Antenatal detection of aberrant subclavian artery (ARSA) by 4D-volume contrast ?maging in mid-trimester ultrasound exam

Background and Purpose: To report a small series of ARSA (Aberrant Right Subclavian Artery) cases which were diagnosed by 4-D (Dimensional) ultrasound (Volume Contrast Imaging-A Plane) with high definition flow technique. Methods: Clinical data of total 1859 singleton, low risk pregnancies from the hospital database. Total 13 cases with isolated ARSA cases were identified. Results: Total 13 cases with isolated ARSA cases were identified. Median maternal age was 32 years old. Median gestational age at ultrasound exam was 21 weeks. Eleven of thirteen cases were isolated. Case 3 had a muscular ventricular septal defect (VSD) and case 6 had an aberrant left subclavian artery. All cases were detected by 4D VCI-A with high definition flow technique successfully. One fetus with ARSA who was misdiagnosed as normal by conventional 2-D ultrasound, 4D VCI-A with high definition flow revealed abnormal courses of the right subclavian artery. Course of azygos vein was discriminated from the ARSA in all cases. Conclusion: 4D VCI-A mode activated with HD-flow (High Definition) is a valuable tool for the investigation of outflow tracts of fetal heart and proximal branches of aorta in midtrimester scans and carries some advantages over conventional 2D sonography combined with High Definition Flow mode.

Primary Care Doctors’ Role in Antenatal Detection and Management of Fetal Bilateral Pleural Effusions: A Report of 2 Cases

Introduction: Fetal pleural effusion is rarely seen in primary care setting. It is more commonly diagnosed among women with diabetes mellitus in pregnancy. Method: This report illustrates two patients with fetal bilateral pleural effusions, detected at 18-week and 24-week period of amenorrhea (POA) during routine antenatal scans by primary care doctors. Result: These two pregnancies were complicated with hydrops fetalis and resulted in fresh stillbirth and intra-uterine death. Conclusion: Primary healthcare providers play an important role in the early diagnosis of fetal congenital anomaly, counseling regarding the ultrasonography findings, neonatal outcome, and referral to obstetrician for further management and monitoring for maternal complications, such as polyhydramnios, preeclampsia, mirror syndrome, and depression as a result of hydrops fetalis.

Antenatally diagnosed congenital anomalies-trend in tertiary care hospital

Background: Antenatally diagnosed, congenital abnormalities of the fetus are frequently offered antenatal surgical consultation in all tertiary care hospitals to adequately counsel prospective parents. We aimed to assess the current trends in antenatally diagnosed congenital malformations of fetus in patients who had presented to our hospital for reassessment or surgical consultation and these patients were counselled and prognosticated after confirmation of anomaly at our centre accordingly.Methods: This was a retrospective study of all the cases diagnosed antenatally with fetal abnormalities. All cases were referred to either pediatric surgery outpatient department or fetal medicine subunit of a tertiary care centre from January 2017-December 2018. The complete records of these pregnant women were perused, presence and type of anomaly confirmed at our centre and trends about types of anomalies analysed.Results: A total of 209 women were analyzed for antenatal anomalies, out of these patients medical termination of pregnancy was offered to 27 (12.9%) patients, in which 38 anomalies were detected and in 182 (87%) patients pregnancy was continued to delivery. A total of 223 anomalies were detected in this group with some patients having fetuses with more than one anomaly. Gastrointestinal abnormalities were present in 94 (51.6%) patients of those who delivered and accounted for the most common anomaly followed by CNS abnormality which accounted for 39 (21.4%) of total abnormalities and genitourinary abnormalities contributed to 28 (13.3%) of abnormalities. A total of 85.2% of patients were referred after 20 weeks.Conclusions: The significant number of patients with major congenital anomalies are still diagnosed at a date later than permissible time for termination of gestation (20 weeks). There were cases where anomaly scan was done at a later gestation and then there were others where inadequate counselling made patient to present late for prognostication. However, there are certain anomalies that are picked up late and are likely to be missed in the routine anomaly scan. Therefore, antenatal detection and early referral helps in offering early counselling and better outcome for pregnancy.

Effect of regular third-trimester ultrasound examination on antenatal detection and perinatal outcomes of small for gestational age infants

Objective To assess the effect of regular third-trimester ultrasound on antenatal detection and perinatal outcomes of small for gestational age (SGA) infants. Methods Data from SGA infants delivered at ≥28 weeks’ gestation were retrospectively studied. Each pregnancy had undergone three regular third-trimester ultrasound examinations, and data were grouped according to with or without antenatal ultrasound suspicion of fetal growth restriction (FGR). Adjusted risk ratios (aRRs) of perinatal outcomes were analysed. Results A total of 407 infants were included, comprising 268 (65.85%) with antenatal ultrasound suspicion of FGR. Antenatal suspicion of FGR was associated with increased risk of iatrogenic delivery (aRR 2.03, 95% confidence interval [CI] 1.31, 3.14) that included risk of preterm birth (aRR 10.61, 95% CI 1.35, 83.62) and elective caesarean section (aRR 1.306, 95% CI 1.051, 1.623). Differences in fetal death, 1-min Apgar score, and admission to neonatal intensive care unit were not statistically significant. Resuscitation risk was reduced (aRR 0.22, 95% CI 0.06, 0.79). Conclusions Regular use of third-trimester ultrasound in one teaching hospital in China showed satisfactory antenatal detection of FGR among SGA infants. Ultrasound suspicion of FGR was associated with higher incidence of iatrogenic deliveries, but not improved neonatal outcomes, except for reduced perinatal resuscitation.

Sirenomelia With Anhydramnios: A Clue From the Movements of Fetal Limbs

Sirenomelia is a rare, lethal congenital malformation of the fetus, typically characterized by the fusion of lower limbs and additional malformations involving the lumbosacral spine and urogenital and gastrointestinal tracts. We report a case of sirenomelia with anhydramnios detected during anomaly scan where the fetus had normal morphology of long bones of the lower limbs. There were associated abnormalities of the lumbosacral spine (caudal dysgenesis). The abortus had fused lower limbs, absent external genitalia and anal orifice, single umbilical artery, and Potter facies. We also highlight the interesting diagnostic challenges faced by us during this antenatal ultrasound. To our knowledge, this is the first case report of sirenomelia where the synchronous movement of lower limbs was a clue that led to the timely antenatal detection of this rare entity. This ultimately helped in perinatal counseling of parents to decide on termination of pregnancy.

Further insights into unusual acrania-exencephaly-anencephaly sequence caused by amniotic band – first trimester fetoscopic correlation with two- and three-dimensional ultrasound

Objectives Antenatal detection of acrania-exencephaly-anencephaly (AEA) sequence beyond 10 completed weeks of gestation is usually straight-forward. An earlier detection and classification of the causative conditions prior to disaggregation of exposed dysplastic brain tissue remains challenging. Case presentation We present two- and three-dimensional ultrasound correlated with fetoscopic findings of an unusual type of neural tube defect at 11 gestational weeks caused by an amniotic constriction ring resulting in cystic degeneration of the developing skull. Conclusions By giving further illustrative insights into early defective brain development, this report confirms recent findings of an unusual subtype of acrania-exencephaly-anencephaly sequence suggesting early disruption of the developing brain, following an amniotic entrapment of the skull.

Fetal Tachycardia in the Delivery Room: Fetal Distress, Supraventricular Tachycardia, or Both?

Background Supraventricular tachycardia (SVT) is seldom considered a cause for fetal tachycardia; commoner etiologies including maternal fever and fetal distress are usually envisaged. Fetal arrhythmia can be missed as a diagnosis, potentially leading to suboptimal management. Cases Three cases are described where detection of fetal tachycardia >200 beats per minute (bpm) at 36, 40, and 38 weeks gestation resulted in emergency cesarean section for presumed fetal distress. Retrospective review of the cardiotocograph in two cases revealed baseline heart rates 120 to 160 bpm, with loss of trace associated with auscultated rates over 200 bpm. The diagnosis of SVT was not initially considered and made later when the infants required cardioversion at the age of 3 weeks, 2 days, and 8 days, respectively. The 36-week infant required noninvasive ventilation for prematurity. Conclusion SVT should be actively considered in the differential diagnosis of fetal tachycardia. Unrecognized fetal SVT may result in avoidable caesarean for suspected fetal distress, with potential prematurity-related problems. The cardiotocograph can be helpful if showing contact loss associated with rapid heart rate auscultation. The antenatal detection of fetal SVT is important as it can allow anticipation and prevention of neonatal SVT, which is potentially life-threatening if not detected and treated promptly.

Peer review of third trimester abdominal circumference measurements

Background Third trimester growth scans represent a significant proportion of the workload in obstetric ultrasound departments. The objective of these serial growth scans is to improve the antenatal detection of babies with fetal growth restriction. The aim of this paper is to describe a method of peer review for third trimester abdominal circumference measurements which is realistic within busy obstetric ultrasound departments in the UK. Method Twenty-two, third trimester, measured abdominal circumference images were randomly selected. Images were assessed subjectively by 12 sonographers using the image Criteria Achieved Score. For quantitative assessment, termed the Inter-operator Variability Score, three of the abdominal circumference (AC) images were blindly remeasured. Following this, a questionnaire was used to ascertain which image criteria sonographers considered most important and to reach an agreement on correct caliper placement. Results The least frequently met image criteria with the lowest Criteria Achieved Score related to an oblique abdominal circumference section. These included fetal kidney present (Criteria Achieved Score 24.6%), multiple oblique ribs (Criteria Achieved Score 39.4%) and oblique spine (Criteria Achieved Score 37.5%). Caliper placement was also identified as inconsistent. Discussion This study demonstrates that the perfect AC section is not always possible and sonographers use their professional judgement to determine whether an image is acceptable. Seventy-three percent of the images reviewed were of an acceptable standard. There can be inconsistencies in sonographer opinion regarding what is an acceptable third trimester abdominal circumference image. These differences need to be addressed to maximise the effectiveness of the third trimester ultrasound examination. Conclusion Peer review can be used to monitor scan quality and identify areas of inconsistency.