Objective To (1) evaluate the normal development of the Sylvian fissures in the anterior coronal view of the fetal brain at 18-30 weeks' gestation by transvaginal threedimensional (3D) ultrasound, (2) develop reference ranges of measurements of the right and left Sylvian fissure angles during normal pregnancy at 18-30 weeks' gestation, and (3) examine intra-and interobserver repeatability of measurements of the right and left Sylvian fissure angles.Methods This was a prospective cross-sectional study of 422 women with a singleton pregnancy attending an ultrasound-based research clinic between March and December 2017. The entry criteria for the study were appropriately grown live fetus with no suspected structural and/or chromosomal defects between 18 + 0 and 30 + 6 weeks' gestation. Normal development of the Sylvian fissures was assessed in the anterior coronal plane of the fetal brain using transvaginal 3D volume multiplanar imaging. The coronal view was visualized as a single image from the three orthogonal views. Subsequently, the right and left Sylvian fissure angles were measured between a horizontal reference line (0 • ) and a line drawn along the upper side of the respective Sylvian fissure. Intra-and interobserver repeatability of the Sylvian fissure angle measurements was assessed by Bland-Altman plots. Reference equations were constructed for right and left Sylvian fissure angles for gestational age (GA) and head circumference (HC) using the Generalized Additive Models for Location Scale and Shape package. ResultsIn the anterior coronal view of the fetal brain, an inward rotation of the upper portion of the Sylvian fissures was observed during the second and third trimesters of pregnancy. There was a significant negative polynomial association between the Sylvian fissure angles and GA and HC. Both Sylvian fissure angles crossed the reference line (zero), going from positive to negative, at around 25 weeks' gestation or at HC of 22 cm. Z-score difference between the smoothed percentiles of the right and left Sylvian fissure angles indicated that median, 10 th and 90 th smoothed percentiles were closest and almost the same for the GA-based references between 18 and 28 weeks and for the HC-based references between 14 and 24 cm. The intraclass correlation coefficient of the right and left Sylvian fissure angle measurements between the two sonographers was excellent at 0.993 (95% CI,, respectively. On Bland-Altman analysis, the mean difference between the two sonographers in right Sylvian fissure angle measurement was 0.4 • (95% CI, −10.2 to 10.1 • ) and in left Sylvian fissure angle it was 1.0 • (95% CI, −9.6 to 11.6 • ).Conclusions Assessment of the Sylvian fissure angles is highly reproducible. Sylvian fissure angle reference charts can serve as a screening tool for malformations of cortical development, guiding subsequent follow-up and referral for fetal brain magnetic resonance imaging and/or assessment by an expert neurosonologist.
Objective To describe a technique to rapidly visualize the in-plane view of the fetal interventricular septum (IVS) to enable the identification of a ventricular septal defect (VSD
Objective To investigate whether gestational age at intervention (< or ≥ 16 weeks) and other factors affect the risk of loss of the cotwin after selective fetal reduction using radiofrequency ablation (RFA) in monochorionic (MC) pregnancy. Methods This was a single‐center retrospective analysis of 63 consecutive RFA procedures performed at our institution from January 2011 to October 2019 for selective fetal reduction in complicated MC pregnancies. Indications for RFA were twin reversed arterial perfusion sequence (13 cases), twin‐to‐twin transfusion syndrome (12 cases), twin anemia–polycythemia sequence (two cases), selective fetal growth restriction (10 cases), discordant anomalies (17 cases) and multifetal pregnancy reduction in triplets or quadruplets with a MC pair (nine cases). Twenty‐six (41.3%) of these procedures were performed before and 37 (58.7%) after 16 weeks. Potential factors that could affect the risk of loss of the cotwin, including gestational age at RFA, order of multiple pregnancy, amnionicity, indication for RFA and number of ablation cycles, were assessed first by univariate analysis and then by multivariate analysis. Results There were 17 (27.0%) cotwin losses. Ablation cycles numbering four or more was the only factor among those investigated to be associated with loss of the cotwin after RFA (P = 0.035; odds ratio, 5.21), while the indication for RFA, order of multiple pregnancy, amnionicity and gestational age at RFA had no effect. Comparing RFA performed at < 16 vs ≥ 16 weeks, there was no difference in the rate of cotwin loss (23.1% vs 29.7%; P = 0.558) or preterm prelabor rupture of the membranes before 34 weeks (7.7% vs 5.4%; P = 0.853), or in the median gestational age at delivery (36.2 vs 37.3 weeks; P = 0.706). Conclusions RFA is a promising tool for early selective fetal reduction in MC pregnancy before 16 weeks. Four or more ablation cycles is a major risk factor for cotwin loss. Careful assessment pre‐ and post‐RFA, together with proficient operative skills to minimize the number of ablation cycles, are the mainstay to ensure that this procedure is effective and safe. © 2020 International Society of Ultrasound in Obstetrics and Gynecology
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