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Prevention and Management of Preterm Parturition

Preterm birth is the principal unsolved problem in perinatal medicine. The rate of preterm birth in the United States has been rising since 2015 to 10.23% in 2019. Advances in care have improved outcomes for preterm infants, but prematurity is still the most common underlying cause of perinatal and infant morbidity and mortality in developed nations. Consequences of preterm birth for surviving infants extend across the…

Multiple Gestation: Clinical Characteristics and Management

The incidence of twin deliveries has fluctuated in the United States over the past several decades with an increase in incidence through the late 20th century ( Table 37.1 ). This was followed by a brief period of stabilization and then a further increase to a peak incidence in 2014. In 1980, the twin birth rate was 18.9 per 1000 total births. In 2009, this rate…

Nonimmune Hydrops

Hydrops fetalis is the term used to describe generalized edema accompanied by collections of fluid in serous spaces in the fetus and neonate. Since first described almost 80 years ago, nonimmune hydrops (NIH) has become far more common than hydrops caused by severe erythroblastosis from red cell alloimmunization. In most centers, at least 75% of cases of hydrops are nonimmune, climbing to 95% if considering fetal…

Hemolytic Disease of the Fetus and Newborn

History Hippocrates recognized hydrops fetalis as long ago as 400 BC, according to Ballantyne, who accepted Hippocrates’ account as the first reported cases of the syndrome. The first clear-cut description of hydrops fetalis, however, did not occur until 1641 when Felix Plater, the famed Renaissance physician, reported a case. Three more centuries would pass before physicians would understand the etiology of hemolytic disease of the fetus…

Invasive Fetal Therapy

Acknowledgments We would like to acknowledge the hard work put forth from the previous edition authors in writing this chapter: Jan Deprest, MD, PhD; Ryan Hodges, PhD, MBBS; Eduardo Gratacos, MD, PhD; and Liesbeth Lewi, MD, PhD. The fetus is now more easily accessible due to technological advances, ultrasound resolution and increased experience by specialty providers performing in-utero surgical procedures. Consequently, several fetal conditions are now…

Intrapartum Fetal Surveillance

Acknowledgment The previous edition of this chapter included the contributions of Dr. Larry C. Gilstrap III. This chapter is built on his contributions and is still reflective of that work, for which the editors and author are greatly appreciative. Factors Controlling Fetal Heart Rate Fetal heart rate (FHR) analysis is the most common means of evaluating a fetus for adequate oxygenation. The rate and regulation of…

Assessment of Fetal Health

Assessment of fetal health is an important part of the management of any pregnancy, but it becomes more critical when maternal and fetal complications arise. Understanding the range of normal fetal behavior and considering the clinical context in which testing is performed are important parts of interpreting the results of fetal assessment. Given the wide variability in normal findings, even in the setting of abnormal test…

Teratogenesis and Environmental Exposure

A teratogenic exposure is defined as one that has the potential to permanently damage the normal structural or functional development of an embryo or fetus. A teratogenic exposure is determined not only by the agent (e.g., a particular chemical) but also by the dose, route, gestational timing, and other circumstances of exposure (e.g., the mother’s concomitant diseases or concurrent use of medication). Although teratogenic exposures are…

Prenatal Diagnosis of Congenital Disorders

The field of prenatal diagnosis, once dominated by amniocentesis and karyotype analysis for advanced maternal age, has changed significantly over the last decade with improved screening technologies reducing the use of diagnostic procedures. Much of this expansion has been associated with the development of molecular technologies fostered by knowledge of the human genome. A description of these technologies is presented in Chapter 2 . Although prenatal…

First-Trimester Imaging

Introduction The later part of the first trimester is an opportune time to assess the fetus for chromosomal aneuploidies and structural anomalies. One approach to screening is utilizing sonographic markers such as measurement of the nuchal translucency (NT) and appearance of the fetal nasal bone in combination with serum analytes to provide a pregnancy-specific risk of the common aneuploidies. An enlarged NT is associated with an…

Uterus and Adnexae Imaging

Adnexal Mass, Complex and Simple The majority of adnexal masses are detected incidentally during obstetric ultrasound examinations; however, some are diagnosed due to symptoms related to their size or complications. Definition An adnexal mass is a lump in the tissue of the adnexa of the uterus, usually in the ovary or fallopian tube. Adnexal masses can be benign or malignant. Incidence and Pathogenesis Adnexal masses are…

Placenta and Umbilical Cord Imaging

Marginal and Velamentous Umbilical Cord Insertion Definition The placental insertion of the umbilical cord (PCI) may occur centrally into the placental disk, eccentrically at the margin, or into the membranes beyond the margin of the placenta (so-called velamentous cord insertion, or VCI). Incidence and Pathogenesis The developmental dynamics that determine the directions of growth of the placental disk and the relative point of insertion of the…

Skeletal Imaging

Skeletal Dysplasia Definition Skeletal dysplasia (also known as osteochondrodysplasia ) is a genetically diverse group of >450 disorders , of the skeleton causing abnormal bone length, shape, and density, with varying degrees of disability. Incidence and Epidemiology Incidence of skeletal dysplasia is approximately 2.4–4.5:10,000 live births. The most common lethal skeletal dysplasia is thanatophoric dysplasia (35%), followed by osteogenesis imperfecta type II (25%) and achondrogenesis (7%);…

Fetal Urogenital Imaging

Pyelectasis Definition Pyelectasis (or pelviectasis) is a fluid collection causing dilation of the fetal renal pelvis, indicating a risk for persistent postnatal renal impairment and/or need for surgical intervention. Incidence/Epidemiology Renal pyelectasis is seen in 2%–5% of all pregnancies. Etiology/Pathogenesis Isolated renal pelviectasis is due to Ureteropelvic junction (UPJ) obstruction, secondary to incomplete canalization and/or maturation of the ureter(s) Vesicoureteral reflux (VUR), particularly in male fetuses…

Fetal Abdominal Imaging

Abdominal Ascites Definition Ascites is an abnormal fluid collection within the fetal peritoneal cavity and is often the first finding in hydrops fetalis. Ascites is present in 85% of cases of nonimmune hydrops fetalis. Isolated fetal ascites indicates there is fluid accumulation in the abdominal cavity without involvement of other body cavities or subcutaneous edema. Incidence and Epidemiology Hydrops fetalis occurs in approximately 1:1700–3000 pregnancies ;…

Fetal Cardiac Malformations and Arrhythmias: Detection, Diagnosis, Management, and Prognosis

Despite the widespread recognition of the importance of prenatal detection of congenital heart disease (CHD), screening for fetal heart disease remains one of the most challenging and, unfortunately, least successful aspects of fetal ultrasonography. The rate of prenatal detection of even severe forms of CHD, albeit continually improving, remains disappointingly low. Moreover, when a fetal heart defect or arrhythmia is confirmed, many professionals may not know…

Fetal Thoracic Imaging

Congenital Diaphragmatic Hernia Definition Congenital diaphragmatic hernia (CDH) refers to an embryologic defect in the diaphragm resulting in variable degrees of herniation of abdominal contents into the thoracic cavity. Incidence and Pathogenesis Incidence is 2.4:10,000 to 4.9:10,000. Most are sporadic. Incidence may be increasing, suggesting the effect of environmental/nutritional exposures. 75% left-sided, 15% right-sided, 10% bilateral; in fetal demises, 47% left-sided, 27% right-sided, 27% bilateral. Results…

Imaging of the Fetal Face and Neck

Cleft Lip and Palate Definition Cleft lip: failure of fusion of the left, right, or bilateral maxillary prominence with the medial nasal prominence. Concomitant cleft palate is present in 80% of cases. Least severe form involves the superficial vermilion border of the lip. Cleft palate: a result of incomplete fusion of the lateral palatal shelves, the nasal septum, and the primary palate. The cleft can be…

Fetal Central Nervous System Imaging

Cephalocele Definition Cephaloceles are cranial defects along bony sutures in which there is a herniation of the brain and/or meninges. Cephaloceles can be occipital, parietal, or frontal; in the Western Hemisphere, 80% are occipital. If the cephalocele sac contains brain tissue, it is termed an encephalocele ; if only cerebrospinal fluid (CSF) is present, it is termed a meningocele . Incidence and Pathogenesis Incidence ranges from…

Role of Magnetic Resonance Imaging in Obstetric Imaging

Magnetic resonance imaging (MRI) has an established role in evaluation of maternal conditions, placenta accreta spectrum, and fetal anomalies. Fetal malformations are addressed in other chapters; here we review the role of MRI, emphasizing appropriate utilization in order to maximize the impact on clinical management. Expertly performed ultrasound (US) is the imaging modality of choice for fetal evaluation. It is readily available and comparatively inexpensive, provides…