The August issue of Ultrasound in Obstetrics & Gynecology includes two Original Articles and accompanying Opinion pieces on the outcome of fetuses with aortic stenosis following fetal aortic valvuloplasty, articles on obstetric and gynecological ultrasound training, and a Systematic Review on the outcome of fetuses with a prenatal diagnosis of isolated severe bilateral ventriculomegaly.

Please see below a selection of articles from the August issue of the Journal chosen specially by the UOG team. To view all UOG content, become an ISUOG member today or login and upgrade.

Fetal valvuloplasty
Aortic stenosis in neonates is associated with varying degrees of underdevelopment of left heart structures. Fetal aortic valvuloplasty (FAV) has been proposed to improve left heart hemodynamics, reducing the chance of progression to hypoplastic left heart syndrome, and to maintain biventricular (BV) circulation. In an Original Article in this issue of the Journal, Friedman et al. evaluate postnatal outcome after FAV in the period before compared with that after refinement of selection criteria regarding whether the left ventricle is likely to recover following FAV. It was found that the proportion of patients achieving BV circulation following FAV has increased, and that LV pressure, size of the ascending aorta and diastolic function are associated with BV circulation after FAV. In a European multicenter study, Kovacevic et al. assess FAV efficacy by comparing survival and postnatal circulation between fetuses that underwent FAV and those that did not. It was found that, while the proportion of those achieving BV circulation was similar in both cohorts, FAV survivors showed improved survival independent of final circulation to 10 years’ follow-up. 

An Opinion article by Jaeggi and Chaturvedi discusses FAV for critical aortic stenosis in the context of these two articles. They suggest that institutional experience, consistency of approach and case volume are important for determining the success rate of FAV, particularly in postnatal management, and advise that further improvements are required in predictive models of ventricular outcome following FAV, particularly with regards to gestational age.

An Opinion article by Gregory DeVore analyzes the data in the study of Friedman et al., comparing the used reference data with those provided in previously published studies, and creating a calculator enabling computation of the potential success rate of FAV in an at-risk fetus. DeVore recommends that the authors publish their Z-score equations, so that the Z-score computations can be compared with the published literature.

In patients with pulmonary atresia with intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS), fetal pulmonary valvuloplasty aims to stimulate and promote prenatal right ventricular growth in order to avoid significant right ventricular hypoplasia at birth, increasing the chance of BV circulation after birth. In an Original Article, Tulzer et al. assess the immediate effects of fetal pulmonary valvuloplasty on right ventricular size and function as well as in-utero right ventricular growth and postnatal outcome. It was found that, in selected fetuses with PAIVS or CPS, in-utero pulmonary valvuloplasty led immediately to a larger right ventricle caused by reduced afterload and increased filling, thus improving the likelihood of BV outcome, even in fetuses with a predicted non-BV circulation.

Ultrasound training
Training in obstetric and gynecological ultrasound varies both between and within countries, which could result in graduates with varying degrees of proficiency. In an Editorial, Leonardi et al. compare and contrast obstetric and gynecological ultrasound training curricula published by regulatory bodies in four high-income English-speaking countries with the standards set by ISUOG, and make a case for the standardization of obstetric and gynecological ultrasound training, with due regard to available resources. 

Also on this topic is an article in which Hillerup et al. publish their findings on the validity and reliability of the ISUOG basic training test, evaluated by assessing 92 medical students, residents, consultants and fetal medicine specialists. A revised 34-item test was devised based on items that met criteria for difficulty and ability to differentiate between high and low performers. Clinical experience was found not to predict theoretical test scores and there was evidence of possible knowledge decay and negative effects of subspecialization after 5 years.

Also included in this issue… 
Outcome of fetuses with prenatal diagnosis of isolated severe bilateral ventriculomegaly: systematic review and meta-analysis
Ventriculomegaly is one of the most frequently diagnosed abnormalities of the fetal central nervous system, although data on isolated severe ventriculomegaly are scarce. In this Systematic Review, Carta et al. quantified from the published literature survival and neurodevelopmental outcome of fetuses with prenatally detected isolated severe bilateral ventriculomegaly. It was found that four-fifths of fetuses with severe ventriculomegaly survive and, of these, just over two-fifths show normal neurodevelopment, although the authors advise that, due to the high rate of termination of pregnancy and the need for longer follow-up to detect subtle abnormalities, mortality and prevalence of developmental delay may actually be even higher (download the accompanying Journal Club slides).

Differences in ultrasound features of papillations in unilocular-solid adnexal cysts: a retrospective international multicenter study
Discriminating correctly between benign and malignant adnexal masses is pivotal to planning optimal management. Whilst transvaginal ultrasound is an excellent tool with which to distinguish these lesions, some adnexal masses are difficult to classify, even for a very experienced examiner. In particular, cysts with one cyst locule and papillations but no other solid components are difficult to classify. In this Original Article from the IOTA group, Landolfo et al. identified ultrasound characteristics of the papillations themselves or of the cyst wall that can help to discriminate between benign and malignant unilocular-solid adnexal cysts, providing novel insights into morphological markers that may help us to manage a particularly difficult group of adnexal masses.

Coming up in the next issue of UOG…

  • A Systematic Review from Buca et al. on maternal outcome following prenatal diagnosis of abnormally invasive placenta. View the EarlyView article.
  • Two articles on how site of cord insertion in twin pregnancies affects outcome. Preview the Accepted Articles of Couk et al. and Kalafat et al.