomic pregnancies in a couple without offspring.

BACKGROUND: Trisomies are the most common chromosomal abnormalities, being a major cause of pregnancy loss in the first trimester. Data from preimplantation embryos support the concept of recurrent aneuploidy in women with recurrent abortion. CASE: The authors report a rare case with three different consecutive trisomic pregnancies: 47,XY,+21, 47,XX,+9, and 47,XX,+18. All pregnancies resulted from the same relationship and no consanguinity was present. Standard clinical cytogenetic analysis indicated that both members had normal peripheral blood karyotype, with no evidence of mosaicism in either patient or her partner. CONCLUSION: The present report sup- ports the hypothesis that some women have a higher risk for nondisjunction than others of the same age. Counseling a couple with re- current trisomies is difficult and future research on genetics of cell division are required to assist them.

Agenesis of ductus venosus in sequential first and second trimester screening.

OBJECTIVE: The goal of this study is to evaluate the potential of first trimester (FT) screening in the diagnosis of agenesis of the ductus venosus (ADV) and to study its prevalence in a low-risk population, the associated conditions, and pregnancy outcome. METHOD: Prospective, sequential screening study at two tertiary units with morpho-functional evaluation of the ductus venosus during the first and second trimester screening. We quantified the FT detection rate, prevalence, and associated conditions: umbilical shunting type, concomitant anomalies, and outcome. RESULTS: In 6114 consecutive pregnancies, we identified 11 cases of ADV. Ten (91%) were identified during the FT examination. The prevalence was 1 in 556, similar for both centers (1/478 vs. 1/691). Major structural defects and fetal effusions were detected in 8 (73%). twenty two percent had a major chromosomal abnormality. In 3 cases, the anomaly was isolated and had normal outcome, independent of liver by-pass, caliber of the shunt, and NT thickness. CONCLUSIONS: Agenesis of the ductus venosus can be detected during FT. The early detection of ADV is important given its high association with major abnormalities.

First trimester two- and four-dimensional cardiac scan: intra- and interobserver agreement, comparison between methods and benefits of color Doppler technique.

OBJECTIVE: To evaluate intra- and interobserver agreement for first-trimester fetal cardiac structural assessment, using two-dimensional (2D) ultrasound (2D-US) and 4D-US (4D spatiotemporal image correlation (STIC) technology), to compare the methods and to assess the advantages of adding color Doppler to each technique. METHODS: Digital videoclips (B-mode and color Doppler) and 4D-STIC volumes (gray-scale and color Doppler) from 632 pregnancies with normal fetal hearts were acquired and stored at the time of detailed first-trimester ultrasound examination. Later analysis on a randomized sample of 100 cases was performed, targeting 11 cardiac structures and features. We compared visualization of fetal heart parameters using 2D-US vs 4D-US and gray-scale vs color Doppler imaging. RESULTS: STIC volumes were considered satisfactory (adequate visualization of at least 8/11 parameters) in 78% of cases and 2D-US acquisitions in 89% of cases. The intra- and interobserver agreement was good for both 2D and 4D methods (kappa > 0.6), and the percentage overall agreement was very high using both methods (95%). 2D- and 4D-US identification of the fetal cardiac parameters did not differ significantly. The differences between gray-scale and color Doppler imaging were statistically significant in identifying similar key cardiac parameters, for both 2D- and 4D-US (P < 0.05). CONCLUSION: Both 2D and 4D methods for assessing first-trimester heart parameters are feasible and repeatable within and between observers. Color Doppler adds valuable information to both methods.

Improved detection rate of structural abnormalities in the first trimester using an extended examination protocol.

OBJECTIVE: To assess the potential of first-trimester sonography in the detection of fetal abnormalities using an extended protocol that is achievable with reasonable resources of time, personnel and ultrasound equipment. METHODS: This was a prospective two-center 2-year study of 5472 consecutive unselected pregnant women examined at 12 to 13 + 6 gestational weeks. Women were examined using an extended morphogenetic ultrasound protocol that, in addition to the basic evaluation, involved a color Doppler cardiac sweep and identification of early contingent markers for major abnormalities. RESULTS: The prevalence of lethal and severe malformations was 1.39%. The first-trimester scan identified 40.6% of the cases detected overall and 76.3% of major structural defects. The first-trimester detection rate (DR) for major congenital heart disease (either isolated or associated with extracardiac abnormalities) was 90% and that for major central nervous system anomalies was 69.5%. In fetuses with increased nuchal translucency (NT), the first-trimester DR for major anomalies was 96%, and in fetuses with normal NT it was 66.7%. Most (67.1%) cases with major abnormalities presented with normal NT. CONCLUSIONS: A detailed first-trimester anomaly scan using an extended protocol is an efficient screening method to detect major fetal structural abnormalities in low-risk pregnancies. It is feasible at 12 to 13 + 6 weeks with ultrasound equipment and personnel already used for routine first-trimester screening. Rate of detection of severe malformations is greater in early- than in mid-pregnancy and on postnatal evaluation. Early heart investigation could be improved by an extended protocol involving use of color Doppler.

Implications of the First Trimester 2d and 3d Ultrasound in Pregnancy Outcome.

BACKGROUND: In this study we researched for the first trimester pregnancy measurements by transabdominal and transvaginal ultrasound: gestational sac volume (GSV), embryo volume (EV), placenta volume (PV), yolk sac volume (YSV) and crown rump lengh (CRL) in predicting pregnancy outcome. Our goals was to demonstrate the ability of the first trimester ultrasound in identifying patients at high risk for abortion, intrauterine growth restriction (IUGR) and low birth weight. METHODS: Prospective observational clinical study that investigated the role of the first trimester 2D and volumetric (3D) measurements in predicting pregnancy outcome. The study was carried out in the Obstetrics and Gynecology Department of the Emergency County Hospital in Craiova during a study period of 3 years (between 2016 and 2018). The study included a number of 87 pregnancies. Patients included in the study were offered an early 2D and 3D transabdominal and transvaginal ultrasound and afterwards they were followed up until delivery. The statistical analyses (standard deviation, coefficient of variety, Cohen K correlation coefficient) determined a correlation between the two ultrasound methods, between the values of these parameters and pregnancy prognosis, the correlation being more relevant for the 3D ultrasound. The GSV, EV, YSV, PV, CRL and pregnancy outcome was established. RESULTS: Our study showed that the concordance degree between the two methods was 89.7%. 3D ultrasound had a diagnostic impact in 96.6% of the cases, while 2D ultrasound had a diagnostic impact in 89.6% of the cases. The incidence of the patients at high risk for complications was recorded in pregnancies with abnormal early ultrasound markers. CONCLUSIONS: First trimester ultrasound is a capable method for identifying a higher percentage of patients at risk of pregnancy complications, counseling and monitoring compared to 2D ultrasound. Also, because there is no radiation exposure, the risks are non-existent.

First Trimester Ultrasound Diagnosis of Right Aortic Arch (RAA).

OBJECTIVES: In the present research we proposed to evaluate the cases diagnosed in the first trimester of pregnancy by ultrasound with RAA, knowing the fact that although, in most cases the disease is isolated and asymptomatic, in some cases the presence of RAA can be associated with other fetal structural abnormalities that must be detected and monitored during pregnancy. We established correlations between the postnatal or anatomopathological examination (in cases ended by therapeutic abortion) and the presence of RAA detected in the first trimester. MATERIAL AND METHOD: We conducted a retrospective analytical study that investigated the role of the RAA early detection (isolated or associated with other cardiac abnormalities) for a correct pregnancy monitoring and postpartum management. Between 2012 and 2018, patients admitted in the first Obstetrics and Gynecology Clinic-the Prenatal Diagnostic Unit-of the Emergency County Hospital from Craiova, were evaluated in the first trimester of pregnancy for genetic abnormalities and early morphology. The study material was represented by the patient's medical records (observation sheets, surgical protocol records, anatomopathological diagnostic records). The obtained information was stored in Microsoft Excel files and statistically processed. RESULTS: During the study period, 14 cases with right aortic arch were diagnosed in the first and second trimester of pregnancy. 4 cases were detected in the first trimester: 2 cases (50%) presented left ductus arteriosus (DA)-RAA type 2 ("U" sign) and 2 cases (50%) presented right DA-RAA type 1 (mirror image-"V" sign). RAA type 1 associated Tetralogy of Fallot in one case (25%) and in another one case (25%) the anomaly was isolated. RAA type 2 associated atrio-ventricular septal defect (AVSD) in one case (25%) and in another one case (25%) the anomaly was isolated. There were no fetal extracardiac structural abnormalities associated with the RAA diagnosis in the first trimester. CONCLUSIONS: Over a seven years study period (2012-2018), 14 cases with RAA in the first and second trimester of pregnancy were detected. In the low-risk pregnancies group, the first trimester incidence of the RAA was 0.11% and the association of congenital heart abnormalities was 50%.

Postpartum Spontaneous Subcapsular Hepatic Hematoma (SSHH)- Conservative Management. Case Report and Review of Literature.

Spontaneous subcapsular hematoma of the liver, with no history of preeclampsia and HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count.), represents an exceptionally rare clinical condition in pregnancy and postpartum. The complications can be devastating in terms of fetal and maternal mortality. We hereby present a case of a 33-year-old female that underwent an emergency Cesarean section (C-section) at term with the extraction of a live foetus. Few hours after delivery, she complained of intense epigastric and abdominal pain. The diagnostic work-up suggested a SSHH. The condition was managed conservatively in a multidisciplinary team.

Ultrasound Evaluation of Fetal Biometry and Doppler Parameters in the Third Trimester of Pregnancy Suspected of Intrauterine Growth Restriction.

PURPOSE: The purpose of this study was to investigate fetal biometry and Doppler parameters in the third trimester of pregnancy with suspected restriction of fetal growth as potential predictors of unfavorable neonatal status. MATERIAL/METHODS: The uterine artery, umbilical and middle cerebral artery, cerebroplacental ratio (CPR), and estimated fetal weight (EFW) were evaluated in a cohort of 126 pregnancies that resulted in the birth of a fetus <10 percentiles (SGA). RESULTS: The demographic data of the studied cases did not show a significant difference between the parameters studied in the two study groups: Late SGA fetuses and Early SGA fetuses. Analyzing fetal biometry we found a significant difference for some parameters in relation to the two study groups. Our study showed that the Early SGA fetuses group had a lower birth weight, a lower gestational age at birth, an increase in the incidence of premature birth with an increase in Doppler abnormal incidence. CONCLUSIONS: Ultrasound examination and Doppler monitoring provide a non-invasive repetitive method for supervising fetuses with growth restriction in order to apply an adequate management.

Prematurity and Sepsis - Features and Approach Difficulties During Neonatal Emergency Transfer.

Purpose - We aimed to identify conditions, means and methods of suspecting, certification and stratification of neonatal sepsis, to prioritize and define levels of management during evacuation, and to follow the neonatal sepsis succeeding the transfer. Material and method - An observational study was conducted between 1January 2011 - the 1 January 2015, that included 610 preterm newborns with suspected sepsis transferred by UTIM NN or HEMS Craiova. We statistically studied confirmation rate of suspected sepsis, the sepsis onset condition, severity stratification, and correlate with medical centers performance assisting newborns and planning transfers. A follow up performed two weeks after evacuation. Results - We detected low rate of detection and affirmed sepsis: n=38 (6.25%) - C.I. (95%): 4.454309335 and very high level of founded unsuspected sepsis: n=85 (13.98026316%) C.I. (95%): 4.982552268, 9of them being very low body weight newborns (1.480263158%). High rate of founded, unaffirmed respiratory distress 23.35526316% (n=142), C.I. (95%): 5.383960957, as sign of sepsis. High rate of accidental hypoglycemia/hypothermia founded by emergency evacuation team: n=131 (21.54605263%), especially to VLBW newborns, associate with sepsis, respiratory failure or confounding with. Conclusions - Newborns transfer its self generates multiple additional risks, including sepsis, but not neglected any stress generated by transport conditions, so that ,,in utero'' transfer has to be extended in current practice for high risk fetus, mother or special medical conditions to limit newborns transfers. Wider use of telemedicine would facilitate refining the transfer criteria.