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 of gestation. In India the outer limit is restricted to 20

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weeks because of the medical termination of pregnancy

Each year in India, roughly 30 million women (MTP) act. Scans between 18-20 weeks may be limited
experience pregnancy and 27 million have a live birth. by patient habitus, which includes abdominal adiposity
Of these, over 100,000 women and one million children and hirsutism, and re-evaluation at 22-24 weeks should
die within 4 weeks of birth annually. A significantly larger be done in these cases.
number of neonates suffer morbidities consequent to
abnormal antenatal events. Proper antenatal care goes
Accuracy of prenatal ultrasound
a long way in ensuring the obvious goal of pregnancy: a
healthy mother and a healthy baby. Ultrasound now
The RADIUS study1,2 has been the largest randomized
occupies a niche role in reducing morbidity and mortality,
clinical trial of routine ultrasound screening during
both for the mother and the neonate, because of its role
pregnancy. The study involving 15,530 women in the
in diagnosing leading causes of maternal, neonatal and
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United States concluded that there was no improvement

infant morbidity and mortality. These include maternal
in perinatal outcome from routine ultrasound screening.
hemorrhage, toxaemia, malpositions, birth defects, low
The study did not consider operator expertise and
birth weight, situations that predispose to birth asphyxia
equipment quality as variables in the final analysis. The
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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.
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 follow-
up 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
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.
Increased accuracy by identifying high risk
groups
Causative factors for anomalies are usually grouped

145
 Journal of Neonatology
into four categories: single gene disorders, chromosome
abnormalities, environmental factors and multi-factorial.
Environmental factors include radiation and drug
exposure, malnutrition, diabetes mellitus and intra-
uterine 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
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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
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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
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immunoglobulin profile.
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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Vol. 22, No.3, July - September 2008
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 down’s
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 at-
risk 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.
 Journal of Neonatology
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
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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
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normal.13
Sonographic markers for down’s syndrome
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(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
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.25-
27
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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Vol. 22, No.3, July - September 2008
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 80±19.7 degrees in fetuses with trisomy 21 and
63.1±20.3 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
 Journal of Neonatology
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 standar-
dization of definitions, operator experience and
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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.
Significance of individual markers
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The accuracy of the genetic sonogram and the
significance of each marker has been evaluated in several
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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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Vol. 22, No.3, July - September 2008
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 beta-
hCG 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.
Trisomy 13 (Patau’s 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
 Journal of Neonatology
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 PAPP-
A 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
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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
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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
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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, occipito-
frontal 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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Vol. 22, No.3, July - September 2008
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.
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.
 Journal of Neonatology
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
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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.
Fetal hypoxia acidosis
In the fetus deprived of energy substrate, oxygen
supply, or both, there is a shift of metabolism to the
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anaerobic lactate pathway. Hypoxemia, hypoxia, acidemia
and acidosis are the common end-points, irrespective of
cause. Surviving intrauterine growth-restricted fetuses
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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.64-
67
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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Vol. 22, No.3, July - September 2008
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
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.
Prediction of premature labor
Cervical length assessed in the anomalies scan at 18-
22 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
Coomb’s 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
 Journal of Neonatology
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,
http:\\www.IndianJournals.com
power and duration As Low As Reasonably Achievable
(ALARA).
Conclusion
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
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to improve neonatal outcomes.
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