Fetal growth restriction can result from a variety of maternal, fetal, and placental conditions. It occurs in up to 10% of pregnancies and is a leading cause of infant morbidity and mortality. This ...complex obstetrical problem has disparate published diagnostic criteria, relatively low detection rates, and limited preventative and treatment options. The purpose of this Consult is to outline an evidence-based, standardized approach for the prenatal diagnosis and management of fetal growth restriction. The recommendations of the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that fetal growth restriction be defined as an ultrasonographic estimated fetal weight or abdominal circumference below the 10th percentile for gestational age (GRADE 1B); (2) we recommend the use of population-based fetal growth references (such as Hadlock) in determining fetal weight percentiles (GRADE 1B); (3) we recommend against the use of low-molecular-weight heparin for the sole indication of prevention of recurrent fetal growth restriction (GRADE 1B); (4) we recommend against the use of sildenafil or activity restriction for in utero treatment of fetal growth restriction (GRADE 1B); (5) we recommend that a detailed obstetrical ultrasound examination (current procedural terminology code 76811) be performed with early-onset fetal growth restriction (<32 weeks of gestation) (GRADE 1B); (6) we recommend that women be offered fetal diagnostic testing, including chromosomal microarray analysis, when fetal growth restriction is detected and a fetal malformation, polyhydramnios, or both are also present regardless of gestational age (GRADE 1B); (7) we recommend that pregnant women be offered prenatal diagnostic testing with chromosomal microarray analysis when unexplained isolated fetal growth restriction is diagnosed at <32 weeks of gestation (GRADE 1C); (8) we recommend against screening for toxoplasmosis, rubella, or herpes in pregnancies with fetal growth restriction in the absence of other risk factors and recommend polymerase chain reaction for cytomegalovirus in women with unexplained fetal growth restriction who elect diagnostic testing with amniocentesis (GRADE 1C); (9) we recommend that once fetal growth restriction is diagnosed, serial umbilical artery Doppler assessment should be performed to assess for deterioration (GRADE 1C); (10) with decreased end-diastolic velocity (ie, flow ratios greater than the 95th percentile) or in pregnancies with severe fetal growth restriction (estimated fetal weight less than the third percentile), we suggest weekly umbilical artery Doppler evaluation (GRADE 2C); (11) we recommend Doppler assessment up to 2–3 times per week when umbilical artery absent end-diastolic velocity is detected (GRADE 1C); (12) in the setting of reversed end-diastolic velocity, we suggest hospitalization, administration of antenatal corticosteroids, heightened surveillance with cardiotocography at least 1–2 times per day, and consideration of delivery depending on the entire clinical picture and results of additional evaluation of fetal well-being (GRADE 2C); (13) we suggest that Doppler assessment of the ductus venosus, middle cerebral artery, or uterine artery not be used for routine clinical management of early- or late-onset fetal growth restriction (GRADE 2B); (14) we suggest weekly cardiotocography testing after viability for fetal growth restriction without absent/reversed end-diastolic velocity and that the frequency be increased when fetal growth restriction is complicated by absent/reversed end-diastolic velocity or other comorbidities or risk factors (GRADE 2C); (15) we recommend delivery at 37 weeks of gestation in pregnancies with fetal growth restriction and an umbilical artery Doppler waveform with decreased diastolic flow but without absent/reversed end-diastolic velocity or with severe fetal growth restriction with estimated fetal weight less than the third percentile (GRADE 1B); (16) we recommend delivery at 33–34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity (GRADE 1B); (17) we recommend delivery at 30–32 weeks of gestation for pregnancies with fetal growth restriction and reversed end-diastolic velocity (GRADE 1B); (18) we suggest delivery at 38–39 weeks of gestation with fetal growth restriction when the estimated fetal weight is between the 3rd and 10th percentile and the umbilical artery Doppler is normal (GRADE 2C); (19) we suggest that for pregnancies with fetal growth restriction complicated by absent/reversed end-diastolic velocity, cesarean delivery should be considered based on the entire clinical scenario (GRADE 2C); (20) we recommend the use of antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks of gestation or for pregnancies between 34 0/7 and 36 6/7 weeks of gestation in women without contraindications who are at risk of preterm delivery within 7 days and who have not received a prior course of antenatal corticosteroids (GRADE 1A); and (21) we recommend intrapartum magnesium sulfate for fetal and neonatal neuroprotection for women with pregnancies that are <32 weeks of gestation (GRADE 1A).
Brief Report: Zika Virus Infection and Fetal Brain Abnormalities
In this case report, the association between Zika virus infection and teratogenicity is strengthened, with evidence that the latency ...period between ZIKV infection of the fetal brain and the detection of microcephaly and intracranial calcifications on ultrasonography may be prolonged.
Zika virus (ZIKV), a mosquito-borne flavivirus and member of the Flaviviridae family, was originally isolated from a sentinel primate in Uganda in 1947.
1
ZIKV was associated with mild febrile disease and maculopapular rash in tropical Africa and some areas of Southeast Asia. Since 2007, ZIKV has caused several outbreaks outside its former distribution area in islands of the Pacific: in 2007 on Yap island in Micronesia, in 2013 and 2014 in French Polynesia, and in 2015 in South America, where ZIKV had not been identified previously.
2
–
5
There are separate African and Asian lineages of the virus,
6
and the latter . . .
Quality control/assessment of ultrasound (US) images is an essential step in clinical diagnosis. This process is usually done manually, suffering from some drawbacks, such as dependence on operator's ...experience and extensive labors, as well as high inter- and intra-observer variation. Automatic quality assessment of US images is therefore highly desirable. Fetal US cardiac four-chamber plane (CFP) is one of the most commonly used cardiac views, which was used in the diagnosis of heart anomalies in the early 1980s. In this paper, we propose a generic deep learning framework for automatic quality control of fetal US CFPs. The proposed framework consists of three networks: (1) a basic CNN (B-CNN), roughly classifying four-chamber views from the raw data; (2) a deeper CNN (D-CNN), determining the gain and zoom of the target images in a multi-task learning manner; and (3) the aggregated residual visual block net (ARVBNet), detecting the key anatomical structures on a plane. Based on the output of the three networks, overall quantitative score of each CFP is obtained, so as to achieve fully automatic quality control. Experiments on a fetal US dataset demonstrated our proposed method achieved a highest mean average precision (mAP) of 93.52% at a fast speed of 101 frames per second (FPS). In order to demonstrate the adaptability and generalization capacity, the proposed detection network (i.e., ARVBNet) has also been validated on the PASCAL VOC dataset, obtaining a highest mAP of 81.2% when input size is approximately 300 × 300.
This final report updates preliminary data on Zika virus infection among pregnant women in Rio de Janeiro. ZIKV infection during pregnancy was associated with fetal death, fetal growth restriction, ...and central nervous system abnormalities.
We have been conducting active surveillance for dengue infection in the general population of Rio de Janeiro since 2007. In 2012, we established a prospective cohort for dengue surveillance in mother–infant pairs within the Manguinhos Rio de Janeiro area. In 2015, we noted an increase in cases of a denguelike illness that was characterized by a descending rash, generally without fever; this increase coincided with a surge in the number of cases of illness characterized by a pruriginous rash in northeastern Brazil.
1
In early 2015, most cases were originally reported to surveillance systems as dengue; however, Zika virus (ZIKV) was . . .
Summary Background In 2006, WHO produced international growth standards for infants and children up to age 5 years on the basis of recommendations from a WHO expert committee. Using the same methods ...and conceptual approach, the Fetal Growth Longitudinal Study (FGLS), part of the INTERGROWTH-21st Project, aimed to develop international growth and size standards for fetuses. Methods The multicentre, population-based FGLS assessed fetal growth in geographically defined urban populations in eight countries, in which most of the health and nutritional needs of mothers were met and adequate antenatal care was provided. We used ultrasound to take fetal anthropometric measurements prospectively from 14 weeks and 0 days of gestation until birth in a cohort of women with adequate health and nutritional status who were at low risk of intrauterine growth restriction. All women had a reliable estimate of gestational age confirmed by ultrasound measurement of fetal crown–rump length in the first trimester. The five primary ultrasound measures of fetal growth—head circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and femur length—were obtained every 5 weeks (within 1 week either side) from 14 weeks to 42 weeks of gestation. The best fitting curves for the five measures were selected using second-degree fractional polynomials and further modelled in a multilevel framework to account for the longitudinal design of the study. Findings We screened 13 108 women commencing antenatal care at less than 14 weeks and 0 days of gestation, of whom 4607 (35%) were eligible. 4321 (94%) eligible women had pregnancies without major complications and delivered live singletons without congenital malformations (the analysis population). We documented very low maternal and perinatal mortality and morbidity, confirming that the participants were at low risk of adverse outcomes. For each of the five fetal growth measures, the mean differences between the observed and smoothed centiles for the 3rd, 50th, and 97th centiles, respectively, were small: 2·25 mm (SD 3·0), 0·02 mm (3·0), and −2·69 mm (3·2) for head circumference; 0·83 mm (0·9), −0·05 mm (0·8), and −0·84 mm (1·0) for biparietal diameter; 0·63 mm (1·2), 0·04 mm (1·1), and −1·05 mm (1·3) for occipitofrontal diameter; 2·99 mm (3·1), 0·25 mm (3·2), and −4·22 mm (3·7) for abdominal circumference; and 0·62 mm (0·8), 0·03 mm (0·8), and −0·65 mm (0·8) for femur length. We calculated the 3rd, 5th 10th, 50th, 90th, 95th and 97th centile curves according to gestational age for these ultrasound measures, representing the international standards for fetal growth. Interpretation We recommend these international fetal growth standards for the clinical interpretation of routinely taken ultrasound measurements and for comparisons across populations. Funding Bill & Melinda Gates Foundation.
Objectives
The aim of this study was to define the prenatal ultrasound semiology of cleft palate without cleft lip using 3D visualization of the fetal palate.
Methods
A prospective longitudinal study ...was performed in our University Hospital Center from 2011 to 2018. The fetal secondary palate was studied in 3D, starting with 2D axial transverse ultrasound view. We defined a cleft palate as a disruption of the horizontal plate of the palatine bone of the secondary palate. Prenatal findings were correlated to anatomic postnatal examinations performed by a paediatric plastic surgeon.
Results
Forty‐three cases of cleft palate without cleft lip were prenatally diagnosed, of whom 34 were associated with malformations. We defined four types of disruptive appearances: isolated nonvisualization of the posterior nasal spine; partial‐disruption or cleft velum; complete disappearance or V‐shaped cleft palate; and complete disappearance or U‐shaped cleft palate. The adjusted kappa coefficient, between prenatal and postnatal evaluation, was 0.88 (95% CI: 0.79‐0.97), corresponding to an excellent agreement.
Conclusions
Using a strictly axial transverse ultrasound view, visualization of the secondary fetal palate enables to diagnose a cleft palate without cleft lip. This method offers a prenatal anatomic classification of cleft palate with a high level of concordance to postnatal findings.
This guideline reviews the evidence-based management of normal and complicated monochorionic twin pregnancies.
Women with monochorionic twin or higher order multiple pregnancies.
Implementation of ...these recommendations should improve the management of both complicated and uncomplicated monochorionic (and higher order multiple) twin pregnancies. They will help users monitor monochorionic twin pregnancies appropriately and identify and manage monochorionic twin complications optimally in a timely manner, thereby reducing perinatal morbidity and mortality. These recommendations entail more frequent ultrasound monitoring of monochorionic twins compared to dichorionic twins.
Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate MeSH headings (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Results were restricted to systematic reviews, randomized controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials.
The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional weak recommendations).
Maternal-fetal medicine specialists, obstetricians, radiologists, sonographers, family physicians, nurses, midwives, residents, and other health care providers who care for women with monochorionic twin or higher order multiple pregnancies.
Canadian (SOGC) guidelines for the diagnosis, ultrasound surveillance and management of monochorionic twin pregnancy complications, including TTTS, TAPS, sFGR (sIUGR), acardiac (TRAP), monoamniotic twins and intrauterine death of one MC twin.
RECOMMENDATIONS.
RESUMEN
Pautas de práctica de ISUOG: la función del ultrasonido en la detección y seguimiento de la preeclampsia
Introducción
La hipertensión en el embarazo afecta hasta el 10% de las mujeres ...embarazadas y la incidencia global combinada de la preeclampsia (PE) es de aproximadamente el 3%. Las diferencias significativas entre los países desarrollados y en desarrollo pueden atribuirse a diferencias reales o a diferencias derivadas de la adquisición de datos. La PE y sus complicaciones contribuyen en gran medida a la morbilidad y mortalidad materna y perinatal en todo el mundo. Dado que la atención oportuna y efectiva puede mejorar los resultados de la PE, el desarrollo de estrategias eficaces de predicción y prevención ha sido uno de los principales objetivos de la atención prenatal y de la investigación.
La PE es una enfermedad multisistémica de origen multifactorial: está relacionada con placentación defectuosa, estrés oxidativo, autoinmunidad, activación de plaquetas y trombina, inflamación intravascular, disfunción endotelial, desequilibrio en la angiogénesis y mala adaptación cardíaca materna. La invasión defectuosa de la placenta está fuertemente asociada con la mayoría de los casos de PE temprana y grave. En contraste, la placentación defectuosa parece ser menos importante para el desarrollo de la PE que se manifiesta más tarde en el embarazo, por ejemplo después de las 34 semanas. En comparación con los embarazos afectados por la enfermedad de aparición temprana, en aquellos complicados con PE a término o cerca de este, la frecuencia de anomalías histológicas de las placentas es significativamente menor, y los factores maternos (p. ej. el síndrome metabólico o la hipertensión crónica) tienen una importancia relativamente mayor. También se observan diferencias entre la PE de aparición temprana y la de aparición tardía en los factores de riesgo, la capacidad de respuesta vascular materna, el rendimiento del cribado y la eficacia de la prevención.
El conocimiento cada vez mayor sobre la fisiopatología de la PE se refleja en las estrategias de cribado actuales, que se basan en el historial, la demografía, los biomarcadores (como la presión arterial) y el Doppler de la arteria uterina.
Actualmente hay más de 10 000 artículos de PubMed relacionados con la detección de la PE, lo que indica el gran interés en este tema. Menos de una quinta parte de estos se refieren a la detección temprana, lo que constituye un avance de la última década. El objetivo de estas Pautas es revisar la evidencia más reciente y, en lo posible, proporcionar recomendaciones basadas en la evidencia con respecto a la función del ultrasonido en el cribado y seguimiento de la PE. Las Pautas se centran en los aspectos técnicos y clínicos del cribado, sin incluir los aspectos económicos y políticos de la salud, como la conveniencia y la rentabilidad del cribado. Además, estas Pautas se elaboraron partiendo del supuesto de que se dispone de los recursos necesarios para la realización del cribado y el seguimiento (equipo, examinadores y conocimientos especializados). Los pasos y procedimientos descritos en estas Pautas no tienen la intención de constituir un estándar legal para el servicio clínico.
摘要
ISUOG实践指南:超声在子痫前期筛查和随访中的作用
前言
妊娠期高血压疾病累及多达10%的孕妇,子痫前期(pre‐eclampsia,PE)总的全球发病率约为3%。发达国家和发展中国家存在明显差异,可能是真实差异或是数据采集造成的差异所致。PE及其并发症是影响全球孕产妇围产期发病率和死亡率的一个重要因素。及时、有效的治疗能够改善PE结局,因此发展有效的预测和预防方法已经成为产前保健和研究的一个主要目标。
PE是一种多因素导致的多系统疾病:包括胎盘形成障碍、氧化应激、自身免疫、血小板和凝血酶激活、血管内炎症、内皮功能障碍、血管生成失衡、孕产妇心脏不适应。胎盘植入障碍与大多数早发型重度PE呈强相关。相反,胎盘形成障碍似乎对晚发型PE(如孕34周后)的发生影响不大。与早发型PE孕产妇相比,足月或接近足月时发生PE的孕产妇其胎盘组织学异常的发生率明显较低,母亲因素(如代谢综合征或长期高血压)具有较大意义。早发型和晚发型PE相比,危险因素、母亲血管反应、筛查能力和预防效能也存在差异。
目前的筛查方法反映了对PE病理生理学的了解逐渐加深,筛查方法是基于病史、流行病学、生物标志物(包括血压)和子宫动脉多普勒检查。
目前PubMed中收录了10 000多篇有关PE筛查的文章,表明人们非常关注这一问题。其中不到五分之一的文章探讨了早期筛查,这是过去十年取得的进展。本指南的目的是回顾最新的证据,如果可能,为超声在PE筛查和随访中的作用提供循证推荐。本指南关注筛查的技术和临床方面,并未扩展到卫生经济学和政策问题,包括筛查的可行性和成本—效益。而且指南的制定是假设能够获得筛查和随访所需的资源(设备、检查人员、专家)。本指南中所描述的步骤和程序并不是作为临床服务的法律标准。
This article's has been translated into Spanish and Chinese. Follow the links from the to view the translations.
Display omitted
We propose a novel attention gate (AG) model for medical image analysis that automatically learns to focus on target structures of varying shapes and sizes. Models trained with AGs ...implicitly learn to suppress irrelevant regions in an input image while highlighting salient features useful for a specific task. This enables us to eliminate the necessity of using explicit external tissue/organ localisation modules when using convolutional neural networks (CNNs). AGs can be easily integrated into standard CNN models such as VGG or U-Net architectures with minimal computational overhead while increasing the model sensitivity and prediction accuracy. The proposed AG models are evaluated on a variety of tasks, including medical image classification and segmentation. For classification, we demonstrate the use case of AGs in scan plane detection for fetal ultrasound screening. We show that the proposed attention mechanism can provide efficient object localisation while improving the overall prediction performance by reducing false positives. For segmentation, the proposed architecture is evaluated on two large 3D CT abdominal datasets with manual annotations for multiple organs. Experimental results show that AG models consistently improve the prediction performance of the base architectures across different datasets and training sizes while preserving computational efficiency. Moreover, AGs guide the model activations to be focused around salient regions, which provides better insights into how model predictions are made. The source code for the proposed AG models is publicly available.
PDF
