Carrier screening is used to determine reproductive risk for autosomal recessive or X-linked conditions, and its clinical implementation varies widely. We evaluated recurring clinical patterns observed at an independent, university-affiliated, high-volume maternal-fetal medicine center in Los Angeles receiving referrals from diverse practice settings. In our view, carrier screening is far too frequently performed later than ideal, which narrows timelines for partner testing, prenatal diagnosis, and decision making and increases patient distress. Carrier screening practices differ by referring clinician, resulting in inequities in detecting genetic risk. Within a single couple, partners are often screened on discordant panels (and sometimes sequentially, maternal-first), which delays risk clarification and increases the chance of misinterpretation. Based on these observations, we believe prepregnancy carrier screening should be prioritized; otherwise, carrier screening should be performed as early as possible in pregnancy with concurrent partner testing. We also believe patients should receive counseling on the benefits and limitations of all available screening options to preserve patient autonomy.

This article is a report of a 2‐day workshop titled “Developing an Optimal Maternal‐Fetal Medicine Ultrasound Practice,” held during the Society for Maternal‐Fetal Medicine's 2023 Annual Pregnancy Meeting. Participants’ fields of expertise included obstetrics and gynecology, sonography, maternal‐fetal medicine, genetics, and genetic counseling. The American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Registry for Diagnostic Medical Sonography, International Society of Ultrasound in Obstetrics and Gynecology, Gottesfeld‐Hohler Memorial Foundation, and Perinatal Quality Foundation cosponsored the workshop. The workshop included presentations and small group discussions, and its goals were to accomplish the following: Review best practices and emerging technologies for designing and running an efficient obstetrical ultrasound unit Discuss strategies for quality assurance in the setting of obstetrical ultrasound at the individual provider and unit level Identify needs and opportunities for ongoing education and training in ultrasound imaging and ultrasound‐guided procedures for maternal‐fetal medicine fellows, physicians, and sonographers Review current and emerging approaches to managing the pregnant patient with obstetrical ultrasound abnormalities

This article is an invitation; it is the start of a conversation that can last far into the future, an invitation to learn how we as clinicians can best support parents who have experienced stillbirth. We discuss an inside look at stillbirth and its impact on the mental health and grief process of bereaved parents. In order to best support bereaved parents, we must understand the context created by historic and current research. This research can inform our understanding of where we have been, what we are currently doing, and our future direction. Lastly, this article will address the differences between grief and mental health and how our care must be tailored toward the specific needs of the bereaved. We have based this information on our clinical experience working with patients affected by stillbirth. Some of us have navigated stillbirth as parents or family members ourselves and appreciate that this life event presents unique challenges for both health care providers and patients. It is our sincere desire that the information here will help in providing compassionate and meaningful care to those who are living with the heartache of stillbirth and help instill comfort and hope for them.

Reproductive genetic carrier screening (RGCS) serves to screen couples for their risk of having children affected by monogenic conditions. The included conditions are mostly autosomal recessive or X-linked with infantile or early-childhood onset. Cystic fibrosis, spinal muscular atrophy, and hemoglobinopathies are now recommended by the American College of Obstetricians and Gynecologists (ACOG) for universal screening. Recommendations for further RGCS remain ethnicity based. The American College of Medical Genetics and Genomics and the National Society of Genetic Counselors in recent years have recommended universal expanded-panel RGCS and moving towards a more equitable approach. ACOG guidelines state that offering RGCS is an acceptable option, however it has not provided clear guidance on standard of care. Positive results on RGCS can significantly impact reproductive plans for couples, including pursuing in vitro fertilization with preimplantation genetic testing, prenatal genetic testing, specific fetal or neonatal treatment, or adoption. RGCS is a superior approach compared to ethnicity-based carrier screening and moves away from single race-based medical practice. We urge the obstetrics and gynecology societies to adopt the guidelines for RGCS put forward by multiple societies and help reduce systemic inequalities in medicine in our new genetic age. Having national societies such as ACOG and the Society for Maternal-Fetal Medicine officially recommend and endorse RGCS would bolster insurance coverage and financial support by employers for RGCS. The future of comprehensive reproductive care in the age of genomic medicine entails expanding access so patients and families can make the reproductive options that best fit their needs.

Objectives: Optimal management of placenta accreta spectrum (PAS) requires antenatal diagnosis. We sought to evaluate the sensitivity of ultrasound findings suggestive of PAS in detecting posterior PAS.Methods: Cohort study of patients with posterior placentation and pathology-confirmed PAS from 2011 to 2020 at a tertiary center. Patients were excluded if ultrasound images were unavailable. Ultrasounds were reviewed for presence of lacunae, hypervascularity, myometrial thinning, loss of the hypoechoic zone, bridging vessels, abnormal uterine serosa-bladder interface, placental bulge, placental extension into/beyond the myometrium, and an exophytic mass. Risk factors, postpartum outcomes, and ultrasound findings were compared by antepartum suspicion for PAS. Sensitivity was calculated for each ultrasound finding.Results: Thirty-three patients were included. PAS was not suspected antenatally in 70 % (23/33). Patients with unsuspected PAS were more likely to be non-Hispanic, have in vitro fertilization, no prior Cesarean deliveries, no placenta previa, and delivered later in gestation. Depth of invasion and estimated blood loss were less for unsuspected PAS, but there was no difference in hysterectomy between groups. Ultrasound findings were less frequently seen in those who were not suspected antenatally: lacunae 17.4 vs. 100 % (p<0.001), hypervascularity 8.7 vs. 80 % (p<0.001), myometrial thinning 4.4 vs. 70 % (p<0.001), and placental bridging vessels 0 vs. 60 % (p<0.001). There was poor sensitivity (0-42.4 %) for all findings.Conclusions: Posterior PAS is less likely to be detected antenatally due to a lower sensitivity of typical ultrasound findings in the setting of a posterior placenta. Further studies are needed to better identify reliable markers of posterior PAS.

Technologic advances and ultrasonographer–physician experience in fetal imaging have led to significant improvements in our ability to distinguish between normal and abnormal fetal structural development in the latter part of the first trimester. As a critical component of pregnancy care, assessment of fetal anatomy at the end of the first trimester with a standardized imaging protocol should be offered to all pregnant patients regardless of aneuploidy screening results because it has been demonstrated to identify approximately half of fetal structural malformations. Early identification of abnormalities allows focused genetic counseling, timely diagnostic testing, and subspecialist consultation. In addition, a normal ultrasound examination result offers some degree of reassurance to most patients. Use of cell-free DNA alone for aneuploidy screening while foregoing an accompanying early anatomic evaluation of the fetus will result in many anomalies that are typically detected in the first trimester not being identified until later in pregnancy, thus potentially diminishing the quality of obstetric care for pregnant individuals and possibly limiting their reproductive options, including pregnancy termination.

Nuchal translucency (NT) measurement in conjunction with serum analytes has been used for first-trimester aneuploidy screening in the United States since 2005. We sought to analyze the trends in reporting of NT measurements to the Nuchal Translucency Quality Review program in all pregnancies beginning after the clinical introduction of cell-free DNA (cfDNA) screening for fetal aneuploidy in 2011. Overall, reported NT measurements decreased 74.3% from 2012 to 2022. A similar decline was noted among individuals with pregnancies at increased risk for aneuploidy based on patient age and twin gestations. The decrease in reporting aligns temporally with the availability of cfDNA screening and the coronavirus disease 2019 (COVID-19) pandemic.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice, and high-quality teaching and research related to diagnostic imaging in women's healthcare. The ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice Guidelines and Consensus Statements as educational recommendations that provide healthcare practitioners with a consensus-based approach, from experts, for diagnostic imaging. They are intended to reflect what is considered by ISUOG to be the best practice at the time at which they are issued. Although ISUOG has made every effort to ensure that Guidelines are accurate when issued, neither the Society nor any of its employees or members accepts any liability for the consequences of any inaccurate or misleading data, opinions or statements issued by the CSC. The ISUOG CSC documents are not intended to establish a legal standard of care because interpretation of the evidence that underpins the Guidelines may be influenced by individual circumstances, local protocol and available resources. Approved Guidelines can be distributed freely with the permission of ISUOG ([email protected]). These guidelines are based on consensus reached between participants following a survey of current practices, conducted by ISUOG in 2014 (Appendix S1). Fetal magnetic resonance imaging (MRI) is an important diagnostic imaging adjunct to ultrasonography1, particularly for the assessment of fetal brain development2. A survey conducted by ISUOG in 2014 (Appendix S1), in which 60 international perinatal centers participated, showed that fetal MRI is being performed in one or more centers in at least 27 countries worldwide. However, the quality of imaging, sequences used and operator experience appear to differ widely between centers3. The impact of such differences should be reduced by development of guidelines to define better the role of fetal MRI in relation to prenatal diagnostic ultrasound. The aim of this document is to provide information on state-of-the-art fetal MRI for those performing the examination, as well as for clinicians interpreting the results. The purpose of fetal MRI is to complement an expert ultrasound examination4, 5, either by confirmation of the ultrasound findings or through the acquisition of additional information6. MRI is not currently used as a primary screening tool in prenatal care, although standardized and complete assessment of the fetal anatomy is probably feasible. Figure 1 presents the survey participants' opinions regarding indications for which MRI can provide useful information. MRI is not associated with known adverse fetal effects at any point in pregnancy, when performed without administration of contrast media7. There are no reported adverse effects of MRI performed at 1.5 Tesla (1.5 T)8. However, there have been no human studies of possible adverse effects at higher field strength, such as 3.0 T7, 9, 10, although recent data show that it may be safe in a porcine model11. There is general consensus that fetal MRI is indicated following an expert ultrasound examination in which the diagnostic information about an abnormality is incomplete. Under these circumstances, MRI may provide important information that may confirm or complement the ultrasound findings and alter or modify patient management. Presently, factors influencing the decision to perform fetal MRI include, but are not limited to: experience/equipment of the ultrasound and MRI facilities, accessibility to MRI, maternal conditions, gestational age, safety concerns, legal consideration regarding termination of pregnancy (TOP) and parental wishes after appropriate counseling3, 10, 12, 13. The ISUOG survey addressed the necessity of MRI for selected indications and used a 7-point rating scale to weight the responses from 0 (not at all indicated) to 7 (definitely indicated) (Figure 1). The variety of responses is likely to reflect the divergence seen between various specialties and the spectrum of pathologies seen at each center. The opinions may also reflect different levels of experience when performing fetal ultrasound and MRI. In general, performance of an ultrasound examination following only the minimum recommendations for second-trimester ultrasound/basic brain examination, as proposed by ISUOG5, is insufficient prior to requesting MRI. Additional views, such as orthogonal views, higher frequency probes and/or transvaginal imaging are required to detail the specific abnormality14, 15. The practice of TOP and associated medicolegal implications may influence the use of fetal MRI at local institutions. In countries in which the decision about TOP has to be made before 24 weeks, the performance of MRI prior to this time may help an individual couple decide on the future of their pregnancy; however, in general, MRI is better reserved for later in the second or third trimester13. Although available data are still inconclusive, MRI for parental reassurance regarding the absence of associated pathologies in fetuses with apparently isolated conditions may be recommended in fetuses with isolated ventriculomegaly16, agenesis of the corpus callosum17, absent septum pellucidum and cerebellar or vermian anomalies18. In addition, fetal MRI has been found to be helpful in monochorionic twin pregnancies after iatrogenic or natural demise of a cotwin to find pathological changes in the surviving twin19, 20. Fetal MRI performed before 18 weeks does not usually provide information additional to that obtained on ultrasound examination. In some cases, additional information can be obtained before 22 weeks13 but MRI becomes increasingly helpful thereafter. Specific examples of pathologies that can be evaluated in the third trimester include, but are not limited to, those of cortical development and neck masses that may cause airway compromise21. Most organs can be visualized in detail between 26 and 32 weeks of pregnancy, when pathologies related to abnormal development are more fully evolved, but each pregnancy and each fetus will differ. It may become more difficult for the woman to stay comfortable in the scanner with advancing gestation and consideration of left-lateral offset is recommended. When indicated, performed properly and interpreted correctly, MRI not only contributes to diagnosis but may be an important component of treatment choice, delivery planning and counseling. Practitioners who interpret fetal MRI should be familiar with fetal diagnosis, as it differs from diagnosis in other patient populations. Choice of appropriate protocols and techniques requires extensive training; thus, the performance of fetal MRI should be limited to individuals with specific training and expertise. The same applies to interpretation of the examination. In many centers this will require a multispecialty collaborative approach, including experts in the field of prenatal diagnosis, perinatology, neonatology, pediatric neurology and neuroradiology, genetics and other related specialties (Table 1), in order to integrate the clinical and family histories and the ultrasound and MRI findings, to optimize patient care. Consultation with a geneticist and other pediatric subspecialists may be required in order to provide the patient with the best counseling and management options. Although at present we are unaware of the existence of a recognized fetal MRI specialization, individuals who perform fetal MRI should have undergone specialized training in collaboration with a teaching center, enabling them to perform a state-of-the-art fetal MRI examination after a sufficient amount of cases (GOOD PRACTICE POINT; i.e. recommended best practice based on the clinical experience of the guideline development group). Performance of fetal MRI according to standardized criteria (Table 2) will improve the management of pregnancies complicated by a fetal malformation or acquired condition (GOOD PRACTICE POINT). At present, 1.5 T is the most commonly used field strength, providing acceptable resolution even as early as 18 weeks22. 3 T has the potential to provide images with higher resolution and better signal-to-noise ratio than does 1.5 T, while maintaining a comparable or lower energy deposition22. Nonetheless, higher field strength is currently not recommended for in-vivo fetal imaging10. In all cases, the field-of-view should be adjusted to the region of interest. A slice thickness of 3–5 mm with a 10–15% intersection gap will be appropriate in most cases. The examination should include at least T2 information in three orthogonal planes of the fetal brain and body, and T1- and GRE-EP sequences in one or two planes, preferably frontal and sagittal. This ‘minimum’ protocol should be executable in less than 30 min, even allowing for fetal movement and sequence repetition. Only examinations that are performed following this protocol should be regarded as ‘state of the art’ (GOOD PRACTICE POINT). Although usually measurements will already have been made with ultrasound, measuring certain structures at the MRI examination may be of benefit in particular cases12. When measuring fluid-containing structures, it is important to remember that MRI measurements are usually around 10% greater than the corresponding ultrasound measurements. In lung volumetry, normal gestational-age related MRI measurements correlate with fetal body volume29 and are considered predictive of outcome in cases of lung pathology30. The whole examination should be stored according to local practice, preferably in electronic format. CDs of the examinations can be produced for the patient to enable second-opinion assessment (GOOD PRACTICE POINT). Fetal situs, stomach and gallbladder (fluid filling), fluid and meconium signals of bowels (Figure 7c,d), kidneys, urinary bladder (fluid filling); on request: female/male external genitals (in case of latter: descent of testes) (Figure 8) Standardized reports should follow the suggested structure outlined in Table 3 (GOOD PRACTICE POINT). As MRI is usually not a first-line examination, but a complementary examination following an ultrasound examination performed in the second trimester31, the emphasis of the examination and report should be on structures that are more difficult to assess with ultrasound. A detailed anatomical assessment may be performed on demand. D. Prayer*, Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria G. Malinger*, Division of Ultrasound in Obstetrics & Gynecology, Lis Maternity Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel P. C. Brugger, Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria C. Cassady, Texas Children's Hospital and Fetal Center, Houston, TX, USA L. De Catte, Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium B. De Keersmaecker, Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium G. L. Fernandes, Fetal Medicine Unit, Department of Obstetrics, ABC Medicine University, Santo Andre, Brazil P. Glanc, Departments of Radiology and Obstetrics & Gynecology, University of Toronto and Sunnybrook Research Institute, Obstetrical Ultrasound Center, Department of Medical Imaging, Body Division, Sunnybrook Health Sciences Centre, Toronto, Canada L. F. Gonçalves, Fetal Imaging, William Beaumont Hospital, Royal Oak and Oakland University William Beaumont School of Medicine, Rochester, MI, USA G. M. Gruber, Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria S. Laifer-Narin, Division of Ultrasound and Fetal MRI, Columbia University Medical Center - New York Presbyterian Hospital, New York, NY, USA W. Lee, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA A.-E. Millischer, Radiodiagnostics Department, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France M. Molho, Diagnostique Ante Natal, Service de Neuroradiologie, CHU Sud Réunion, St Pierre, La Réunion, France J. Neelavalli, Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA L. Platt, Department of Obstetrics and Gynecology, David Geffen School of Medicine, Los Angeles, CA, USA D. Pugash, Department of Radiology, University of British Columbia and Department of Obstetrics and Gynecology, BC Women's Hospital, Vancouver, Canada P. Ramaekers, Prenatal Diagnosis, Department of Obstetrics and Gynecology, Ghent University Hospital, Ghent, Belgium L. J. Salomon, Department of Obstetrics, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France M. Sanz, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA I. E. Timor-Tritsch, Division of Obstetrical & Gynecological Ultrasound, NYU School of Medicine, New York, NY, USA B. Tutschek, Department of Obstetrics & Gynecology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany and Prenatal Zurich, Zürich, Switzerland D. Twickler, University of Texas Southwestern Medical Center, Dallas, TX, USA M. Weber, Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria R. Ximenes, Fetal Medicine Foundation Latin America, Centrus, Campinas, Brazil N. Raine-Fenning, Department of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham and Nurture Fertility, The Fertility Partnership, Nottingham, UK *D. P. and G. M. contributed equally to this article. These Guidelines should be cited as: ‘Prayer D, Malinger G, Brugger PC, Cassady C, De Catte L, De Keersmaecker B, Fernandes GL, Glanc P, Gonçalves LF, Gruber GM, Laifer-Narin S, Lee W, Millischer A-E, Molho M, Neelavalli J, Platt L, Pugash D, Ramaekers P, Salomon LJ, Sanz M, Timor-Tritsch IE, Tutschek B, Twickler D, Weber M, Ximenes R, Raine-Fenning N. ISUOG Practice Guidelines: performance of fetal magnetic resonance imaging. Ultrasound Obstet Gynecol 2017; 49: 671–680.’ Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Antenatal diagnosis of placenta accreta spectrum (PAS) improves maternal and neonatal outcomes by allowing for multidisciplinary planning and preparedness. Ultrasound is the primary imaging tool. Simplification and standardization of placental evaluation and reporting terminology allows improved communication and understanding between teams. Prior to 10 weeks of gestation, gestational sac position and least myometrial thickness surrounding the gestational sac help PAS diagnosis very early in pregnancy. Late first-, second-, and third-trimester evaluation includes comprehensive evaluation of the placenta, transabdominal and transvaginal with partially full maternal urinary bladder, and by color Doppler. Subsequently, the sonologist should indicate whether the evaluation was optimal or suboptimal; the level of suspicion as low, moderate, or high; and the extent as focal, global, or extending beyond the uterus. Other complementary imaging modalities such as 3D-power Doppler ultrasound, magnetic resonance imaging (MRI), and vascular topography mapping strive to improve antenatal placental evaluation but remain investigational at present. KEY POINTS: · Antenatal imaging, primarily using ultrasound with partially full maternal urinary bladder, is an essential means of evaluation of those at risk for PAS.. · Simplification and standardization of placental evaluation and reporting will allow improved communication between the multidisciplinary teams.. · Gestational sac location prior to 10 weeks of gestation and four markers after that (placental lacunae and echostructure, myometrial thinning, hypoechoic zone with or without bulging between placenta and myometrium, and increased flow on color Doppler)..

Objectives:Standard genetic testing can fail to identify an underlying genetic etiology in pregnancies affected by multiple fetal abnormalities. Recently, whole exome sequencing (WES) studies have shown promise in recognizing genetic diagnoses where standard genetic testing does not yield answers. Case presentation:A 35-year-old G1P0 healthy female found at anatomy scan to have multiple fetal anomalies, including severe bilateral ventriculomegaly, renal pyelectasis, and short long bones. Karyotype and microarray were normal. Whole exome sequencing showed the fetus was compound heterozygous for likely pathogenic variants in the ROBO1 gene. Conclusions:In the presence of multiple fetal anomalies with normal karyotype and microarray, whole exome sequencing should be considered to not only provide answers for the affected parents, but also aid in future pregnancy planning.

a multidisciplinary task force published a consensus report outlining an ultrasound curriculum and competency assessment tool for use in obstetric and gynecologic residency programs. 1 This document outlined the rationale for standardized ultrasound training among residents, citing both the integral role of ultrasound in the clinical practice of obstetrics and gynecology and the need for formal educational strategies and competency assessments in light of resident work hour restrictions. The residency ultrasound training document was based on published guidelines 2,3 and was intended to provide tools to facilitate ultrasound training in residency programs, with learning objectives stratified by postgraduate year.

Ultrasound in Obstetrics & GynecologyVolume 59, Issue 6 p. 709-712 Opinion Guidance for fetal cardiac imaging in patients with degraded acoustic windows M. Sklansky, Corresponding Author M. Sklansky msklansky@mednet.ucla.edu orcid.org/0000-0002-9146-0701 Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USACorrespondence. (e-mail: msklansky@mednet.ucla.edu)Search for more papers by this authorY. Afshar, Y. Afshar Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USASearch for more papers by this authorT. Anton, T. Anton Department of Reproductive Medicine, University of California, San Diego, CA, USASearch for more papers by this authorG. R. DeVore, G. R. DeVore Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA Fetal Diagnostic Centers, Pasadena, Tarzana and Lancaster, CA, USASearch for more papers by this authorL. Platt, L. Platt Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA, USASearch for more papers by this authorG. Satou, G. Satou Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USASearch for more papers by this author M. Sklansky, Corresponding Author M. Sklansky msklansky@mednet.ucla.edu orcid.org/0000-0002-9146-0701 Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USACorrespondence. (e-mail: msklansky@mednet.ucla.edu)Search for more papers by this authorY. Afshar, Y. Afshar Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USASearch for more papers by this authorT. Anton, T. Anton Department of Reproductive Medicine, University of California, San Diego, CA, USASearch for more papers by this authorG. R. DeVore, G. R. DeVore Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA Fetal Diagnostic Centers, Pasadena, Tarzana and Lancaster, CA, USASearch for more papers by this authorL. Platt, L. Platt Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA, USASearch for more papers by this authorG. Satou, G. Satou Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USASearch for more papers by this author First published: 03 February 2022 https://doi.org/10.1002/uog.24872Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Open Research DATA AVAILABILITY STATEMENT Data sharing is not applicable to this article as no new data were created or analyzed in this study. Citing Literature Volume59, Issue6June 2022Pages 709-712 RelatedInformation

BACKGROUND:Ultrasound training is a vital component of maternal-fetal medicine fellowships in the United States. Of the 18 months of core clinical training, the American Board of Obstetrics and Gynecology currently requires a minimum of 3 months to be dedicated to ultrasound to be eligible for board certification. However, the experience and degree of hands-on training differ among the fellowship programs and have not been reassessed for nearly a decade.OBJECTIVE:To assess regional heterogeneity in the ultrasound training experience during maternal-fetal medicine fellowship in the United States.STUDY DESIGN:A survey was distributed to postgraduate year (PGY)-6 maternal-fetal medicine fellows registered to attend an annual ultrasound training course before the conference (n=114). For programs with >1 fellow attending (n=39), only 1 of them completed the survey to represent the program. The questions included demographics of the program, ultrasound training structure, the fellows' self-perception of ultrasound capabilities, research, mentorship, and technical aspects of sonography.RESULTS:Seventy two postgraduate year 6 fellows with a wide geographic distribution as follows completed the survey (96% response rate): 10 (14%) from the West, 16 (22%) from the Midwest, 17 (24%) from the South, and 29 (40%) from the Northeast. Respondents undergoing training in the South were less likely to report feeling comfortable performing nuchal translucency and detailed anatomic surveys than those from other regions (nuchal translucency: P=.046; anatomy: P=.011). Most of the respondents reported feeling comfortable performing growth (78%) and umbilical artery Doppler (58%) and feeling uncomfortable with three-dimensional ultrasound, neurosonography, and fetal echocardiography. Respondents in the Northeast were more likely to report feeling comfortable performing chorionic villus sampling (P=.001). There was no difference among fellowship programs in the presence or absence of ultrasound curriculum, bedside teaching, ultrasound-focused research mentorship, or months of ultrasound training.CONCLUSION:Despite the standardization of ultrasound training structure across the United States, there remains regional heterogeneity in fellow self-reported comfort with specific ultrasound techniques and chorionic villus sampling at a midpoint in their fellowship training. The maternal-fetal medicine attending involvement at the bedside did not affect the fellow self-reported comfort with ultrasound surveys. This study highlights the need for further optimization of maternal-fetal medicine fellowship ultrasound training, especially in advanced sonography and diagnostic procedures.

Growth-restricted fetuses are at risk of hypoxemia, acidemia, and stillbirth because of progressive placental dysfunction. Current fetal well-being, neonatal risks following delivery, and the anticipated rate of fetal deterioration are the major management considerations in fetal growth restriction. Surveillance has to quantify the fetal risks accurately to determine the delivery threshold and identify the testing frequency most likely to capture future deterioration and prevent stillbirth. From the second trimester onward, the biophysical profile score correlates over 90% with the current fetal pH, and a normal score predicts a pH >7.25 with a 100% positive predictive value; an abnormal score on the other hand predicts current fetal acidemia with similar certainty. Between 30% and 70% of growth-restricted fetuses with a nonreactive heart rate require biophysical profile scoring to verify fetal well-being, and an abnormal score in 8% to 27% identifies the need for delivery, which is not suspected by Doppler findings. Future fetal well-being is not predicted by the biophysical profile score, which emphasizes the importance of umbilical artery Doppler and amniotic fluid volume to determine surveillance frequency. Studies with integrated surveillance strategies that combine frequent heart rate monitoring with biophysical profile scoring and Doppler report better outcomes and stillbirth rates of between 0% and 4%, compared with those between 8% and 11% with empirically determined surveillance frequency. The variations in clinical behavior and management challenges across gestational age are better addressed when biophysical profile scoring is integrated into the surveillance of fetal growth restriction. This review aims to provide guidance on biophysical profile scoring in the in- and outpatient management of fetal growth restriction.

Objective The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception. Methods We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log(10) NT MoM and slope of NT with respect to crown- rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders. Results Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% hadNTmedianMoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway. Conclusions Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. (C) 2021 International Society of Ultrasound in Obstetrics and Gynecology.

[This corrects the article DOI: 10.1371/journal.pmed.1002220.].

Placenta accreta spectrum (PAS) is a high-risk obstetrical condition associated with significant morbidity and mortality. Current clinical screening modalities for PAS are not always conclusive. Here, we report a nanostructure-embedded microchip that efficiently enriches both single and clustered circulating trophoblasts (cTBs) from maternal blood for detecting PAS. We discover a uniquely high prevalence of cTB-clusters in PAS and subsequently optimize the device to preserve the intactness of these clusters. Our feasibility study on the enumeration of cTBs and cTB-clusters from 168 pregnant women demonstrates excellent diagnostic performance for distinguishing PAS from non-PAS. A logistic regression model is constructed using a training cohort and then cross-validated and tested using an independent cohort. The combined cTB assay achieves an Area Under ROC Curve of 0.942 (throughout gestation) and 0.924 (early gestation) for distinguishing PAS from non-PAS. Our assay holds the potential to improve current diagnostic modalities for the early detection of PAS.

Importance: Data regarding efficacy and safety of anti-COVID-19 mRNA vaccines during lactation is needed to address vaccination guidelines, ease vaccine hesitancy concerns, and inform public health strategies for this population. Objective: To determine whether anti-COVID-19 mRNA-based vaccines administered during lactation illicit an immune response or the transfer of anti-SARS-CoV2 antibodies into human milk. Design: Plasma and milk samples were collected from a prospective cohort of lactating individuals who received the mRNA-based vaccines for COVID-19 and from individuals who recovered from COVID-19 infection. Setting: Ambulatory or during postpartum hospitalization. Participants: We report results from lactating participants who received the mRNA-1273 (Moderna, n=9) or the BNT162b2 (Pfizer, n=14) vaccine or recovered from natural SARS-CoV-2 infection (n=3). Interventions and Exposures: Anti-COVID-19 mRNA vaccination (BNT-162b2 and mRNA-1273) or natural SARS-CoV-2 infection. Main Outcome(s) and Measure(s): Plasma and milk samples were collected from lactating individuals before first vaccine dose, on the day of the second dose, and 4 weeks after the second dose. Maternal plasma was evaluated for vaccine-derived IgM and IgG antibodies. Human milk was evaluated by ELISA for vaccine-induced IgA antibodies specific for SARS-CoV-2. Results: Twenty-three lactating individuals were recruited for this study. Levels of IgG and IgM were significantly increased in plasma samples on the day of the second vaccine dose (post vaccine 1), when compared to pre-vaccine samples. In addition, plasma IgG levels 4 weeks after second vaccine dose were significantly higher than plasma IgG levels pre-vaccine or on the day of the second dose. In addition, our results show transfer of anti-SARS-CoV2-Receptor Binding Domain (RBD) IgA antibodies to human milk, 3-4 weeks after each dose of the COVID-19 mRNA vaccines (BNT-162b2 and mRNA-1273). The levels of anti-SARS-CoV2-RBD IgA antibody in milk of vaccinated individuals were not significantly different from levels among participants who experienced SARS-CoV-2 infection. Conclusions and Relevance: Administration of anti-COVID-19 mRNA vaccines during lactation leads to increased anti-SARS-CoV2 IgM and IgG levels in the plasma of lactating mothers and increased anti-SARS-CoV2-RBD IgA levels in human milk. Lactating women who receive the vaccine should continue breastfeeding their infant human milk to allow continuing transfer of anti-SARS-CoV-2 IgA antibodies to the neonate. Additional studies are needed to evaluate the effect of these vaccines on lactation outcomes and infant health.

To assess the current maternal-fetal medicine (MFM) ultrasound (U/S) training experience during fellowship. An anonymous survey of 51 questions was distributed to 114 postgraduate year (PGY-6) MFM fellows (from 75 MFM programs) registered to attend the annual Gottesfeld-Hohler Memorial Foundation MFM Fellow Ultrasound Training Course in December 2019. For programs with more than one PGY-6 fellow, instructions were given for only one fellow to represent the program. The survey included continuous, ordinal, and categorical scale questions on U/S training structure, fellows' self-perception of U/S capabilities, research, mentorship, and technical aspects of sonography. Categorical outcomes were compared using chi-square test and Fisher's exact test, as appropriate. Completed surveys were submitted by 72 fellows (96% response rate), with 10 (13.9%) from the West, 16 (22.2%) Midwest, 17 (23.6%) South, and 29 (40.3%) Northeast. The majority of fellows reported feeling comfortable performing growth U/S (78%) and uterine artery Doppler interrogations (58%), and feeling uncomfortable with 3D U/S, neurosonography, and fetal echocardiography (Table 1). Fellows undergoing training in the South were less likely to report feeling comfortable performing detailed anatomic surveys and nuchal translucency (NT) when compared to other regions (NT: p=0.046; anatomy: p=0.011) (Table 1). Fellows in the Northeast were more likely to report feeling comfortable performing chorionic villus sampling (CVS) when compared to other regions (p=0.001) (Table 2). There was no difference among fellowship programs in U/S curriculum, bedside teaching, ultrasound-focused research mentorship, or months of U/S training. There is wide geographic variation in fellow comfort with U/S and diagnostic procedures in the United States. This study highlights the need for further optimization and standardization of MFM fellowship U/S training, especially in advanced sonography and diagnostic procedures.View Large Image Figure ViewerDownload Hi-res image Download (PPT)