Ultrasound Obstet Gynecol 2011; 37: 369–372
Published online in Wiley Online Library (wileyonlinelibrary.com).
Letters to the Editor
Discordance of arterial and venous flow velocity
waveforms in severe placenta-based fetal growth
restriction
Balancing iatrogenic prematurity against stillbirth due to
terminal placental dysfunction poses a crucial dilemma
in the management of severe fetal growth restriction
(FGR). The role of multivessel Doppler assessment
in defining severity and progression is clear, but
gestational age at delivery remains the single most
important factor when FGR is severe and early onset1 .
Recently, Diemert and Hecher2 reported FGR cases
where venous Doppler indices may have called for
delivery, but pregnancy was extended because arterial
indices were not so abnormal. Is this discordance a
rare curiosity, or a significant caution to the Doppler-
based management of FGR? We were prompted by this
question to analyze our collaborative database of 604
FGR cases3,4 .
In any study of Doppler and FGR, methodology is key.
Our collaborative group included 12 academic perinatal
centers that enrolled patients with suspected placenta-
based FGR in local, prospective studies. When a review
suggested that all centers were using comparable entry
criteria, Doppler methods and outcome measures, a true
collaborative effort was conceived. We took several steps
to test the comparability of measurements within this
diverse international group:
• A manual of standard imaging and measurement
techniques was distributed.
• Collaborating centers demonstrated concordance with
these techniques, including submission of representative
images to the principal author (A.A.B.).
• Inter-center variation for Doppler parameters and
primary outcomes was analyzed to test relative
uniformity of participating centers.
• Further detailed analysis of group vs. individual per-
formance statistics and center-by-center contribution to
mortality and morbidity was completed to ensure that
results could be reliably grouped3 .
Table 1 Outcomes for fetuses with fetal growth restriction and arterial/venous (A/V) discordance stratified by umbilical artery end-diastolic
velocity (UA-EDV)
UA-EDV category n (%)
PEDV (n = 242) 15 (6.2)
A/REDV (n = 362) 39 (10.8)
*Morbidity defined as Grade III/IV intraventricular hemorrhage, bronchopulmonary dysplasia or necrotizing enterocolitis. †Fisher’s exact
test; all other P-values by chi-square test. A/REDV, absent or reversed end-diastolic velocity; PEDV, positive end-diastolic velocity.
Copyright  2011 ISUOG. Published by John Wiley & Sons, Ltd.
These steps ensured that our cases could be pooled
for subsequent assessment. Our first-hand knowledge
(A.A.B.) with Doppler techniques utilized at the University
of Hamburg Eppendorf demonstrates compatibility with
their population as well. In short, we believe the
following illustrate typical characteristics of a large
group of FGR pregnancies followed by serial Doppler
assessment.
We defined significant discordance between arterial and
venous (A/V) Doppler in two ways: Categorical definition:
for patients with positive end-diastolic velocity (PEDV)
in the umbilical artery (UA), absence or reversal of
the ductus venosus a-wave (DV-RAV) was considered
to be significantly A/V discordant (analogous to the
cases presented by Diemert and Hecher2 ). When UA
Doppler showed absent or reversed end-diastolic velocity
(A/REDV), we reasoned that there would be no clinical
difference between antegrade DV a-wave and DV-RAV, so
categorical definition did not apply; Numerical definition:
since the UA and DV pulsatility indices (PI) can be
calculated regardless of end-diastolic velocity, significant
discordance was also denoted if a Z-score difference > 2
was present when DV-PI Z-score was compared with
UA-PI Z-score.
Fifty-four of 604 fetuses (8.9%) had significant A/V
discordance of the Doppler parameters. Thirty-four of
these had major complications and 23 died during the
neonatal period (all, chi-square P < 0.0001 compared
with FGR fetuses with concordant A/V measures). Since
many experienced major morbidity and ultimately died,
cases may be recorded in both adverse outcome groups.
Intact survivors numbered 17, 4/15 (26.7%) in the
PEDV group and 13/39 (33.3%) in the A/REDV group.
Outcomes for fetuses stratified by UA end-diastolic
velocity are displayed in Table 1.
Within both subgroups, UA cord pH and the amniotic
fluid index were significantly lower in patients with
disproportionally worse DV Doppler parameters, while
gestational ages at delivery did not differ.
This secondary evaluation of UA and DV Doppler
parameters, prompted by the report by Diemert and
Hecher2 , illustrates several important points:
Mortality Morbidity*
8/15 (P < 0.0001)† 10/15 (P = 0.010)
15/39 (P = 0.048) 24/39 (P < 0.003)
LETTERS TO THE EDITOR
370
1. Discordance of DV and UA Doppler parameters is
observed in a smaller proportion of fetuses with
positive UA end-diastolic velocity compared to fetuses
with A/REDV. While disproportional worsening of
DV parameters in A/REDV fetuses is a well-described
response to worsening placental dysfunction this
observation is less well defined in patients with positive
UA end-diastolic velocity.
2. Irrespective of UA end-diastolic category, discordant
deterioration of the DV Doppler parameters is
associated with worse outcome in neonates with
preterm FGR. This appears to be related to fetal
deterioration rather than gestational age as illustrated
by the lower pH and amniotic fluid parameters.
3. A minority of patients with A/V discordance have
normal outcome, but these are important because if
timing of delivery is determined by DV parameters
alone, 30% of patients with PEDV and up to 50% of
patients with A/REDV may be delivered earlier than
necessary.
4. The TRUFFLE study4 may answer many questions
regarding the neurodevelopmental impacts of deliv-
ery triggers based on the DV and computerized
cardiotocography. However, the cases presented by
Diemert and Hecher2 and our analysis suggest that dis-
cordance of Doppler deterioration and outcome may
be a significant confounder – additional fetal variables
may be important.
5. The discriminatory role of amniotic fluid assessment
as one of the biophysical parameters suggests the merit
of further evaluation of integrated fetal testing in the
context of FGR management1 .
A. A. Baschat* and C. R. Harman
Department of Obstetrics, Gynecology and
Reproductive Sciences,
University of Maryland School of Medicine,
Baltimore, MD, USA
*Correspondence.
(e-mail: abaschat@umm.edu)
DOI: 10.1002/uog.8926
References
1. Turan S, Miller J, Baschat AA. Integrated testing and manage-
ment in fetal growth restriction. Semin Perinatol 2008; 32:
194–200.
2. Diemert A, Hecher K. Severely abnormal flow patterns in the
ductus venosus in the presence of otherwise normal fetal Doppler
parameters in two cases of severe intrauterine growth restriction.
Ultrasound Obstet Gynecol 2009; 34: 605–607.
3. Baschat AA, Cosmi E, Bilardo CM, Wolf H, Berg C, Rigano S,
Germer U, Moyano D, Turan S, Hartung J, Bhide A, Müller T,
Bower S, Nicolaides KH, Thilaganathan B, Gembruch U, Fer-
razzi E, Hecher K, Galan HL, Harman CR. Predictors of neona-
tal outcome in early-onset placental dysfunction. Obstet Gynecol
2007; 109: 253–261.
4. Lees C, Baumgartner H. The TRUFFLE study a collaborative
publicly funded project from concept to reality: how to negotiate
an ethical, administrative and funding obstacle course in
the European Union. Ultrasound Obstet Gynecol 2005; 25:
105–107.
Copyright  2011 ISUOG. Published by John Wiley & Sons, Ltd.
Letters to the Editor
Cerebral ventricle width measurements vary in
relation to gestational age, fetal gender and
cephalometry
Lateral cerebral ventricle width (VW) measurement at the
level of the atrium is performed as part of routine prenatal
ultrasound examination1 . Although this measurement
may vary across gestational age2 , a measurement above
10 mm is usually considered as abnormal3 . It is also
commonly thought that VW may vary according to fetal
size and gender2 , and large males are believed to be more
prone to have enlarged VW. We evaluated the relationship
of gestational age-adjusted VW with fetal gender and
size.
Over a study period of 4 years a single operator,
unaware of the subsequent analysis, prospectively and
routinely performed cerebral VW measurements at the
level of the atrium as recommended in the guidelines
of the International Society of Ultrasound in Obstetrics
and Gynecology (Figure 1)1 . Measurements were then
transformed into Z-scores based on previously published
charts2 . The relationships between VW-Z-scores, fetal
gender, fetal head circumference (HC) and estimated fetal
weight (EFW) were investigated by means of robust
regression. VW-Z-score was available in 4735 cases.
Mean VW-Z-score was −0.003 ± 1.000, confirming
appropriate modeling. As suspected, VW-Z score was
significantly different according to fetal gender, HC-
Z-score and EFW-Z-score. In multivariate analysis,
gender (β = 0.16, P < 10−4 ) and HC-Z-score (β = 0.17,
P < 10−4 ) remained significant predictors of VW-Z score.
Thus at 22 weeks’ gestation a male fetus would on average
have a VW 0.2 mm greater than that of a female fetus of
the same gestational age with the same HC. In addition a
fetus with a 97th centile HC would on average have a VW
0.75 mm greater than a fetus of the same gender with a
3rd centile HC.
Figure 1 Ventricle width is measured in an axial plane, at the level
of the frontal horns and cavum septi pellucidi, with the calipers
positioned at the level of the internal margin of the medial and
lateral wall of the atria, at the level of the glomus of the choroid
plexus, on an axis perpendicular to the long axis of the lateral
√
ventricle1 . Correct ( ) and incorrect (×) caliper placement is
shown.
Ultrasound Obstet Gynecol 2011; 37: 369–372.
Letters to the Editor 371

Our study confirms the belief that large-for-gestational-
age males have larger VW measurements, information that
is important for parental counseling and the management
of enlarged fetal ventricles.
L. J. Salomon†, G. E. Chalouhi†*, J. J. Stirnemann†,
J. P. Bernard‡ and Y. Ville†
†Department of Obstetrics and Fetal Medicine,
Necker-Enfants-Malades Medical School, Paris
Descartes University, Paris, France; ‡Centre Européen
de Diagnostic et d’Exploration de la Femme (CEDEF),
Le Chesnay, France
*Correspondence.
(e-mail: gihad.chalouhi@gmail.com)
DOI: 10.1002/uog.8889
References
1. International Society of Ultrasound in Obstetrics and Gynecology
Education Committee. Sonographic examination of the fetal
central nervous system: guidelines for performing the ‘basic
examination’ and the ‘fetal neurosonogram’. Ultrasound Obstet
Gynecol 2007; 29: 109–116.
2. Salomon LJ, Bernard JP, Ville Y. Reference ranges for fetal
ventricular width: a non-normal approach. Ultrasound Obstet
Gynecol 2007; 30: 61–66.
3. Melchiorre K, Bhide A, Gika AD, Pilu G, Papageorghiou AT.
Counseling in isolated mild fetal ventriculomegaly. Ultrasound
Obstet Gynecol 2009; 34: 212–224.
The brush tips of two plastic pap smear stick handles
were removed and the sticks inserted into a medium
sized pear (Figure 1a and b). Cherries were stuck onto
the sticks, with one on the right and two on the left
for easy orientation. Two liters of jelly solution were
prepared in a standard pathology specimen container
and the model uterus and ovaries was placed in it.
When the jelly had set, it was covered with a piece
of standard plastic food sheet to prevent direct probe
contact (Figure 1c). Care was taken to avoid air bubbles
between the plastic wrap and the jelly to prevent
artifacts.
In practice, the model was kept refrigerated and was
used only after usual work hours. The probes were
disinfected before and after use to prevent possible
contact with infective agents. The jelly content of
the model usually starts to dehydrate after 3–5 days
depending on use and climate, and it then has to be
discarded.

A model for basic ultrasound set-up and training

for 3D/4D ultrasound scanning

Three-dimensional (3D) ultrasound has been available

for more than 10 years and is being used increasingly
widely1 . Obtaining sonographic volumes allows for the
visualization of data in any plane and in any direction,
with enormous potential for medical ultrasound2,3 .
Figure 1 Photographs showing steps in the construction of the
Acquiring clear and accurate images in 3D and four- training model using a pear, cherries, pap smear sticks and jelly
dimensional (4D) ultrasound requires training and famil- (a–c). (d) Two-dimensional ultrasound image of the model.
iarization with the set-up and controls of the ultrasound
equipment and software. The ultrasound manufactur-
ers provide training and support for their products, but
usually only for a limited time after purchase. The organi-
zation of additional training programs for new operators
of ultrasound devices is expensive and needs to be fitted
into the busy daily schedule. This has led us to design an
efficient and cost-effective model for operators to practice
set-up and image acquisition using ultrasound machines.
We used the Siemens Antares Sonoline ultrasound system
(Siemens Medical Solutions, Erlangen, Germany) with a
C5F1 3D/4D 5.1-MHz transducer during our practice
with the model.
A commercial plant-based jelly (Dr Oetker Gida San.
ve Tic. A.Ş. Izmir, Turkey) was used for the medium and
fruits were used as imaging objects for their distinctive
shapes and fluid content: a pear was used to simulate Figure 2 Multiplanar display with three-dimensional rendered
the uterus and cherries were used to simulate ovaries. ultrasound image of the training model.

Copyright  2011 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 369–372.
372
Figure 3 Ultrasound images illustrating use of the training model to practice adjustment of opacity settings, showing a gradual increase in
opacity. Other parameters were kept constant.
Training with the model starts with abundant appli-
cation of ultrasound gel to minimize friction and to
maximize phase coupling. When the volume probe is
touched onto the gel, the uterus model can be clearly visu-
alized (Figure 2). When a 3D image of the model is seen
on the screen, the trainee can then practice the different
set-ups on the ultrasound equipment for better visualiza-
tion. When volume acquisition is complete, the trainee can
practice editing using the available software, for example
to eliminate unnecessary volumes or to view individual
slices of the acquired volumes. To illustrate the efficacy of
our model in training using surface rendering, increases
in opacity settings and the resulting visual changes to the
acquired image are shown in Figure 3.
With our model, familiarization with the following
skills is possible without time limitations:
1. Acquisition of the optimal ultrasound image of the
model in two dimensions.
2. Orientation of the X-, Y- and Z-planes in 3D and
4D imaging, rotation of the image in these planes and
adjustment of the size of the rendering box.
3. Use of 3D acquisition settings and the movement of
the probe for manual volume acquisitions.
4. Use of additional controls for 4D image acquisition,
for example the effects of smoothness and opacity.
Copyright  2011 ISUOG. Published by John Wiley & Sons, Ltd.
Letters to the Editor
5. Use of software for image processing.
Although it does not replicate the ultrasonographic
properties of the human body, as the acoustic properties
of jelly and the human body are different, we believe
that our model is a cost-effective and readily accessible
alternative to expensive commercial ultrasound training
models.
K. E. Karaşahin* , M. Ercan, I. Alanbay, U. Keskin,
M. Dede, M. C. Yenen and I. Başer
Gulhane Military Medical Academy, Ankara, Turkey
*Correspondence.
(e-mail: dremrekarasahin@hotmail.com)
DOI: 10.1002/uog.8887
References
1. Lee S, Pretorius DH, Asfoor S, Hull AD, Newton RP, Hollen-
bach K, Nelson TR. Prenatal three-dimensional ultrasound: per-
ception of sonographers, sonologists and undergraduate students.
Ultrasound Obstet Gynecol 2007; 30: 77–80.
2. Benacerraf BR, Shipp TD, Bromley B. How sonographic tomog-
raphy will change the face of obstetric sonography: a pilot study.
J Ultrasound Med 2005; 24: 371–378.
3. Goncalves LF, Lee W, Espinoza J, Romero R. Three- and 4-
dimensional ultrasound in obstetric practice: does it help?
J Ultrasound Med 2005; 24: 1599–1624.
Ultrasound Obstet Gynecol 2011; 37: 369–372.