Postmortem Assessment of Isolated Congenital Heart Defects Remains Essential Following Termination of Pregnancy.

OBJECTIVES: To investigate the correlation between prenatal ultrasound (US) and autopsy findings in pregnancies terminated due to isolated congenital heart defects (CHDs), including CHDs associated with heterotaxy syndrome. MATERIALS AND METHODS: The material consists of 67 fetuses with prenatally detected isolated CHDs or CHDs associated with heterotaxy syndrome at a tertiary center in Norway between 1985 and 2014. The main CHDs were categorized into subdiagnoses of CHDs in accordance with ICD-10. The US and autopsy findings were categorized according to degree of concordance. RESULTS: Gestational age at termination was 12 + 0-22 + 6 weeks. Hypoplastic left heart syndrome was the most common main diagnosis among the 67 fetuses (32.8%). There was full agreement between US and autopsy findings in 97.4% (222/228) of all subdiagnoses. The discrepant findings in three fetuses had no influence on the decision to terminate the pregnancy. CONCLUSIONS: The correlation was high between prenatal US and postmortem findings in fetuses with isolated CHDs. Meticulous assessment of cardiac anatomy is particularly necessary when the decision to terminate relies on isolated CHDs. The trend of earlier termination challenges verification of diagnoses at autopsy. Consequently, the fetus should be examined at a tertiary center with fetal medicine specialists, pediatric cardiologists and perinatal pathologists.

Randomised controlled trial showed that neonates received better pain relief from a higher dose of sucrose during venepuncture.

AIM: We compared the effect of two different doses of sucrose on neonatal pain scores during venepuncture. METHODS: This randomised crossover study focused on neonates born weighing more than 1000 g from December 2014 to June 2016, who received neonatal intensive care at two hospitals: one in Empangeni, South Africa, and one in Trondheim, Norway. During two consecutive venepuncture procedures, 27 neonates from South Africa and 26 neonates from Norway were randomised to receive 0.2 mL or 0.5 mL sucrose. Half was administered two minutes before venepuncture and the rest immediately before the procedure. South Africa used 25% sucrose and Norway 24%. Pain scores were measured twice using the Premature Infant Pain Profile-Revised: during skin puncture and after the needle was removed. RESULTS: The mean pain scores during skin puncture were significantly lower with 0.5 mL sucrose than with 0.2 mL (5.3 versus 6.8, p=0.008), but the mean pain scores after the needle was removed were similar with both doses (4.7 versus 5.4, p=0.29). We found no significant association between weight and pain scores. CONCLUSION: We showed that neonates received better pain relief from 0.5 mL than 0.2 mL sucrose during venepuncture but not after the needle was removed.

Estimation of fetal weight in pregnancies past term.

INTRODUCTION: The aim of the study was to investigate the accuracy of estimating fetal weight with ultrasound in pregnancies past term, using the eSnurra algorithm. MATERIAL AND METHODS: In all, 419 women with pregnancy length of 290 days, attending a specialist consultation at Stavanger University Hospital, Norway, were included in a prospective observational study. Fetal weight was estimated using biparietal diameter (BPD) and abdominal circumference (AC). The algorithm implemented in an electronic calculation (eSnurra) was used to compute estimated fetal weight (EFW). Results were compared with birthweight (BW). RESULTS: The mean interval between the ultrasound examination and birth was 2 days (SD 1.4). The median difference between BW and EFW was -6 g (CI -40 to +25 g) and the median percentage error was -0.1% (95% CI -1.0 to 0.6%). The median absolute difference was 190 g (95% CI 170-207 g). The BW was within 10% of EFW in 83% (95% CI 79-87%) of cases and within 15% of EFW in 94% (95% CI 92-96%) of cases. Limits of agreement (95%) were from -553 g to +556 g. Using 5% false-positive rates, the sensitivity in detecting macrosomic and small for gestational age fetuses was 54% (95% CI 35-72%) and 49% (95% CI 35-63%), respectively. CONCLUSION: The accuracy of fetal weight estimation was good. Clinicians should be aware of limitations related to prediction at the upper and lower end, and the importance of choosing appropriate cut-off levels.

A randomized controlled trial of third-trimester routine ultrasound in a non-selected population.

OBJECTIVE: To compare detection rates of small-for-gestational-age fetuses, large-for-gestational-age fetuses, congenital anomalies and adverse perinatal outcomes in pregnancies randomized to third-trimester routine ultrasound or ultrasound on clinical indication. DESIGN: Randomized controlled trial. SETTING: National Center for Fetal Medicine in Norway between 1989 and 1992. POPULATION: A total of 6780 pregnancies from a non-selected population. METHODS: Two routine ultrasound examinations at 18 and 33 weeks were compared with routine ultrasound at 18 weeks and ultrasound on clinical indication. Suspected small-for-gestational-age fetuses were followed with serial scans and cardiotocography. Doppler ultrasound was not used. MAIN OUTCOME MEASURES: Detection rates of small-for-gestational-age and large-for-gestational-age fetuses, congenital anomalies and adverse perinatal outcomes. RESULTS: Third trimester routine ultrasound improved detection rates of small-for-gestational-age fetuses from 46 to 80%, but overall perinatal morbidity and mortality remained unchanged. Detection of large-for-gestational-age fetuses increased from 36 to 91%. There was a significant increase of induction of labor and elective cesarean sections due to suspected small-for-gestational-age and a significant decrease of induction of labor and elective cesarean sections due to suspected large-for-gestational-age in the study group; there were no other differences regarding intervention. The detection rate of congenital anomalies was 56%, with no significant difference between the groups. CONCLUSIONS: Routine use of third-trimester routine ultrasound increased detection rates of small-for-gestational-age and large-for-gestational-age fetuses. This did not alter perinatal outcomes. Third-trimester ultrasound screening should not be rejected before a policy of adding Doppler surveillance to the high-risk group identified has been investigated further.

The 18-week fetal examination and detection of anomalies.

From its beginning in the fifties the use of ultrasound in gynaecology and obstetrics has expanded extensively. Ultrasound technology has taken us from a time when the mother was our prime focus to the present where it is the unborn baby. Ultrasound assessments may have significant consequences for pregnancy care by optimizing the time, the mode and the location of the delivery as well as preparing the postnatal staff for a prenatally defined fetal problem. A major factor in the development was the groundbreaking work of an obstetrician, Ian Donald, and an engineer, Tom Brown, at Queen Mother's Hospital in Glasgow, who produced an ultrasound instrument called the Diasonograph. The first screening program offering a systematic ultrasound examination to a large pregnant population began in Malmoe, in 1973 and aimed to detect twins. Since then the examination has evolved over the years to include a systematic evaluation of the intrauterine contents. A number of randomized controlled trials have been reported and several large studies have reported the efficiency of routine fetal examinations for the detection of anomalies. Detection rates for the various subsets are presented. The learning curve regarding the ability to detect anomalies and the importance of proper training has also been shown. The procedure 'routine fetal examination' has been significant in supporting the continuous development of fetal medicine. The consequences of the improved dating of every pregnancy and the in utero transport of a sick fetus rather than an emergency transportation of a sick neonate, have an established evidence base. Ultrasound technology has had a remarkable ability to trigger great technical minds to move the technology forward year after year. Through a continuous cooperation between technicians and clinicians, this impressive technology of ultrasound will continue to support our work for the unborn child.

Severe intrauterine anemia: a new form of epsilongammagammadeltabeta thalassemia presenting in utero in a Norwegian family.

Severe intrauterine anemia of unknown cause presents a diagnostic challenge. We describe a Norwegian case, managed successfully by intrauterine transfusions, that further investigations demonstrated to be due to a rare type of thalassemia. A deletion of the 5' end of the beta globin gene cluster was characterized, the breakpoints sequenced and a new type of epsilongammagammadeltabeta thalassemia identified. This case highlights the need to consider diagnoses of rare conditions not normally associated with a particular population.

Quantitative Doppler Analysis Using Conventional Color Flow Imaging Acquisitions.

Interleaved acquisitions used in conventional triplex mode result in a tradeoff between the frame rate and the quality of velocity estimates. On the other hand, workflow becomes inefficient when the user has to switch between different modes, and measurement variability is increased. This paper investigates the use of power spectral Capon estimator in quantitative Doppler analysis using data acquired with conventional color flow imaging (CFI) schemes. To preserve the number of samples used for velocity estimation, only spatial averaging was utilized, and clutter rejection was performed after spectral estimation. The resulting velocity spectra were evaluated in terms of spectral width using a recently proposed spectral envelope estimator. The spectral envelopes were also used for Doppler index calculations using in vivo and string phantom acquisitions. In vivo results demonstrated that the Capon estimator can provide spectral estimates with sufficient quality for quantitative analysis using packet-based CFI acquisitions. The calculated Doppler indices were similar to the values calculated using spectrograms estimated on a commercial ultrasound scanner.

Induction of labor or serial antenatal fetal monitoring in postterm pregnancy: a randomized controlled trial.

OBJECTIVE: To compare induction of labor at gestational age 41 weeks with expectant management in regard to neonatal morbidity. Secondary aims were to assess the effect of these managements on mode of delivery and maternal complications. METHODS: Between September 2002 and July 2004, postterm women with singleton cephalic presentation and no prelabor rupture of membranes were randomly assigned to induction of labor at 289 days or antenatal fetal surveillance every third day until spontaneous labor. Main outcome measures were neonatal morbidity, operative delivery rates, and maternal complications. RESULTS: Five hundred eight women were randomly assigned, 254 in each group. No differences of clinical importance were observed in women in whom labor was induced compared with women who were expectantly managed with regard to the following outcomes: neonates whose 5-minute Apgar score was less than 7 (three neonates in the induction group compared with four in the monitoring group, P=.72); neonates whose umbilical cord pH was less than 7 (three compared with two, P=.69); prevalence of cesarean delivery (28 compared with 33, P=.50); or prevalence of operative vaginal delivery (32 compared with 27, P=.49). In the induction group more women had precipitate labors (33 compared with 12, P<.01; number needed to treat was 13), and the duration of second stage of labor was more often less than 15 minutes (94 compared with 56, P<.01; number needed to treat was 7). CONCLUSION: No differences were found between the induced and monitored groups regarding neonatal morbidity or mode of delivery, and the outcomes were generally good. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00385229. LEVEL OF EVIDENCE: I.

Outcomes of pregnancy beyond 37 weeks of gestation.

OBJECTIVE: The aim of the study was to evaluate pregnancy outcomes by weeks of gestation. A second aim was to assess the outcomes in groups with spontaneous or induced labor. METHODS: This was a prospective cohort study of singleton pregnancies delivered after 37 weeks of pregnancy covering a well defined region in Norway from 1990 to 2001 (N = 27,514). Linear regression, chi 2 tests, and multivariable logistic regression analysis were used. RESULTS: Maternal complications varied with gestational age, and were lowest at 39 weeks and highest postterm (cesarean delivery 12.3-21.6%, operative vaginal delivery 10.7-15.4%, maternal hemorrhage 9.7-14.6%). Poor neonatal outcome varied with gestational age only for spontaneous labors (Apgar at 5 minutes less than 7 1.0-2.3%, pH less than 7.10 3.4-5.2%), whereas induction of labor was a risk factor for delivery complications (odds ratio 1.3-2.8), independent of gestational weeks. CONCLUSION: Poor pregnancy outcomes vary with gestational age. Postterm pregnancy and induced labor are prognostic factors for poor outcome.

A cardiovascular profile score in the surveillance of fetal hydrops.

OBJECTIVE: To assess the value of a cardiovascular profile score in the surveillance of fetal hydrops. METHODS: In a retrospective study, 102 hydropic fetuses were examined between 15 and 37 completed weeks of gestation with ultrasonographic assessment of hydrops, heart size, and cardiac function, and arterial umbilical and venous Doppler sonography of the ductus venosus (DV) and the umbilical vein (UV). A cardiovascular profile score (CVPS) was constructed by attributing 2 points for normal and taking away 1 or 2 points for abnormal findings in each category. The score of the final examination prior to treatment, delivery, or fetal demise was compared to the fetal outcome in these 102 fetuses after exclusion of terminated pregnancies. The scores of the first and last examinations were compared in 40 fetuses and the relationship between these scores and the evolution of fetal hydrops and fetal outcome was assessed. RESULTS: Twenty-one pregnancies were terminated (21%). Fifty-four of the remaining 81 hydropic fetuses survived (67%) and perinatal death (PNM) occurred in 27 fetuses (33%). The median CVPS was 6.0 (IQR 4.75-8.00) for all fetuses, with a median of 6.0 (IQR 5.00-6.00) in fetuses who died in the perinatal period compared to a median of 7.0 (IQR 4.00-8.00) in those who survived (p < 0.035). All fetuses in this study had a 'severe' form of hydrops with skin edema. The best predictor for adverse outcome was the venous Doppler sonography of UV and DV, in particular umbilical venous pulsations. Among fetuses included in the longitudinal arm of the study, the survival rate was 40% and the PNM was 60%, after exclusion of terminated pregnancies. CVPS increased by a median of 1 (IQR 0.00-2.00) point in the last exam for those fetuses that lived, whereas among those fetuses that died, the CVPS decreased by a median 1.5 (IQR 0.25-2.75) points (p < 0.001). CONCLUSIONS: The fetal cardiovascular profile score can be used in the surveillance of hydropic fetuses for prediction of the presence of congestive heart failure and as an aid for predicting fetal outcome.

Adaptive Spectral Envelope Estimation for Doppler Ultrasound.

Estimation of accurate maximum velocities and spectral envelope in ultrasound Doppler blood flow spectrograms are both essential for clinical diagnostic purposes. However, obtaining accurate maximum velocity is not straightforward due to intrinsic spectral broadening and variance in the power spectrum estimate. The method proposed in this paper for maximum velocity point detection has been developed by modifying an existing method-signal noise slope intersection, incorporating in it steps from an altered version of another method called geometric method. Adaptive noise estimation from the spectrogram ensures that a smooth spectral envelope is obtained postdetection of these maximum velocity points. The method has been tested on simulated Doppler signal with scatterers possessing a parabolic flow velocity profile constant in time, steady and pulsatile string phantom recordings, as well as in vivo recordings from uterine, umbilical, carotid, and subclavian arteries. The results from simulation experiments indicate a bias of less than 2.5% in maximum velocities when estimated for a range of peak velocities, Doppler angles, and SNR levels. Standard deviation in the envelope is low-less than 2% in the case of experiments done by varying the peak velocity and Doppler angle for steady phantom and simulated flow, and also less than 2% in the case of experiments done by varying SNR but keeping constant flow conditions for in vivo and simulated flow. Low variability in the envelope makes the prospect of using the envelope for automated blood flow measurements possible and is illustrated for the case of pulsatility index estimation in uterine and umbilical arteries.

Adaptive Spectral Estimation Methods in Color Flow Imaging.

Clutter rejection for color flow imaging (CFI) remains a challenge due to either a limited amount of temporal samples available or nonstationary tissue clutter. This is particularly the case for interleaved CFI and B-mode acquisitions. Low velocity blood signal is attenuated along with the clutter due to the long transition band of the available clutter filters, causing regions of biased mean velocity estimates or signal dropouts. This paper investigates how adaptive spectral estimation methods, Capon and blood iterative adaptive approach (BIAA), can be used to estimate the mean velocity in CFI without prior clutter filtering. The approach is based on confining the clutter signal in a narrow spectral region around the zero Doppler frequency while keeping the spectral side lobes below the blood signal level, allowing for the clutter signal to be removed by thresholding in the frequency domain. The proposed methods are evaluated using computer simulations, flow phantom experiments, and in vivo recordings from the common carotid and jugular vein of healthy volunteers. Capon and BIAA methods could estimate low blood velocities, which are normally attenuated by polynomial regression filters, and may potentially give better estimation of mean velocities for CFI at a higher computational cost. The Capon method decreased the bias by 81% in the transition band of the used polynomial regression filter for small packet size ( N=8 ) and low SNR (5 dB). Flow phantom and in vivo results demonstrate that the Capon method can provide color flow images and flow profiles with lower variance and bias especially in the regions close to the artery walls.

Sonographic development of the normal foetal thorax and abdomen across gestation.

In the following review, the development of the thorax and abdomen, as described by embryologists and anatomists in modern embryological text books, is compared with sonoanatomic descriptions from 2D and 3D ultrasound studies, week by week in the first trimester. The anatomic descriptions are limited to details that are of interest for the understanding of ultrasound examinations. For the second and third trimester, the description of the sonographic development of the thorax and abdomen is divided into thoracic skeleton, diaphragm, lungs, oesophagus, stomach, liver, spleen, bowel and gall bladder. The review is restricted to the normal development, appearance and biometric assessment of these organs; and discusses topical literature.

Pelvic floor muscle strength and thickness in continent and incontinent nulliparous pregnant women.

The aim of the study was to measure pelvic floor muscle function in continent and incontinent nulliparous pregnant women. The study group consisted of 103 nulliparous pregnant women at 20 weeks of pregnancy. Women reporting urinary incontinence once per week or more during the previous month were classified as incontinent. Function was measured by vaginal squeeze pressure (muscle strength) and increment in thickness of the superficial pelvic floor muscles (urogenital diaphragm) assessed by perineal ultrasound. Seventy-one women were classified as continent and 32 women as incontinent. Continent women had statistically significantly higher maximal vaginal squeeze pressure and increment in muscle thickness when compared with incontinent women. There was a strong correlation between measurements of vaginal squeeze pressure and perineal ultrasound measurements of increment in muscle thickness. This study demonstrates statistically significant differences in pelvic floor muscle function measured by strength and thickness in continent compared with incontinent nulliparous pregnant women.