A thorough and accurate history and physical examination of the pregnant woman has always been an integral part of obstetrical care. From the onset of modern medicine everywhere in the world, the importance of inspection, auscultation, percussion, and palpation was taught. Measurement and palpation of the pregnant abdomen have been crucial for determining fundal height, lie, and presentation of the fetus, as well as gestational age and estimated fetal weight. Every obstetrical visit included a measurement of the fundal height with a measuring tape (McDonald's rule). International standards for measurement of fundal height have been developed and validated.1-4 Fundal height measurements have been used to confirm gestational age and screen for discrepancies in fetal growth5-7 and amniotic fluid.8 With the exception of sonography, fundal height measurement correlated better than other screening methods for determining gestational age.9 The American College of Obstetricians and Gynecologists continues to recommend symphysis pubis to top of the fundus measurements be obtained at routine prenatal visits.10, 11 Examples of countries with similar published prenatal guidelines include United Kingdom, New Zealand, Canada, Ireland, and France.12 All of medicine, including obstetrics, has changed over the years, primarily because of advancements in technology. It is quite amazing that within the course of the last 30 years, in Israel the pregnant woman's abdomen is no longer routinely palpated and the fundal height is no longer measured. Leopold maneuvers for lie, presentation, position, and clinical estimated fetal weight are in fact rarely used, and these skills have been forgotten. Although still appearing in textbooks, students and residents in Israel are no longer exposed to measurement of fundal height or to perform Leopold's maneuvers chiefly because their mentors have themselves stopped the practice. The accuracy or necessity of this clinical approach is now questioned by the younger generation of obstetricians who may have no idea how and why to measure fundal height. In addition, in the #MeToo era, physicians have become hesitant to touch (palpate) a patient's abdomen especially as patients are becoming accustomed not to having this done. Patients themselves now question what is going on when approached by an obstetrician with a measuring tape and may never come in contact with one. Of course, we cannot be completely certain that there are not a few stragglers, like ourselves, who continue to carry a measuring tape in their laboratory coats. This hands-off trend is not unique to Israel, but seems to be occurring in some other high resource countries as well, such as some Western European countries. On the other hand, low resource countries and areas still rely on fundal height and abdominal examination. The main reason for the abandonment of the measuring tape and palpation coincides with advancements in modern technology and the ultrasound machine. At each visit in areas of an abundance of resources, instead of using a measuring tape, the physician reaches for the readily available ultrasound transducer. Most often, fetal biometry, fetal heart activity, and a subjective assessment of amniotic fluid are quickly documented at every encounter. This corresponds to a routine of at least 10 ultrasound examinations for low-risk women throughout their pregnancy, and some high-risk women may have more than 20 such examinations. Women have come to expect an answer to their question "how much does my baby weigh today?"; "does everything look okay today?"; or “why aren't you scanning my baby today?” They are also looking for the "wow" factor, to be able to see their fetus, to get a picture, and post it online even before the visit is completed. A picture of a measuring tape is not nearly as compelling. There are several factors that have facilitated this change. First, there are no universally accepted and published guidelines in many countries for prenatal care especially in regard to palpation and fundal height measurement. Second, in Israel and other high resource countries, ultrasound machines have become readily available in every outpatient clinic. Third, in many countries there is no extra patient charge for these limited office sonograms and in some countries there is actually a financial incentive for the physician to perform these scans. This is in contrast to the restricted use of ultrasound in the United States where medical insurance might only pay for a dating scan, a second-trimester anomaly scan, and/or possibly a third-trimester growth scan in low-risk women. In many countries, in obstetric hospitals and clinics, an ultrasound machine usually sits alongside the examination table. It is neither rolled in and out as needed nor is it even in a separate room. The woman is not asked to move to a separate room for a "special" examination. The machine is there, on display, and easily accessible. The examination itself is easy to perform and for basic needs takes no more than a minute or two. The physician is pleased, since the patient is pleased. The expectant mother gets to see parts of the baby, maybe some movement, maybe a facial profile, certainly the heart activity which can be heard as well if Doppler is applied. Finally, the physician cannot perform these brief ultrasound examinations only on select patients since the ethical principle of justice requires equal treatment for all pregnant women regardless of their risk status. Pregnant women now expect to have this same feeling of satisfaction at each visit and will take notice if ultrasound is not done. This symbiosis, in an exponential fashion, has led to replacement of the measuring tape in the examination room. Fundal height is no longer recorded, and there is no need for “touching” the abdomen. Has this been a change for the good or is it a false sense of security when the physician says everything looks well on these brief ultrasound examinations? In the past when an obstetrician tried to reassure a patient, everyone understood the limitations of these reassurances. Today, false reassurance may have dire medical-legal consequences for the health care provided. The physician has adapted well. Patient satisfaction is maintained at minimal additional effort or time investment. However, with no training and experience in fundal height measurement, the obstetrician has forgotten that fundal height and clinical examination, when done meticulously, are very good screening tools for abnormalities of fetal growth in most women. One may argue that these frequent ultrasound examinations may detect more abnormalities in amniotic fluid volume. This might be true, but would not a patient with oligo- or polyhydramnios have an abnormal fundal height triggering an ultrasound examination? Of course, the real question remains: Does the routine use of ultrasound improve pregnancy outcomes? In one study comparing clinical weight estimation to sonographic weight estimation, there was no difference in mean error between the two modalities.13 In fact, in the weight range 2500-4000 g, clinical estimation was found to more accurate.14 It is unknown whether the routine use of ultrasound results in less morbidity and mortality to the fetus/newborn. It is not known for sure whether this practice has had an influence on interventions, such as induction of labor, cesarean delivery, or future litigation. Whatever the case, the measuring tape and abdominal examination are disappearing from obstetrical practice in many places, probably never to return unless there will be national guidelines and a unified attempt and cooperation by practitioners and their patients to limit the use of ultrasound. This same fate might be inevitable in other high-technological societies where low-cost and pocket ultrasound machines are becoming readily available. Other instruments and procedures used in obstetrics have had similar fates throughout the years for various reasons, such as the pudendal needle, Kielland and Piper forceps, and x-ray pelvimetry. Transvaginal measurement of cervical length is usurping digital examination of the cervix, when in fact neither test offers a significant advantage in predicting preterm birth.15 Whatever the case, changing technology leads to changes in practice. Until high-quality research is available, whether these changes lead to better perinatal outcomes is up to each of us to decide.

To assess the effect of incorporating URAD, with maternal age and/or second-trimester maternal serum screening, to calculate a final risk for Down Syndrome (DS) on patients' decision for amniocentesis. Between 9/1/03 and 9/1/05, 1339 (22.3%) of 6000 consecutive patients at risk for DS were enrolled in our URAD screening program between 17–22 weeks gestation. 81 patients (6%) failed to complete URAD due to inappropriate gestational age, unfavorable fetal position, maternal weight or inability to complete anatomic survey. URAD included 6 fetal markers: nuchal thickness (likelihood ratio [LR] = 11), echogenic bowel (LR = 6.7), short femur (LR = 1.5) or short humerus (LR = 5), echogenic intracardiac focus (LR = 1.8) and pyelectasis (LR = 1.5). If a single marker was noted, the initial risk, which was based on maternal age and/or maternal serum screening, was multiplied by the LR of that marker. When more than one marker was found, then the initial risk was multiplied by the highest LR or 6.2. The absence of a marker had a LR of 0.5. After URAD, the patients were assigned into two groups depending upon whether their final calculated risk was greater or less than 1/270. The at risk group was further divided into an intermediate risk and high risk group (> 1/100 risk). Group A total of 162 patients (12.1%) had amniocentesis for prenatal diagnosis. More patients with a final risk greater 1/270 had an amniocentesis with a LR of 1.8 (95% confidence intervals 1.5–2.1). The sub group with the highest risk for DS, had the highest rate of amniocentesis. Although the decision to have amniocentesis is multifactorial in nature, risk modification including URAD, maternal age and maternal serum screening had a significant effect on patients' decision for amniocentesis.

To determine the frequency of 6 markers for DS in a high-risk population. Between 9/1/03 and 9/1/05, 1339 (22.3%) of 6000 consecutive patients at risk for DS on the basis of maternal age or MSAFP results, were enrolled in our ultrasonographic risk assessment for Down syndrome (URAD) screening program to further assess their risk for DS. URAD was performed between 17–22 weeks gestation. Patients with a desire for a diagnostic test, a fetal anomaly, or declined testing were excluded from the URAD program. 81 patients (6%) failed to complete URAD due to inappropriate gestational age, unfavorable fetal position, maternal weight or inability to complete anatomic survey. URAD included 6 fetal markers: nuchal thickening, echogenic bowel, short humerus, echogenic intracardiac focus, short femur, and pyelectasis. Presence of any of these markers was considered to be a positive URAD, and the absence of these markers was considered as a negative URAD. 94% (1258/1339) of fetuses were able to be evaluated. This included 8 fetuses (0.6%) with DS. 171/1258 (13.6%) patients had 1 or more DS markers. The incidence of each of the ultrasonographic markers for DS is seen in Table below. There were 217 total markers found in the 171 fetuses. 5 of the 8 (62.5%) fetuses with DS had 1 or more markers. Markers for DS were identified in 13.6% of fetuses in a population at risk for chromosomal anomalies. Echogenic intracardiac focus was the most common marker identified.

To assess the efficiency of both URAD, and final risk assessment based on URAD, maternal age, and/or maternal serum screening for the detection of DS. Between 9/1/03 and 9/1/05, 1339 (22.3%) of 6000 patients at risk for DS were enrolled in our URAD screening program between 17–22 weeks gestation. Patients with a desire for a diagnostic test, a fetal anomaly, or declined testing were excluded from the URAD program. 81 patients (6%) failed to complete URAD due to inappropriate gestational age, unfavorable fetal position, maternal weight or inability to complete anatomic survey. URAD included 6 fetal markers. If any marker was noted, the URAD was considered positive. The markers used were: nuchal thickness (likelihood ratio [LR] = 11), echogenic bowel (LR = 6.7), short femur (LR = 1.5) or short humerus (LR = 5), echogenic intracardiac focus (LR = 1.8) and pyelectasis (LR = 1.5). If a single marker was noted, the initial risk, which was based on maternal age and/or maternal serum screening, was multiplied by the LR of that marker. When more than one marker was found, then the initial risk was multiplied by the highest LR or 6.2. The absence of a marker had a LR of 0.5. Eight patients in the study group had DS. The distributions of these patients are noted below on the basis of either the presence or absence of a URAD marker or if their final calculated risk was less than or greater than 1/270. The relative risk (RR) of having Down syndrome with a positive URAD is 10.6 with 95% confidence intervals (CI) of 2.6–43.9. The RR with a final risk of > 1/270 is 13.5 with 95% CI 1.7–109.6. Although the prevalence of DS in our study is low, both URAD and calculated final risk are efficient screening techniques. Final risk based on URAD, maternal age and/or maternal serum screening is the more efficient predictor of this condition over URAD alone.

To assess the effects of URAD on patients' decision for amniocentesis. Between 9/1/03 and 9/1/05, 1339 (22.3%) of 6000 consecutive patients at risk for Down Syndrome (DS) were enrolled in our URAD screening program to further assess their risk for DS. URAD was performed between 17–22 weeks gestation. Patients with a desire for a diagnostic test, a fetal anomaly, or declined testing were excluded from the URAD program. 81 patients (6%) failed to complete URAD due to inappropriate gestational age, unfavorable fetal position, maternal weight or inability to complete anatomic survey. URAD included 6 fetal markers: nuchal. thickening, echogenic bowel, short humerus, echogenic intracardiac focus, short femur, and pyelectasis. Presence of any of these markers was considered to be a positive URAD, and the absence of any of these markers was considered as a negative URAD. A total of 162 patients (12.1%) had amniocentesis for prenatal diagnosis. More patients with a positive URAD underwent amniocentesis with a likelihood ratio of 2.1 (95% confidence intervals 1.6–2.9). A positive URAD was noted in 12.7% of patients at risk for DS in a perinatal setting. Although the decision to have amniocentesis is multifactorial in nature, URAD finding of a marker associated with DS had a significant effect on patients' decision for amniocentesis.

The recognition and treatment of fetal hypothyroidism are believed to be important to optimize growth and intellectual development in affected fetuses. We present a case of fetal goiter diagnosed by ultrasonography in the second trimester of pregnancy. Cordocentesis performed at 28 weeks confirmed the presence of fetal hypothyroidism. Fetal therapy was performed with weekly intra-amniotic injections of thyroxine from 29 to 36 weeks. A repeat cordocentesis at 35 weeks showed normalization of fetal thyroid function. The fetal goiter decreased rapidly in size following fetal treatment. Amniotic fluid levels of thyroid stimulating hormone (TSH) and free thyroxine were obtained with each amniocentesis. Sulfated iodothyronine concentrations in maternal blood were obtained before and after fetal thyroxine treatment. This report discusses the role of amniotic fluid levels of TSH and free thyroxine and maternal levels of sulfated iodothyronine in the diagnosis and management of fetal hypothyroidism. A review of the English literature is presented.

Short-term ultrasound-guided fetal umbilical cord catheterization in humans has been reported. However, before chronic umbilical vein catheterization is attempted in humans the technique must be tested in the non-human primate model. If the fetus was to tolerate this procedure, chronic fetal umbilical vein catheterization could be used for drug administration, parenteral fetal nutrition or to monitor the changes of hematologic parameters during and after open or endoscopic fetal surgery. In this study, 4 pregnant baboons were used to test the feasibility of ultrasound-guided umbilical vein catheterization. Although the umbilical vein was successfully catheterized in all the animals, only 1 fetus survived the postoperative period. The 3 immediate fetal deaths were due to a fetal intra-amniotic hemorrhage, while the most likely cause of death of the 4th animal was infection. In the surviving fetus and mother, blood was sampled once a day. Neither fetomaternal hemorrhage nor thrombosis could be documented. We conclude that ultrasound-guided transplacental umbilical vein chronic catheterization is technically difficult but feasible in the baboon model. Further studies in this model are needed to improve the catheterization technique and to monitor the extent of time that the catheter may be tolerated within the umbilical vein.

The availability of normal data on fetal rib bone length would be of value in a variety of circumstances under which ultrasound examinations are performed. Fetal rib length measurements were obtained in 257 singleton fetuses in a prospective cross-sectional study. The study population consisted of pregnancies between 14 and 40 weeks with no evidence of growth disturbances, or structural or karyotypic abnormalities. Fetal rib length, as a function of gestational age, was expressed by the regression equation: RL = -0.5834 + 0.2030 (GA), where RL is the rib length in centimeters and GA the gestational age in weeks. The correlation was R = 0.94 (p < 0.0001). The normal limits of fetal rib length are defined, and a high correlation between fetal rib length, gestational age, and other standard determinants of fetal growth is demonstrated. Our results indicate that fetal rib length can be a useful adjunct in determining normal fetal growth and in the management of the pregnancy with fetal skeletal dysplasia.

All fetuses benefit from ultrasonographic estimation of gestational age and evaluation of growth patterns. Monitoring the pregnancies of obese women is perceived as more difficult than monitoring those of nonobese women. The aim of this study was to determine if maternal obesity affects the growth and Doppler resistance indices (RI) of the fetus. Twenty-eight women with a preconception weight > 90.7 kg underwent obstetric ultrasonographic evaluations from the 20th week of gestation. Their ultrasonographic data were compared with those of controls. Ten of the obese women developed gestational diabetes and had lower umbilical artery RIs for a given gestational age (P < .0001) than did those obese women without other medical complications, those with medically controlled pregnancy-induced hypertension or those from the control population. The relation between fetal unit weight and umbilical artery RIs was established. The pattern of RI changes was similar in all groups when estimated fetal weight instead of gestational age was used as the covariant. Fetal growth and Doppler velocimetry can be monitored adequately in obese women. Gestational diabetes significantly influences the pattern of fetal growth and the impedance to flow in the umbilical artery.

Diagnostic ultrasonography has given us the opportunity to diagnose several congenital malformations in utero. Skeletal dysplasias is a heterogeneous group of disorders of the skeleton. Although disorders of bone growth are often diagnosed in utero, it is usually a general diagnosis because the exact syndrome cannot be specified. This is due to the fact that many anomalies of the skeleton have similar features. The wing of the iliac bone can be either affected or normal in skeletal dysplasias and its appearance may help in the differential diagnosis. This study was undertaken to establish values for the width of the iliac bone wing during normal gestations and thus enable us to use it in the evaluation of fetal growth and the recognition of specific congenital anomalies.

In this prospective study conducted from 1984 through 1987, the ability to correctly predict growth discordancy in twin gestations by ultrasonic estimated fetal weights is examined. Discordancy was defined as an intertwin birth weight difference of 25% or greater. This method resulted in a sensitivity rate of 77% and a specificity rate of 92%. The positive predictive value of an abnormal test (i.e. discordant growth) was 67% and the negative predictive value of a normal test (i.e. concordant growth) was 95%. The perinatal mortality rate of 217/1,000 in discordant twin fetuses was significantly higher than 29/1,000 in the concordant twins in this study population (p < 0.01) and even more of a contrast to the rate of 10/1,000 in our singleton population. Accurate prediction of discordant twin pregnancies which are at high risk for poor outcome opens the opportunity for potential in utero treatment modalities.

Objective: To compare the clinical value of umbilical artery Doppler velocimetry and oxytocin-challenge test (OCT) in predicting perinatal outcome following a nonreactive nonstress test (NST). Methods: Prospective blind study of 250 high-risk pregnancies. All patients were examined by NST and Doppler velocimetry between 28 and 41 weeks. Nonreactive NST was followed by OCT. Outcome was defined as poor if one of the following was present: fetal distress as indication for delivery, birth weight <10th percentile, 5-min Apgar <7, cord pH <7.2, early neonatal death. Results: Doppler velocimetry and NST had similar indices of prediction for perinatal outcome (with a sensitivity of 81.7% and 80% and a specificity of 95.3% and 92.6%, respectively). Doppler and NST were concordant in 79.6% and Doppler and OCT in 95.8%. Doppler and OCT also had identical degrees of prediction. Doppler velocimetry results following a nonreactive NST were highly correlated to OCT results. Conclusions: Separately, Doppler and NST are equally poor predictors of perinatal outcome. When combined, they become a more effective screening tool. Our results also suggest that Doppler velocimetry can possibly be offered instead of OCT to patients with abnormal NSTs to further define fetal status.

The value of Doppler velocimetry in predicting fetal distress or perinatal infection was investigated in 60 patients with premature rupture of the membranes (PROM) between 25 and 38 weeks of gestation. Studies were performed in the umbilical and uterine arteries after admission to the hospital and repeated every 24 to 76 hours until delivery. Results of the last study, performed less than 24 hours before delivery and comparison between longitudinal studies in the same patient, failed to disclose statistical differences between patients who did or did not develop the perinatal complications under study. We conclude that Doppler velocimetry is not a sensitive enough means of predicting fetal distress or infection in PROM.

The addition of color Doppler imaging (CDI) to the vaginal probe now enables sonographers to study more accurately the maternal-fetal circulation at the early stages of the gestation. Doppler studies of normal intrauterine first trimester gestations have been published, and our investigation was an attempt to study uteroplacental blood flow in abnormal intrauterine first trimester gestations. Although the calculated indices did not differ significantly from those found in normal gestations, we did find a higher rate of color detection in gestations defined as anembryonic as compared to those defined as missed abortions. Circulation abnormalities probably play a significant role in early pregnancy failures, and we believe CDI will help define the different etiologic mechanisms causing these early complications.

The changes in fetal presentation throughout pregnancy were observed ultrasonographically in 332 sets of twins. Seventy-eight percent of the leading twins were vertex at 26-30 weeks' gestational age, 75% at 31-34 weeks and 81% at 35-38 weeks. The incidence of nonvertex presentation for either twin was 73.0%, 64.5% and 59.5% at the same gestational ages. The results are not significantly different from those on concordant twins delivered at the same gestations. Thus, one can counsel parents of twins at all gestational ages in regard to the potential for malpresentation.

Among 12,572 pregnant women referred for ultrasound examination from 1985-1990, 76 fetuses had ultrasonographic findings of hydrops fetalis, ten immune and 66 nonimmune. Fetuses with cystic hygroma (20), heart defects or arrhythmias (13), or other congenital anomalies (15) accounted for the majority of the nonimmune cases. Antenatal chromosomal studies were available in 42 fetuses with nonimmune hydrops, of which 14 (34%) were abnormal with seven monosomes and six trisomies. Seventeen cases of hydrops (22%) were classified as idiopathic because they had no recognizable etiology. It is concluded that: 1) The ultrasonographic incidence of fetal hydrops in referral centers can be as high as one in 165 pregnancies; 2) most cases of fetal hydrops are of the nonimmune type, which can occur in a low-risk population and can be detected with early secondtrimester ultrasound screening; and 3) the complexity of this condition and the high rate of chromosomal abnormalities require referral to a high-risk center for evaluation and pregnancy management.

A prospective blinded study was performed on 191 high-risk patients with pregnancies ranging from 25 to 42 weeks gestation to investigate the value of a single Doppler analysis of the umbilical artery blood flow waveform (systolic-to-diastolic ratio, S/D) for predicting poor perinatal outcome. This was defined as the presence of heavy meconium, delivery of a growth-retarded infant, an umbilical cord arterial pH less than 7.2, or a 5-minute Apgar score less than 7. The interval between Doppler examination and delivery ranged from 12 hours to 15 weeks. No clinical data were available to the examiner performing the Doppler study. Moreover, the Doppler measurements were unknown to the attending physicians. The sensitivity, specificity, and positive and negative predictive values of the Doppler study in predicting outcome were 30.4%, 92.9%, 36.8%, and 92.6%, respectively, with an adverse outcome prevalence of 12%. These results indicate that a single random S/D ratio from the umbilical artery is not an adequate screening test for the risk of perinatal complications.

Characteristic changes of low resistance and high diastolic blood flow velocity were identified by Doppler studies starting in the early phase of the second trimester. These changes were attributed by some authors to trophoblastic invasion of the uterine vasculature converting the uterus into a low-resistance organ. Because of technical limitations previous studies were confined to the uterine artery and its main branches. With the development of color Doppler and transvaginal ultrasonography we can now identify blood flow in various small vessels in the placental bed. This study was performed to assess the ability of color Doppler ultrasonography to evaluate subtrophoblastic blood flow by color identification in the early phase of normal pregnancy from 5 to 9 weeks' gestation. Results show that the characteristic increase in diastolic blood flow is evident as early as 5 weeks' gestation.

Blood velocity waveform analysis by pulsed Doppler ultrasonography in preterm premature rupture of membranes is described. Reduced amounts of amniotic fluid did not impair determination of the resistance indices from the umbilical artery. Good results were obtained from the internal carotid artery in 82% of cases. Failure in measurements at the internal carotid artery occurred when fetal head engagement prevented good study planes. Ninety-three percent of umbilical artery determinations fell within the normal limits for our control population as did 89.2% of those at the internal carotid artery. No differences in the resistance indices could be attributed to the length of the latent period in prematurely ruptured membranes or subclinical chorioamnionitis. Therefore, if a mother or fetus has an underlying condition that affects fetoplacental circulation, the resulting abnormal blood velocity waveform should reflect this condition rather than the effect of ruptured membranes.

Fetal sacrococcygeal teratoma (SCT) is being recognized with increasing frequency. Placentomegaly and hydrops fetalis are preterminal events, and it has been suggested that fetal death may be due to high-output cardiac failure from arteriovenous shunting through the tumor. We had a chance to examine this hypothesis when a 21-week fetus presented with a huge sacrococcygeal teratoma. There were marked placentomegaly, cardiomegaly, hyperdynamic ventricles, and a pericardial effusion. Doppler studies showed tremendous flow through the SCT with extreme enlargement of the inferior vena cava, consistent with congestive heart failure from increased flow through the tumor. Hydrops developed, and the fetus was delivered because of placental abruption. This case provides supportive evidence that the teratoma acts as a large arteriovenous shunt, causing high-output cardiac failure. We have now collected 18 more cases of sacrococcygeal teratoma diagnosed in utero. Of the total 45 cases of fetal SCT, 9 had placentomegaly and/or fetal hydrops and all 9 fetuses died in utero or shortly after birth. We conclude that the only hope for survival in these severely affected fetuses is to reduce blood flow to the tumor before birth.