The September issue of Ultrasound in Obstetrics & Gynecology includes a series of papers on the fetal brain, including a study on the role of prenatal magnetic resonance imaging in fetuses with isolated mild or moderate ventriculomegaly and updated ISUOG Practice Guidelines on the sonographic examination of the fetal central nervous system (Part 1), as well as a study and accompanying video abstract on the treatment and outcome of 370 cases with spontaneous or post-laser twin anemia–polycythemia sequence managed in 17 fetal therapy centers, a study on the use of pregnancy-associated plasma protein-A, placental growth factor or both for first-trimester pre-eclampsia screening, and a study on transrectal high-intensity focused ultrasound for management of rectosigmoid deep infiltrating endometriosis.
Role of prenatal magnetic resonance imaging in fetuses with isolated mild or moderate ventriculomegaly in the era of neurosonography: international multicenter study
Ultrasound is the primary imaging tool for assessment of the fetal brain, while fetal magnetic resonance imaging (MRI) has been shown to detect additional anomalies in 20% to 50% of cases. The ENSO Working Group assessed the role of fetal MRI in detecting associated anomalies in 556 fetuses presenting with mild or moderate isolated ventriculomegaly (VM) undergoing multiplanar ultrasound evaluation of the fetal brain. The incidence of an associated fetal anomaly missed on ultrasound and detected only on fetal MRI was found to be lower than that reported previously. The large majority of these anomalies are difficult to detect on ultrasound. The findings from this study support the practice of MRI assessment in every fetus with a prenatal diagnosis of VM, although parents can be reassured of the low risk of an associated anomaly when VM is isolated on neurosonography.
The findings of this study are discussed in an Editorial by Malinger et al.. The authors point out that, while the findings of the ENSO study are encouraging, there are a few factors that should be considered, and conclude that, when an optimal dedicated neurosonographic examination has been performed, the additional yield of fetal MRI will be low, but that fetal brain MRI studies should be indicated in some circumstances.
Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia–polycythemia sequence managed in 17 fetal therapy centers
The best antenatal management for twin anemia–polycythemia sequence (TAPS) is still unknown. Tollenaar et al. investigated the antenatal management and outcome in an international cohort of 370 monochorionic twin pregnancies with spontaneous or post-laser TAPS in 17 fetal therapy centers. It was found that antenatal treatment for TAPS differs considerably amongst fetal therapy centers. The rate of perinatal mortality was comparable following treatment of TAPS with expectant management, laser surgery, intrauterine transfusion (IUT) (with or without partial exchange transfusion (PET)), delivery or selective feticide. Severe neonatal morbidity was significantly higher in cases treated with IUT (±PET) or delivery within 7 days after diagnosis. Prolongation of pregnancy was best achieved by expectant management or treatment by laser surgery or selective feticide. Watch the accompanying video abstract:
Screening for pre-eclampsia at 11–13 weeks’ gestation: use of pregnancy-associated plasma protein-A, placental growth factor or both
One of the barriers to implementation of universal first-trimester screening for pre-eclampsia (PE) relates to the additional cost of measuring placental growth factor (PlGF). Mazer Zumaeta et al. examined the additive value of PlGF and pregnancy-associated plasma protein-A (PAPP-A) in first-trimester screening for preterm PE by maternal factors, mean arterial pressure and uterine artery pulsatility index and defined the risk cut-off and screen-positive rate to achieve a desired detection rate of PE if PAPP-A rather than PlGF was to be used for first-trimester screening. It was found that, in first-trimester screening for PE, the preferred biochemical marker is PlGF rather than PAPP-A. However, if PAPP-A was to be used rather than PlGF, the same detection rate can be achieved but at a higher screen-positive rate.
Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial
Several studies have reported the efficacy of high-intensity focused ultrasound (HIFU) for treating gynecological disorders. In a Phase-I clinical trial, Philip et al. evaluated the feasibility of treatment with transrectal HIFU in patients presenting with posterior deep infiltrating endometriosis with rectosigmoid involvement. No major complication was observed after 20 procedures, and there was a significant effect on gynecological and digestive symptoms. Morphological effects remain to be demonstrated. If the efficacy and safety of transrectal HIFU are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis.
On a related topic is an Opinion by Leonardi et al., reporting the results of an international survey of obstetrician-gynecologists (OBGYNs) on how they think of and use advanced transvaginal ultrasound (TVS) in the diagnosis and management of endometriosis. Variations in availability and utilization of advanced TVS for endometriosis, nomenclature, education and culture of OBGYNs were found across various regions of the world, and the majority of OBGYNs were not aware of and do not utilize ultrasound techniques to diagnose and map endometriosis.
ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 1: performance of screening examination and indications for targeted neurosonography
Ultrasound has been used for nearly 30 years as the main modality to help diagnose fetal central nervous system (CNS) anomalies. Updated ISUOG Practice Guidelines review, describe and update the technical aspects of the screening evaluation of the fetal brain to be performed as part of the midtrimester anomaly scan. The Guideline also presents the indications for the detailed evaluation of the fetal CNS, which constitutes ‘targeted fetal neurosonography’, a dedicated examination of the fetal brain and spine that requires specific expertise and sophisticated ultrasound equipment. This examination will be the focus of Part 2 of this Guideline.
Enter the UOG Cover Image Competition by 28th September for a chance to have your image featured on the cover of our 30th anniversary special issue. Find out more here.
Coming up next month…
- An ex-vivo and in-vivo study on a new device permitting non-invasive reversal of fetoscopic tracheal occlusion. Preview the Accepted Article.
- A study on the survival outcomes in severe left diaphragmatic hernia with and without fetal endoscopic tracheal occlusion in a country with suboptimal neonatal management. Preview the Accepted Article.
- A study comparing single- vs three-layer fetoscopic open neural tube defect repair. Preview the Accepted Article.
- A study on the short- and long-term outcome after fetal first-trimester primary cytomegalovirus infection according to prenatal imaging findings. Preview the Accepted Article.