Journal of Neonatology

Vol. 22, No.3, July - September 2008

REVIEW ARTICLE

Antenatal ultrasound its utility and limitations

Ashok Khurana
Consultant in Reproductive Ultrasound, The Ultrasound Lab, C-584, Defence Colony, New Delhi

ashokkhurana@ashokkhurana.com

Abstract
Each year in India, roughly 30 million women experience pregnancy and 27 million have a live birth. Of these, over 100,000 women and one million children die within 4 weeks of birth annually. A significantly larger number of neonates suffer morbidities consequent to abnormal antenatal events. Proper antenatal care goes a long way in ensuring the obvious goal of pregnancy: a healthy mother and a healthy baby. Ultrasound now occupies a niche role in reducing morbidity and mortality, both for the mother and the neonate, because of its role in diagnosing leading causes of maternal, neonatal and infant morbidity and mortality. These include maternal hemorrhage, toxaemia, malpositions, birth defects, low birth weight, situations that predispose to birth asphyxia and events that lead to prematurity. Access to primary, secondary and tertiary care reduces morbidity and mortality in all socioeconomic population groups. This review assesses the role of antenatal ultrasound in reducing morbidity and mortality in the neonate and infant.

of gestation. In India the outer limit is restricted to 20 weeks because of the medical termination of pregnancy (MTP) act. Scans between 18-20 weeks may be limited by patient habitus, which includes abdominal adiposity and hirsutism, and re-evaluation at 22-24 weeks should be done in these cases.

Accuracy of prenatal ultrasound

The RADIUS study1,2 has been the largest randomized clinical trial of routine ultrasound screening during pregnancy. The study involving 15,530 women in the United States concluded that there was no improvement in perinatal outcome from routine ultrasound screening. The study did not consider operator expertise and equipment quality as variables in the final analysis. The detection rate of anomalies was extremely low and does not represent the current diagnostic capabilities of ultrasound. The EUROFETUS3,4 study on the other hand showed a 50.9% overall sensitivity compared to 16.6% in the RADIUS study. Detection rates were significantly higher for tertiary care centres when compared to community hospitals and office-based facilities. Inaccuracy is intrinsic to the diagnostic process in medicine and cannot be eradicated. It is imperative to inform the patients of what to expect from an anomalies scan. Since the ability to detect anomalies is directly dependent on operator skill and equipment resolution, an appropriate referral pattern needs to be evolved. Current sensitivity rates, that is, the ability to detect an anomaly when it is actually present, vary widely from 16 to 84% in various series. Lower rates are reported from multi-centric trials and laboratories with low expertise. Studies involving high-risk groups such as those with significant past and family histories or teratogen exposure have reported a much higher detection rate. With appropriate operator expertise and good equipment, detection rates of major anomalies average at about 90%. About 75% of those requiring neonatal intensive care and corrective surgery can be identified and about a third of minor anomalies can be seen.

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Ultrasound evaluation of birth defects

Congenital anomalies occur in about 1 out of every 33 pregnancies and result in spontaneous abortion, fetal demise, perinatal morbidity and mortality and post-natal mental and physical disabilities. These abnormalities encompass genetic disorders, chromosomal anomalies and dysmorphic developmental anomalies, in isolation or in combination. The detection of these abnormalities is a major goal of prenatal care. Unfortunately, this requires a vast degree of knowledge in a variety of disciplines including anatomy, embryology, genetics, obstetrics, imaging and pediatric surgery. Fortunately, remarkable technological progress in the equipment resolution of ultrasound scanners and rapidly increasing sonographer expertise has resulted in an increased detection of significant anomalies in the past decade. A detailed sonographic evaluation of the fetus, and followup invasive diagnostic procedures, are now crucial to obstetric management and outcome, and, in the long term, to patient counseling. Whereas anomalies can be detected as early as 9 weeks of gestation, accuracy estimates dictate that the anomalies scan is best performed between 18-22 weeks

Increased accuracy by identifying high risk groups

Causative factors for anomalies are usually grouped

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into four categories: single gene disorders, chromosome abnormalities, environmental factors and multi-factorial. Environmental factors include radiation and drug exposure, malnutrition, diabetes mellitus and intrauterine infections. All patients in these groups should be referred for an anomalies scan and possible consideration for invasive procedures such as chorionic villus sampling (CVS), amniocentesis or cordocentesis. It must be remembered that many genetic disorders do not have a dysmorphic marker and need a first trimester diagnosis. Most chromosomal disorders have various conglomerates of dysmorphic stigmata which when seen should warrant an invasive fetal testing. Clinical high risk markers include advanced maternal age, previous history of a malformed fetus/infant, family history of a malformed fetus/ infant, consanguinity, exposure to drugs or radiation, maternal diabetes mellitus, a bad obstetric history with unexplained abortions/ intra uterine fetal deaths/neonatal deaths and a history of bleeding per vaginum in early pregnancy or a history of uterine instrumentation in early pregnancy. During the course of a sonographic examination the following findings should prompt a thorough search for congenital anomalies: symmetric intra-uterine growth retardation, polyhydramnios, oligohydramnios, twins, breech presentation, one identified anomaly, abnormal results from a CVS/ triple test and an abnormal immunoglobulin profile.

connections, their functional significance and progression. 3D and 4D studies have revolutionized the antenatal ultrasound diagnosis of facial anomalies, anomalies of the musculoskeletal system, cardiac anomalies, pulmonary hypoplasia, thoracic mass lesions, progression of abdominal masses, and cranial anomalies.4-20

Prediction of normalcy
Accurate prediction of fetal normalcy after prenatal, biochemical, chromosomal and sonographic screening is over 99%. However, true identification of the abnormal fetus is lower at 76-98% even in expert hands. This must be borne in mind when patients are advised to submit to prenatal diagnostic protocols. Even though the yield in low risk populations is very low, every patient, in spite of resource limitations, should be informed of the options available. All biochemical parameters must be evaluated in the perspective of an ultrasound gestational age.

Second trimester screening for downs syndrome and other trisomies

The Genetic sonogram is an ultrasound examination done on second trimester fetuses that not only evaluates the fetus for structural malformations, but also searches for the sonographic markers of fetal Downs syndrome8. Most workers have extended the definition to the second trimester fetal anatomic survey targeted at identifying features associated with any aneuploidy.9-12 It has evolved as an adjunctive screening tool capable of further refining the individualized risk-calculation for trisomy that is based on maternal age or serum screening markers.13 The common aneuploidies include Trisomy 21 (Down syndrome), 13 (Patau syndrome) and 18 (Edward Syndrome), Turner Syndrome (XO) and Triploidy. Other trisomies are rarer and are encountered most frequently in abortus karyotypes. Trisomy 21 is associated with potential long-term morbidity and has an estimated prevalence of 1.21 per 1000 live births.14 Trisomy 13 and 18 usually abort spontaneously or result in intra-uterine demise and if born alive, rarely survive beyond the neonatal period. The greatest emphasis in the genetic sonogram, therefore, is to screen the population and then follow-up with an appropriate definitive diagnostic procedure for Down syndrome. Screening procedures refer to tests that define an atrisk population and diagnostic tests refer to an actual demonstration of fetal karyotype. Screening tests for aneuploidies include maternal age, serum markers and ultrasound markers. The chromosomes themselves can be demonstrated by karyotyping of cells from amniotic fluid, chorionic villi or fetal cord blood or by identifying an abnormal karyotype by fluorescent in situ hybridisation (FISH) or quantitative polymerase chain reaction (Qf-PCR) studies.

Prenatal ultrasound diagnosis and the embryologic time-table

It must be remembered that knowledge of fetal anatomy and its change over the antenatal period is imperative in diagnosing malformations. The bowel returns to the fetal abdominal cavity at 10-12 weeks. Therefore, a first trimester diagnosis of an omphalocele before the tenth week is not possible except for very large defects. Similarly, in infantile polycystic kidney disease, the kidneys and urinary bladder may appear completely normal upto the 24th week of gestation. Another example, is the relative absence of cerebral sulcation upto the mid-trimester. A diagnosis of agyria is unjustified until after 20-24 weeks of gestation.

New technology
Several anomalies are beyond the reach of standard Real-time 2D gray scale equipment and require color Doppler, 3D (Three Dimensional) and 4D (Real Time Three Dimensional) technology. These conditions include single umbilical artery, absent renal arteries, anomalous pulmonary venous connections, pulmonary sequestration, vein of Galen aneurysms, hemangiomas and endotheliomas of the liver, sacrococcygeal teratomas, agenesis of the corpus callosum and of course the delineation of abnormal cardiac configuration,

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Although, the incidence of Down syndrome increases with increasing maternal age particularly beyond 35 years, 80% of Down syndrome babies are born to women younger than 35 years1. The prevalence of trisomy 21 decreases with increasing gestational age16. In recent years, improved resolution of ultrasound and its consequent ability to demonstrate abnormal morphology, have placed the sonographic examination in a more sensitive and specific position than maternal age and maternal serum screening. This is very significant in the perspective of the observation that amniocentesis for prenatal detection of chromosomal aneuploidy, a diagnostic tool offered at one time arbitrarily to all pregnant women aged 35 years or over, has in recent years lost favor as a first-line investigation.13 This shift in practice stems from a recognition that selection of candidates for amniocentesis on the basis of maternal age alone is an ineffective screening method for aneuploidy.18 Furthermore, the well-established iatrogenic fetal loss rate associated with amniocentesis, although low (<1%), is increasingly being regarded by patients as unacceptable, particularly when the vast majority of apparently at-risk pregnancies are chromosomally normal.13

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Sonographic markers for downs syndrome (Trisomy 21)

Major anomalies are seen in about one third of affected fetuses and include heart defects particularly ventricular septal defects and atrio-ventricular septal defects, ventriculomegaly, cystic hygromas, omphalocele and hydrops.21-26 Major markers include a thickened nuchal skin fold, short femur, short humerus, echogenic intra-cardiac focus, echogenic bowel and renal pyelectasis.27-32 Minor markers include flat iliac wings, brachycephaly and frontal lobe shortening, clinodactyly, sandal gap, great toe deformity, short ear length, cerebellar hypoplasia and a single palmar crease.33-34

bowel echogenecity consequent to ingested heme pigments. The echogenic intracardiac focus (EIF) refers to calcified papillary muscle that is seen as a bright dot on ultrasound. This is usually in the left ventricle but occasionally in the right ventricle or both ventricles. It should be as bright as bone. Sixteen percent of fetuses with trisomy 21 and 39% of fetuses with trisomy 13 demonstrate this feature.23,31,32 The risk for trisomy is higher if the echogenic focus is in the right ventricle or both ventricles. The prevalence of this marker in normal fetuses is as high as 30% in normal fetuses of Asian ethnic origin.33 As an isolated marker, therefore, it does not warrant further investigation. An EIF is not associated with cardiac anomalies in low-risk patients 22. Pyelectasis refers to an increase in the anteroposterior diameter of the renal pelvis beyond 4 mm at 15-20 weeks of gestation. 20-25% of fetuses with Down syndrome demonstrate this feature.34,35 In isolation, this marker is not an indicator for amniocentesis. It should be used in conjunction with other markers. Short humerus and short femur are defined as an observed-to-expected length of <0.9. 31,36 These have been identified as markers for trisomy 21 and are useful when combined with other markers.37 Both these markers are limited by the requirement of data specific to the population being studied and by ethnic diversity. Femur/ foot length ratio, although useful in assessing skeletal dysplasias are not useful in assessing for Down syndrome.37 A short humerus is more sensitive as a marker than a short femur.38

Minor markers
A widened iliac angle has been observed in children with Down syndrome and this has been extended to assessing the iliac angle in the fetuses. 39,40 The mean iliac angle is 8019.7 degrees in fetuses with trisomy 21 and 63.120.3 degrees in normal fetuses. The technique of measurement is cumbersome and limits routine use of this marker. Clinodactyly refers to hypoplasia of the middle phalanx of the fifth digit and is a morphological feature of children with trisomy 21 and can be seen in the fetus as well.3 Although initially regarded with skepticism, this marker has performed well and shows a sensitivity of 17.1% and a false positive rate of 3%. 41 A wide space between the first and second toes is seen more frequently in trisomy 21 fetuses and is called a sandal gap toe deformity. The reliability in various studies is variable. 42-44 Nasal bone hypoplasia is a highly sensitive and specific marker for trisomy 21. It is a feature of 62% of trisomy 21 fetuses and approximately 1% of chromosomally normal fetuses.45 The nasal bone was initially considered to be hypoplastic if it was either absent or strikingly small (less than 2.5 mm). Later data has described the nasal bone length increasing with gestation from a mean of

Major markers
A thickened nuchal skin fold was the first major marker identified for trisomy 21.24 This remains the most useful marker to date. This is measured in an axial plane through the posterior cranial fossa and calipers are placed corresponding to the outer surface of the occipital bone and the outer surface of the skin. A thickness of more than 5 mm is significant before 18 weeks of gestational age and a thickness exceeding 6 mm beyond 18 weeks.2527

Although echogenic bowel is often a normal variant in the second trimester, one in eight fetuses with Down syndrome show this feature.28-30 Bowel may also be echogenic in fetuses with cystic fibrosis, mesenteric ischemia and cytomegalovirus infections. Fetuses that swallow blood from a placental bleed also show increased

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4.7 mm at 15 weeks to 8.2 mm at 22 weeks and such normative data is likely to be more specific in assessing this marker.46-47 Brachycephaly in fetuses with trisomy 21 reflects a frontal lobe shortening and has been assessed in several studies.21,48,49

Sensitivity of marker detection

There is a wide variation in the detection rates of sonographic markers of trisomy 21.50-51 Strict standardization of definitions, operator experience and dedication can largely overcome this.52 Other variables that influence detection rates include gestational age and maternal body habitus. The detection rate rises from 1 in 8 at 15 weeks of gestation to greater than 60% after 18 weeks.53 Serial reviews are therefore to be considered if the maternal abdomen is fat and hirsute and if the genetic sonogram is performed prior to 18 weeks of gestation. Pelviectasis is more frequently picked up in male fetuses.
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plexus cysts. The authors demonstrated that, where amniocentesis was reserved for fetuses scoring 2, 73% of fetuses with trisomy 21 and 85% of fetuses with trisomy 18 could be identified with a false positive rate of 4%. Using likelihood ratios, two approaches have been proposed by Nyberg and Nicolaides to calculate a revised risk.13 The Nyberg method involves multiplication of the a prior risk by the likelihood ratio (LR) associated with any identified marker or markers. The latter calculation, proposed by Nicolaides, further takes into account the negative likelihood ratios associated with absent markers.

Trisomy 18 (Edwards syndrome)

Ninety percent of fetuses with trisomy 18 have an abnormal early second trimester morphology and upto 100% have an abnormal third trimester morphology. Common stigmata include choroid plexus cysts, ventriculomegaly, strawberry shaped skull, a large cisterna magna, agenesis of the corpus callosum, meningomyeloceles, microphthalmos, hypertelorism, low set ears, cystic hygromas, thickened nuchal skin fold, cardiac defects, diaphragmatic hernia, renal anomalies, omphalocele, short radial ray, clenched hand with overlapping fingers, rocker bottom foot, club foot, polyhydramnios, fetal growth restriction and a single umbilical artery, umbilical cord cysts and absent end diastolic umbilical artery flow velocity waveforms. Ultrasound is often used to detect trisomy 18 when the triple screen shows a low alpha-fetoprotein, low betahCG and low free estriol. In addition, when choroid plexus cysts are present, the search for other stigmata should be intensified. Isolated choroid plexus cysts do not warrant an amniocentesis for karyotyping.

Significance of individual markers

The accuracy of the genetic sonogram and the significance of each marker has been evaluated in several studies.9,10,21,30,41,42,49,54-60 All studies refer to the presence of major structural anomaly, major and minor soft markers or both. Identification of at least one marker conferred an overall sensitivity of 72-77% with a false positive rate of about 13%. Significantly, about half of all fetuses had a nuchal fold thickness of 5 mm or more rendering this the most sensitive individual marker. The risk of trisomy 21 increases with the number of markers detected.30,44,54 The greatest challenge in risk assignment is where a marker is identified in isolation. If isolated soft markers are used as a basis for deciding to offer invasive testing, the resultant fetal loss rate would exceed the number of cases of trisomy 21 detected and indeed, that detection rates would fall. This assertion has been challenged by others, who argue that while this may confirm the poor contribution that isolated soft markers make to risk assignment for aneuploidy, the performance of combined markers has been well validated in screening paradigms.35 The unacceptably high false-positive rate associated with identification of isolated soft-markers in low-risk women presents a challenge. For this several scoring systems have been devised which correlate maternal age, serum biochemistry and sonographic markers. A simple sonographic scoring index for the detection of chromosomal aneuploidy was devised by Benacerraf et al. 32,54 Major structural anomalies and a thickened nuchal fold were each given a score of 2, as these are sufficiently strong even when detected in isolation. Soft markers were each allocated a score of 1. The panel of soft markers included short femur, short humerus, pyelectasis, EICF, echogenic bowel, and choroid

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Trisomy 13 (Pataus syndrome)

Morphologic abnormalities are evident from 10 weeks onwards and the sensitivity is 90-100%. It is very unusual for an affected fetus not to have a morphological stigma. Features include holoprosencephaly, agenesis of the corpus callosum, ventriculomegaly, enlarged cisterna magna, microcephaly, microphthalmia, hypotelorism, cyclopia, proboscis, cleft lip and palate, midline facial hypoplasia, nuchal thickening, cystic hygroma, cardiac defects, neural tube defects, echogenic enlarged kidneys, echogenic bowel, echogenic intracardiac focus, omphalocele, cystic kidneys, radial ray aplasia, polydactyly and a single umbilical artery.

First trimester screening for aneuploidies

First trimester genetic screening is now widely available and involves assessing maternal serum biochemistry and sonographic markers in order to identify patients who should undergo invasive testing. This is

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carried out between 11 and 13 weeks 6 days of pregnancy and has the advantage of an easier and safer termination of pregnancy and less parental psychological trauma. There has been a global shift to first trimester screening in recent years. The combination of maternal serum PAPPA and free hCG along with fetal crown-rump length to assess fetal size and a group of ultrasound markers allows detection of 88-90% of fetuses with Down syndrome. The ultrasound markers include nuchal translucency thickness, nasal bone delineation, fetal ductus venosus studies and fetal tricuspid regurgitation. In this group of patients sequential screening with a second trimester genetic sonogram enhances the detection rate for Down syndrome to 94-96%.

Identification and quantification of fetal growth restriction (FGR)

The assessment of gestational age is central to the evaluation of growth restriction. Experience and published work has shown that an accurate menstrual history can be off the mark by 2.5 weeks and that fundal height and abdominal girth measurements can miss the mark by 4 weeks. Crown-rump measurements between 6 to 12 weeks are by far the most accurate predictor and are specific to as high as +/- 3 days. This equals the accuracy of assessments from ovulation studies and embryo transfer calculations. Mean gestational sac diameter, which is measured before the embryo is visualized, has an accuracy of +/- 1 week. Early second trimester ultrasound scans show a +/- 1 week variation. Later scans are off the mark by +/- 3 weeks. The ultrasound estimate is, therefore, inversely related to fetal age. The optimal method varies with gestational age, and in later pregnancy accuracy increases with increase in the number of variables. In late gestation, serial measurements enhance accuracy. The parameters and indices to be ideally used in the second and third trimester include the biparietal diameter, head perimeter, occipitofrontal distance, cephalic index, abdominal perimeter, femur length, cerebellar transverse diameter, the head perimeter to abdominal perimeter ratio and the diameter of the distal femoral epiphysis. In late gestation, serial measurements enhance accuracy. By convention, and in order to comprehend the growth restriction in perspective, parameters are plotted on growth curves. These curves demonstrate norms for a parameter plotted against gestational age and indicate mean and percentile values. Postnatal definitions of FGR include a birth weight less than 2 standard deviations below the mean for gestational age, a birth weight less than the 10th percentile on standard charts, a birth weight at term less than 2.5 kilograms and a Ponderal index of less than 2.0 to 2.32. On ultrasound these translate to an abdominal perimeter less than the 10 th percentile on standard growth charts, no increase in abdominal perimeter and/or head perimeter on two scans two weeks

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apart or a head perimeter to abdominal perimeter ratio greater than two standard deviations. Fetuses in the 3rd to 10th percentile group have a ten times greater perinatal morbidity and fetuses that are below the 3rd percentile have a twenty times greater perinatal morbidity. It is important to classify growth restriction as asymmetric or symmetric. Asymmetric IUGR is restricted to the abdominal perimeter and often bone lengths, has a usual onset in the third trimester, is usually consequent to placental insufficiency or maternal malnutrition and has a generally better prognosis. Symmetric growth restriction is often consequent to chromosomal disorders, malformations or intra-uterine infections, involves all fetal parameters to a variable degree, is usually early in onset and frequently has a poor prognosis. It is pertinent to emphasize that asymmetric FGR can progress to a symmetric slowing of fetal growth. Early onset placental insufficiency often manifests as symmetric FGR. The causes of growth restriction that can be identified on an ultrasound scan include fetal causes such as chromosomal and structural anomalies and multifetal pregnancy, and, placental causes such as some abnormal invasions, chronic abruption, velamentous cord insertion, circumvallate placenta and placental chorioangiomas.

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Amniotic fluid assessment

In the late second trimester and in the third trimester amniotic fluid volume is largely consequential to fetal urinary production. The compromised fetus produces less urine and oligoamnios is, therefore, a reliable index of fetal compromise. Whereas earlier methods used a maximum vertical pocket depth as an index for amniotic fluid volume assessment, current practice relies reliably on the amniotic fluid index. This index is a sum of the maximum vertical depth of the deepest pocket free of fetal parts and cord in each of four uterine quadrants. Normal range charts and curves now exist which show the mean and percentile for gestational period. As a rule of thumb an index of 80-120 mm represents mild oligohydramnios, 50-80 mm is moderate oligohydramnios and less than 50 mm is a severe/critical oligohydramnios. Delineating the cord with color flow in each quadrant enhances accuracy.

Performance characteristics of biometric parameters and oligohydamnios

The negative predictive value of normal biometry and a normal amniotic fluid index is high for the absence of growth restriction. The specificity of various parameters for growth restriction is low for most variables except a decreased amniotic fluid index, a decreased abdominal perimeter and an elevated head perimeter/abdominal perimeter ratio. It is wise, therefore, to base a firm diagnosis of growth restriction only on the latter.

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Uterine artery flow velocity waveforms

Color flow mapping and pulsed wave Doppler evaluation of the uterine arteries is now an accepted, reliable method of evaluating the low-risk mother for prediction of severe pre-ecclampsia prior to 34 weeks of pregnancy and instituting maternal therapy with low dose aspirin or heparin analogues to improve pregnancy outcomes. Additionally, it can also predict other hypertensive disorders in pregnancy, abnormal placental function, low birth weight, incidence of operative deliveries for fetal distress in labor, and, the need for intensive neonatal care. Indices used to predict adverse outcome should be deployed based on gestational age charts. The variables include abnormal flow indices, a notch in early diastole in the waveform, systolic notch and a large difference of the right and left sides of the uterine circulation.

hypoxic fetus initially show increased end diastolic velocities. In the deteriorating fetus, this progresses to an inability for compensation that is shown by a reduced flow representing fetal brain edema. An isolated assessment of this vessel is unable to predict or identify this occurrence. The ductus venosus systolic/atrial ratio of 4.5 is the value below which the high-risk fetus is unlikely to be compromised.37,71-73 Resorting to such an analysis can greatly improve perinatal outcomes by postponing obstetric intervention in non-critically ill hypoxic fetuses. It is, therefore, also useful in assessing which pregnancies would benefit from transfer to tertiary centres prior to delivery. Abnormal flow observed in the fetal descending aorta, fetal renal arteries and fetal mesenteric arteries coincides with neonatal observations of asymmetric growth restriction, oliguria and necrotizing enterocolitis.

Evaluation of hemorrhage Fetal hypoxia acidosis

In the fetus deprived of energy substrate, oxygen supply, or both, there is a shift of metabolism to the anaerobic lactate pathway. Hypoxemia, hypoxia, acidemia and acidosis are the common end-points, irrespective of cause. Surviving intrauterine growth-restricted fetuses show a significant relationship between neurodevelopmental scores and the presence of acidemia at cordocentesis.61,62 Whereas conventional ultrasound is able to identify abnormal fetal growth, quantify liquor amnii and assess fetal biophysical parameters, it fails to identify where in the hypoxia cascade the fetus lies and, therefore, what is the ideal time for obstetric intervention. Doppler ultrasound studies of the fetal circulation in intra-uterine growth restriction and other hypoxic states have shown increased resistance to flow in the umbilical arteries and redistribution of fetal cardiac output to favor the cranial circulation and the myocardium and to restrict or deprive the flow to abdominal viscera and extremities.63-67 In conjunction with ultrasound evaluation of fetal size and maturity, quantification of liquor amnii and assessment of the fetal biophysical profile, abnormal Doppler velocimetry is now used extensively to identify the fetus at risk for death or hypoxic damage in utero.6467 The need for reliably identifying or quantifying a clear cut-off level in these parameters is especially relevant in the premature small-for-gestation age fetus where neonatal course can be drastically different for an asphyxiated mature fetus compared to a mildly premature non-asphyxiated fetus. The duration of the time interval from the onset of absent end-diastolic flow in the umbilical artery to abnormal fetal heart rate pattern can vary from 0-7 weeks. 68-70 This can incorrectly influence obstetric decision-making based on this Doppler parameter alone. Middle cerebral artery flow velocity waveforms in the
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Placental location and retroplacental clots can be accurately identified with ultrasound in 97% and 90% of clinical situations. This permits the clinician to make informed decisions with reference to urgent operational delivery.

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Prediction of premature labor

Cervical length assessed in the anomalies scan at 1822 weeks can serve as a predictor of premature labor. Critical measurements have varied in several studies, but recent analyses show a high incidence of preterm labor when the length of the pregnant cervix, assessed by a transvaginal scan, is less than 15 mm. Appropriate institution of parenteral progesterone can postpone the onset of premature labor.

Rhesus isoimmunisation and ultrasound

Color Doppler evaluation of the middle cerebral artery (MCA) flow velocity waveforms has replaced invasive fetal testing for fetal anemia and hyperbilirubinemia in recent years. This is based on the logic that the anemic fetus will display an increased peak systolic velocity (PSV) in its MCA circulation. The relationship between fetal hematocrit and the MCA -PSV is now reliably established. A baseline evaluation is done during the anomalies scan at 18-20 weeks and serial evaluations are carried out based on previous medical history and the indirect Coombs test. An ideal time for serial evaluation is two weeks prior to the abnormal event in previous pregnancies.

Safety of ultrasound
The Bioeffects Committee of the American Institute of Ultrasound in Medicine has repeatedly determined that

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current data indicate that there are no confirmed biologic effects on patients and their fetuses from the use of diagnostic ultrasound evaluation and that the benefits to patients exposed to the prudent use of this modality outweigh the risks if any. It is wise, however, as for any medical test, to perform the examination only when clearly indicated. The operator performing the examination should exercise due care to use appropriate energies and keep a track of the duration of the study in order to comply with the ALARA principle. This principle simply states that the use of technologies should be optimized to obtain quality images with frequencies, power and duration As Low As Reasonably Achievable (ALARA).

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Conclusion
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Emerging from the murky waters of the First World War and progressing through the stage of metal flaw detection, ultrasound technology has revolutionized the way Obstetrics is practiced today. Knowledge of its utility and a multispecialty approach, are however, imperative to improve neonatal outcomes.

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