No competing interests declared.

Objective To construct reference ranges for cisterna magna (CM)

Purpose: Assessment of cardiac function in the fetal heart is challenging because of its small size and high heart rate, restricted physical access to the fetus, and impossibility of fetal ECG recording. We aimed to standardize the acquisition and postprocessing of fetal echocardiography for deformation analysis and to assess its feasibility, reproducibility, and correlation for longitudinal strain and strain rate measurements by tissue Doppler imaging (TDI) and 2D speckle tracking (2D-strain) during pregnancy. Methods: Echocardiography was performed in 56 fetuses. 2D and color TDI in apical or basal four-chamber views were recorded for subsequent analysis. Caution was taken to achieve a frame rate >70 Hz for speckle tracking and >150 Hz for TDI analysis. For each acquisition, 7.5 s of noncompressed data were stored in cine loop format and analyzed offline. Since fetal ECG information is by definition not available, aortic valve closure was marked from aortic flow and the onset of each cardiac cycle was manually indicated in the 2D images. Sample volume length was standardized at the minimum size. Two observers measured the left and right ventricular peak systolic longitudinal strain and strain-rate. Results: Strain and strain rate measurements were feasible in 93% of the TDI and 2D-strain acquisitions. The mean time spent on analyzing TDI images was 18 min, with an intraclass agreement coefficient of 0.86 (95% CI 0.77–0.92), 0.83 (95% CI 0.72–0.90), 0.96 (95% CI 0.93–0.98), and 0.86 (95% CI 0.76–0.92) for basal left and right free wall peak systolic strain and strain rate, respectively. Agreement between observers using tissue Doppler also showed high reliability. The mean time spent for 2D-strain analysis was 15 min, with an intraclass agreement coefficient of 0.97 (95% CI 0.95–0.98), 0.94 (95% CI 0.89–0.96), 0.96 (95% CI 0.93–0.98), and 0.84 (95% CI 0.73–0.90) for basal left and right free wall peak systolic strain and strain rate, respectively. Agreement between observers also showed a high reliability that was similar for TDI and 2D-strain. There was a weak correlation between TDI and 2D-strain measurements. Conclusions: A standard protocol with fixed acquisition and processing settings, including manual indication of the timing events of the cardiac cycle to correct for the lack of ECG, was feasible and reproducible for the evaluation of longitudinal ventricular strain and strain rate of the fetal heart by TDI as well as 2D-strain analysis. However, both techniques are not interchangeable as the correlation between them is relatively poor.

Fetal growth restriction (FGR) because of placental insufficiency affects 5% to 7% of pregnancies and represents one of the leading causes of perinatal morbidity and mortality.1 Numerous historical cohort studies 2 and animal models 3 have demonstrated that FGR has a strong association not only with metabolic but also with primary cardiovascular remodeling that lead to long-term adverse consequences in later life. The rapid cell proliferation and differentiation during fetal growth are sensitive to any of the even smallest changes damaging the environment that can lead to permanent alterations in structural and functional constitution, which may persist into the adult life. 2 The heart is a central organ in the prenatal adaptation to placental insufficiency and fetal hypoxia. Previous studies have demonstrated remodeled hearts (more globular) with signs of systolic and diastolic dysfunction and preserved ejection fraction. [4][5][6] FGR cases are associated with prenatal adverse cardiac remodeling 4,5 that persists postnatally, 6 and low birth weight was linked to increased cardiovascular mortality in adulthood.2 Chronic pressure/volume overload together with hypoxia in utero have been postulated as the potential underlying mechanistic pathway of prenatal cardiovascular remodeling in FGR. 5,6 Editorial see p 759 Clinical Perspective on p 787Although evaluation of cardiac function with echocardiography has traditionally been limited to volume-based assessment, recent developments in cardiac ultrasound allow the noninvasive measurement of cardiac deformation with direct assessment of myocardial muscle by assessing regional Background-Fetal growth restriction (FGR) is associated with global adverse cardiac remodeling in utero and increased cardiovascular mortality in adulthood. Prenatal myocardial deformation has not been evaluated in FGR to date. We aimed to evaluate prenatal cardiac remodeling comprehensively in FGR including myocardial deformation imaging. Methods and Results-Echocardiography was performed in 37 consecutive FGR (defined as birthweight <10th centile) and 37 normally grown fetuses. A comprehensive fetal echocardiography was performed including tissue Doppler and 2-dimensional-derived strain and strain rate. Postnatal blood pressure measurement at 6 months of age was also performed. FGR cases showed signs of more globular hearts with decreased longitudinal motion (left systolic annular peak velocity: controls mean 6 cm/s [SD myocardial strain and strain rate. [7][8][9] Strain is defined as change in length/thickness of a segment of myocardium relative to its resting length and is expressed as a percentage; strain rate is the velocity of this deformation.7-9 Myocardial deformation imaging has demonstrated a high sensitivity for detecting preclinical myocardial dysfunction in various pathological conditions characterized by myocardial dysfunction, despite preserved ejection fraction, such as asymptomatic carriers of hypertrophic cardiomyopathy, sarcomeric mutations, Fabry disease, or myocardial ste...

Background Prediction of neonatal respiratory morbidity may be useful to plan delivery in complicated pregnancies. The limited predictive performance of the current diagnostic tests together with the risks of an invasive procedure restricts the use of fetal lung maturity assessment. Objective The objective of this study was to evaluate the performance of quantitative ultrasound texture analysis of the fetal lung (quantusFLM) to predict neonatal respiratory morbidity in preterm and early-term (<39.0 weeks) deliveries. Study Design This was a prospective multicenter study conducted in 20 centers worldwide. Fetal lung ultrasound images were obtained at 25.0-38.6 weeks of gestation within 48 hours of delivery, stored in Digital Imaging and Communication in Medicine format, and analyzed with quantusFLM. Physicians were blinded to the analysis. At delivery, perinatal outcomes and the occurrence of neonatal respiratory morbidity, defined as either respiratory distress syndrome or transient tachypnea of the newborn, were registered. The performance of the ultrasound texture analysis test to predict neonatal respiratory morbidity was evaluated. Results A total of 883 images were collected, but 17.3% were discarded because of poor image quality or exclusion criteria, leaving 730 observations for the final analysis. The prevalence of neonatal respiratory morbidity was 13.8% (101/730). The quantusFLM predicted neonatal respiratory morbidity with a sensitivity, specificity, and positive and negative predictive values of 74.3% (75/101), 88.6% (557/629), 51.0% (75/147), and 95.5% (557/583), respectively. Accuracy was 86.5% (632/730), and the positive and negative likelihood ratios were 6.5 and 0.3, respectively. Conclusion The quantusFLM predicted neonatal respiratory morbidity with an accuracy similar to that previously reported for other tests with the advantage of being a non-invasive technique.

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Objective: To update the reference ranges for the ductus venosus pulsatility index (DVPI) at 11+0 to 13+6 gestational weeks. Methods: DVPI was calculated in 14,444 singleton fetuses at 11+0 to 13+6 weeks in two Fetal Medicine Centers, during a 4-year period. Using previously described medians, DVPI evolution was assessed both over the study period on a yearly basis and over gestation, grouping fetuses according to 5-mm crown-rump length (CRL) ranges. Weighted DVPI medians, the 5th and 95th percentiles and distribution parameters for unaffected and trisomy 21 fetuses were newly calculated. Results: A significant DVPI multiple of the median decrease was observed over both the study period (p < 0.01) and over gestation (p < 0.01) using previous medians, in the two centers. Newly calculated weighted medians were lower than those previously described, decreasing with CRL. Distribution parameters calculated using the new medians were different from those previously described. Conclusion: DVPI reference ranges were lower than those previously reported and decreased with CRL. Updated medians and distribution parameters should be considered to include the DVPI as a Gaussian marker in trisomy 21 screening and for quality control purposes.

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