Volume 45, Issue 2 - Highlight: Fetal Diagnosis

Aim: The aim of this study was to review prenatally diagnosed tumors of the head and neck in the fetus and to report antenatal and postnatal outcomes. Methods: PubMed/Medline, EMBASE/SCOPUS, Cochrane database and Google Scholar were reviewed over the last 20 years. No language or article type restriction was used. Results: A total of 1940 record were retrieved. Of the 713 records screened, 566 full-text articles were assessed for eligibility. After 445 articles were excluded for specified reasons, 111 studies met the research criteria and were included for qualitative analysis. Overall, 306 cases of fetal tumors of the head and neck were reviewed. Maternal age was an independent factor. The mean maternal age was 28.2 years and gestational age at prenatal diagnosis was 27.1 weeks. Conventional 2D ultrasound was the standard diagnostic procedure in 27.9% of cases and was implemented in 27.3% of cases by 3D ultrasound and fetal magnetic resonance imaging (MRI). Diagnostic evaluation of intracranial spreading and high-airway obstructions was greatly enhanced by fetal MRI. The more common type of fetal tumor was hemangioma/lymphangioms (42.1%), followed by teratomas (29.7%), tumors of the gingiva (10.1%) and lymphatic venous malformations (9.1%), respectively. Fetal karyotyping was performed only in 9.8% of cases; within fetuses undergoing karyotype, chromosomal abnormalities accounted for 20% of cases. The most common pregnancy complication was polyhydramnios (26.3%). Ex utero intrapartum treatment (EXIT) procedure was performed in 30.1% of cases while surgical excision was used in 22.9% during postnatal life. The survival rate was 35.35%. Conclusion: Fetal tumors of the head and neck are rare congenital malformations. Two-dimensional ultrasound is diagnostic in almost all cases; however, MRI may be an important diagnostic adjunct in targeted cases and help patient selection for immediate intubation at the time of delivery. EXIT procedure and surgical removal of the tumor was associated with good prognosis.

Background: Due to the recent outbreak of Zika virus, there has been a newfound interest in fetal and neonatal microcephaly. In 1984, Chervenak et al. proposed criteria for the prenatal ultrasound diagnosis of microcephaly as ≤3 standard deviations (SD) from the mean. Despite improvements in medicine these criteria have not been reevaluated in 30 years. Objective: To examine how the original 1984 Chervenak et al. criteria for the diagnosis of fetal microcephaly apply to a current population utilizing modern ultrasound equipment and techniques. Study design: Retrospective database review of 27,697 ultrasound exams between 18 and 40 weeks’ gestation. Mean and SDs were calculated for each week of gestation from 18 to 40 completed weeks and these were compared to the 1984 data. Results: There is no statistically significant difference in gestational age-specific mean head circumference (HC) between the two studied populations. Because the current dataset is larger the SD differ. Conclusions: The 1984 ultrasound criteria for microcephaly remain valid. Physicians today have two alternatives: either use the 3SD cutoff as recommended by Chervenak et al. and endorsed by the Society for Maternal-Fetal Medicine (SMFM) or develop a new dataset for one’s population with statistical validation.

Objective: Global racial variability in human development can lead to differences in size of fetal cardiac structures during gestation. Our objective is to establish normal reference ranges of fetal cardiac dimensions between 20 and 34 weeks from fetal echocardiograms recorded at a single center in China. Methods: A prospective cross-sectional study was undertaken on single pregnancies with normal fetuses of varying gestational ages (GAs). A total of 4396 normal fetuses were divided into 15 groups from 20 to 34 weeks according to the GA. Measurements included the inner diameter of the fetal cardiac chambers and arteries, the aortic arch isthmus (AI), the descending aorta (DAO), the ductus arteriosus (DA), and the foramen ovale (FO). Measurements were statistically analyzed and regression analysis was applied to assess for correlation with GA. Results: Normal reference values of fetal cardiovascular dimensions between 20 and 34 weeks were obtained from 4396 subjects at a single center in China. Measurements of fetal cardiac structures increase with advancing GA. It seems there is no difference in r values among linear, cubic, and quadratic model analyses (P > 0.05). However, the r values for the exponential models appear to be smaller than those of the other three models (P < 0.05). Ratios of the diameters of fetal cardiac structures were calculated in order to identify for differential changes in the growth of structures. Conclusions: The presented data derived from 4396 normal fetuses provide the reference values of fetal echocardiography in China, which provide guidance to fetal echocardiography examinations.

Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery – 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions.

Objectives: To compare two first-trimester screening strategies: traditional combined screening and the one based on ultrasound markers only. We investigated the effect of maternal age (MA) on the screening performance of both of these strategies. Methods: This was a prospective observational study based on a non-selected mixed-risk population of 11,653 women referred for first-trimester screening. The study population was divided in two groups: combined screening (CS) and ultrasound-based screening (US). Absolute risk was calculated to determine the influence of MA on screening performance. Results: The CS arm comprised 5145 subjects including 51 cases of trisomy 21 (T21), and the US arm comprised 5733 subjects including 87 subjects with T21. Seven hundred and seventy-five subjects were excluded from the study. For a false positive rate (FPR) of 3%, the detection rate (DR) of T21 in CS arm was 78% vs. 90% in US arm. For 5% FPR, DR was 84% and 94% in CS and US arm, respectively. MA had an influence on DR positive rates in CS: both DR and FPR for T21 increased with advance in MA. Conclusions: The US protocol showed higher DR of T21 compared to the CS one. It may be considered as a viable alternative to CS for T21 where access to biochemical testing is limited.

Objective: The aim of this study was to compare transabdominal chorionic villus sampling, transcervical chorionic villus sampling and amniocentesis with respect to their total fetal loss rates. Methods: We retrospectively evaluated procedures of invasive prenatal testing performed during a 14-year period (2001–2014) including 936 amniocentesis procedures and 1051 chorionic villus samplings, of which 405 cases were executed transabdominally and 646 transcervically. Only singleton pregnancies before 24 weeks and 0 days of gestation where the pregnancy outcome was known were included. Fetal loss was defined as an abortion occurring either before 24 weeks and 0 days of gestation or <2 weeks after the procedure. Results: The total fetal loss rates were determined to be 1.73% for transabdominal chorionic villus sampling, 2.01% for transcervical chorionic villus sampling and 1.18% for amniocentesis. No statistically noticeable differences between the total fetal loss rates of all three procedures were found (P=0.399). Conclusion: Our study has shown that chorionic villus sampling (either transabdominal or transcervical) and amniocentesis are equal methods for invasive prenatal testing with respect to their abortion risk.

Objective: To determine the impact of the chorion villus sampling (CVS) technique on adverse perinatal outcomes. Methods: In this case-control study, 412 women who underwent CVS at 11–14 weeks of gestation and 231 women who did not undergo any invasive procedure were retrospectively evaluated. The women in the CVS group were further divided into two groups according to the use of single-needle technique (n=148) vs. double-needle technique (n=264). The adverse outcomes were compared between controls and the two CVS groups, and regression analysis was used to determine the significance of independent contribution. Results: The rate of preeclampsia for the control group was 2.2%, for the double-needle group was 3% and for the single-needle group was 8.1%. CVS with single-needle technique was found to be an independent and statistically significant risk factor for preeclampsia [odds ratio (OR)=2.1, 95% confidence interval (CI); 1.4–2.7, P=0.008]. Conclusion: The risk of preeclampsia after CVS appears to be increased with single-needle technique compared with double-needle technique.

Down syndrome (DS) is the most common chromosome abnormality among live-born infants and the most frequent genetic cause of intellectual disability. The majority of pregnancies affected by DS are terminated. The decision concerning whether or not to continue a pregnancy following the prenatal diagnosis of DS is complex and amongst others, motivated by attitudes towards termination, socioeconomic factors, and ultrasound findings. In Germany, termination of pregnancy (TOP) is a legal option, even during the later stages of gestation. The aim of the present study was to evaluate the pregnancy outcomes as well as possible factors that influence the decisions made by women with trisomy 21-affected pregnancies. In our study 112 pregnancies affected by trisomy 21 were included. Our data confirm that most patients are more likely to terminate a trisomy 21-affected pregnancy [76 (67.9%) vs. 36 (32.1%) continued pregnancies]. Beyond that we found that women who continued their pregnancy tended to be at an advanced stage in their pregnancy at the time of karyotyping. With regards to factors from their medical history as well as sonographic findings there was no identifiable single factor that could distinguish between women that opted to continue or terminate their pregnancy.

Objective: The present study aims to compare the presence and localization of collagen type IV in the prenasal tissue of fetuses with and without Down syndrome (DS). Methods: Products of conception were obtained from mid-gestation uterine evacuations of 14 DS fetuses and 15 unaffected controls. Microdissection of the prenasal area and an analysis of the prenasal tissue specimens were performed by a single pathologist, blinded to the karyotype results. Immunohistological presence and localization of type IV collagen were analyzed in the basement membrane (BM), blood vessels, and stroma of the tissues. Results: There were no statistically significant differences in the presence and localization of antibodies for collagen IV in the blood vessels and stroma between the two groups. However, the presence and localization of type IV collagen in the BM of the prenasal skin were significantly higher in DS specimens compared to the control group (P=0.023). When combining both groups altogether, a significant correlation was found between the increased prenasal thickness (PT) and the high presence and location of collagen type IV, irrespective of the karyotype results (Spearman’s correlation; R=0.459; P=0.012). Conclusion: Using the immunohistochemistry technique, we were able to confirm the overexpression of collagen type IV in the BM of the prenasal area. This may explain the sonographic finding of increased PT seen mainly in DS fetuses.

Objective: To compare endotracheal fluid (EF) and amniotic fluid (AF) phospholipidic profile changes following tracheal occlusion (TO) in the congenital diaphragmatic hernia (CDH) fetal lamb model, in order to support the efficacy of TO on lung maturity. Methods: A diaphragmatic defect was induced at 70 days’ gestation, TO was carried out at day 102 and cesarean section at 136 days’ gestation. EF and AF samples, collected at delivery, were evaluated using mass spectrometry (the analysis focused on palmitoyloleoyl-phosphatidylcholine [POPC, PC(18:1/16:0)], dipalmitoyl-phosphatidylcholine [DPPC, PC(16:0/16:0)] and sphingomyelins [SMs]). Results: The effects of CDH and TO were different on AF and EF. POPC levels were higher than DPPC levels in AF of healthy lambs. Following induction of the diaphragmatic malformation, an evident decrease in POPC was noted, while a substantial return to normal POPC levels and an increased DPPC peak were prompted by the TO. After CDH induction, a decrease in N-palmitoyl-D-sphingomyelin [SM(d18:1/16:0)] was revealed (P<0.01) and an increased peak in SMs in AF was prompted by the TO (P=0.05). While the most represented phosphatidylcholine (PC) species in EF of healthy lambs was DPPC, CDH induced a decrease in the DPPC peak and treatment with TO induced its partial recovery. SMs were detectable only in healthy EF samples. Conclusion: The phospholipid recovery profile following TO suggests the potential role of this therapy in restoring processes involved in surfactant-mediated lung maturation, even though other interactions involved in AF turnover should be considered. Moreover, these metabolites could be used as biomarkers of fetal pulmonary development.

Objective: To determine if intrauterine intraumbilical supplementation with amino acids (AA) and glucose can improve neonatal outcome of severe growth restricted human fetuses (IUGR). Methods: Prospective pilot study of intrauterine treatment of severe IUGR fetuses [n=14, 27 weeks of gestation (range 23–31)] with cerebroplacental ratio <1, with long-term intraumbilical AA and glucose supplementation (10% of feto-placental blood volume/day) using a perinatal port system alone (n=5) or combined with hyperbaric oxygenation (n=1, HBO) vs. control group (n=8). Results: The duration of continuous intraumbilical AA/glucose supplementation was 11 (6–13) days. Daily intravascular fetal nutrition significantly prolonged the brain sparing to delivery interval by 24 (14–33) days vs. 5.6 (2–12) days in controls. Fetal nutrition reduced blood flow resistance in the placental circulation but did not affect the Doppler profile of cerebral arteries. Higher weight gain of 113.5 (36–539) g was observed following supplementation compared to 33.3 (8–98) g in the control group (P<0.05). In spite of this, fetuses below 28 weeks of gestation did not sufficiently benefit from infused commercial AA. We found a reduced fetal plasma concentration of the essential AA histidine, threonine, lysine and arginine, and non-essential AA taurine, in severe IUGR fetuses in both groups. Long-term supplementation with a commercial AA formula led to a slight, but not significant, reduction of histidine, threonine, lysine, arginine, asparagine and glutamine. However, the concentration of tryptophan and glutamic acid slightly increased. HBO can be combined with AA supplementation via a port system. In one case, the port system was also successfully used for fetal blood transfusion. Conclusions: Intravascular treatment of IUGR with fetal nutrition can prolong pregnancy with severe placental insufficiency and brain sparing for many weeks. However, rather than normalizing AA concentrations, an enhanced AA imbalance was observed in IUGR fetuses following supplementation. These deviations in AA concentrations prevent the recommendation for use of commercial AA solutions for prenatal treatment of extreme preterm IUGR fetuses.

Objective: Elafin is a low molecular weight protein with antileukoproteinase, anti-inflammatory, antibacterial and immunomodulating properties. The profile of Elafin in fetal membranes is not well characterized. This study determined the changes in Elafin expression and concentration in human fetal membrane from patients with preterm prelabor rupture of membranes (PPROM) and in vitro in response to intra-amniotic polymicrobial pathogens. Method: Elafin messenger RNA (mRNA) expressions were studied in fetal membranes from PPROM, normal term as well as in normal term not in labor membranes in an organ explant system treated (24 h) with lipopolysaccharide (LPS), using quantitative reverse transcription-polymerase chain reaction (RT-PCR). Enzyme-linked immunosorbent assay (ELISA) measured Elafin concentrations in culture supernatants from tissues treated with LPS and polybacterial combinations of heat-inactivated Mycoplasma hominis (MH), Ureaplasma urealyticum (UU) and Gardnerella vaginalis (GV). Results: Elafin mRNA expression in fetal membranes from women with PPROM was significantly higher compared to women who delivered at term after normal pregnancy (5.09±3.50 vs. 11.71±2.21; P<0.05). In vitro , LPS-stimulated membranes showed a significantly increased Elafin m-RNA expression (P<0.05). However, the protein levels after LPS stimulation was not changed. Similarly, polymicrobial-treated fetal membranes also showed no changes in Elafin protein concentrations compared to untreated controls. Conclusion: Higher Elafin expression in PPROM fetal membranes suggests a host response to an inflammatory pathology. However, lack of Elafin response to LPS and polymicrobial treatment is indicative of the minimal anti-inflammatory impact of this molecule in fetal membranes.

Aim: To discover the potential role of recombinant VEGF 121 (rVEGF 121 ) injection for the prevention of fetal growth restriction in a preeclampsia (PE) mouse model (Mus musculus). Subjects and methods: This is an experimental study of 30 pregnant mice that were randomly divided into three groups: normal, PE, and PE with rVEGF 121 injection. The PE mouse model was created by injecting anti Qa-2 10 ng iv, which is deleterious to Qa-2 expression (homologous to HLA-G), from the first to the fourth day of gestation. PE was validated by measuring serum levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor(PIGF) and also by kidney histopathology. Recombinant VEGF 121 was given on the ninth day until the 11 th day of pregnancy; mice were terminated on the 16 th day. Fetal weights were acquired with a Denver analytical balance. Serum levels of sFlt-1 and PlGF were measured using enzyme-linked immunosorbent assay (ELISA). The data were statistically analyzed via analysis of variance (ANOVA). Results: On average, fetal birth weight was 0.7150 g in the normal group, 0.4936 g in the PE group, and 0.6768 g in the PE with rVEGF 121 injection group. ANOVA showed significant growth restriction in the PE group (P=0.006), confirming the use of anti Qa-2 as a suitable PE model. Kidney histopathology results, sFlt-1 levels, and PlGF levels also demonstrated that anti Qa-2 consistently conferred hallmarks of PE in mice. Vascular endothelial growth factor (VEGF) injection prevented fetal growth restriction; comparable fetal weights were observed between the PE model with VEGF treatment and the normal group (P=0.610) but differed from the untreated PE group (P=0.021). Conclusions: Injection of rVEGF 121 has the potential to prevent fetal growth restriction in a newly proposed PE mouse model.

Objective: To compare different ultrasonographic fetal weight estimation formulas in predicting the fetal birth weight of preterm premature rupture of membrane (PPROM) fetuses. Methods: Based on the ultrasonographic measurements, the estimated fetal weight (EFW) was calculated according to the published formulas. The comparisons used estimated birth weight (EBW) and observed birth weight (OBW) to calculate the mean absolute percentage error [(EBW–OBW)/OBW×100], mean percentage error [(EBW–OBW)/OBW×100)] and their 95% confidence intervals. Results: There were 234 PPROM patients in the study period. The mean gestational age at which PPROM occured was 31.2±3.7 weeks and the mean gestational age of delivery was 32.4±3.2 weeks. The mean birth weight was 1892±610 g. The median absolute percentage error for 33 formulas was 11.7%. 87.9% and 21.2% of the formulas yielded inaccurate results when the cut-off values for median absolute percentage error were 10% and 15%, respectively. The Vintzileos’ formula was the only method which had less than or equal to 10% absolute percentage error in all age and weight groups. Conclusions: For PPROM patients, most of the formulas designed for sonographic fetal weight estimation had acceptable performance. The Vintzileos’ method was the only formula having less than 10% absolute percentage error in all gestational age and weight groups; therefore, it may be the preferred method in this cohort. Amniotic fluid index (AFI) before delivery had no impact on the performance of the formulas in terms of mean percentage errors.