BACKGROUND:An obstetrician on standby assessed an 18-year-old primiparous captive gorilla with a term singleton fetus with a protracted labor course.CASE:After it was determined that an arrest of descent had occurred, a viable, 2,280 g male neonate was delivered through an operative vaginal birth with forceps assistance without major complications.CONCLUSION:Given the numerous anatomic and biochemical similarities of humans and other great apes, it is possible that the high maternal mortality and stillbirth rates of gorillas could be reduced by using the same principles of obstetric management in a multidisciplinary fashion.

Massive fetomaternal hemorrhage (FMH) can cause devastating pregnancy outcomes. Perinatal prognosis may be improved by intrauterine transfusion, but the appropriate management for these pregnancies remains unclear. To determine the recurrence risk of FMH after intrauterine transfusion, we performed a systematic review of all case reports/ series of patients with proven FMH treated with intrauterine transfusion and who had subsequent follow-up of at least 72 h until delivery. This revealed 13 cases, with 1 additional case from our institution. Ten patients (71.4%) had a second episode of FMH requiring a second intrauterine transfusion. Five patients (35.7%) required at least 3 intrauterine transfusions. The time interval between intrauterine transfusions was progressively reduced. The gestational age at the onset of signs/symptoms was 26.6 +/- 2.1 weeks, and gestational age at delivery was 34.2 +/- 4.2 weeks. Two cases of fetal demise (14.3%) and no neonatal deaths were recorded. Limited postnatal follow-up on 8 neonates was normal. The mean neonatal hemoglobin and transfusion rates were 13.2 +/- 5.7 g/dL and 33.3%, respectively. Close fetal monitoring, likely daily, is necessary to recognize FMH recurrence. Several transfusions may be necessary once FMH is diagnosed if pregnancy is allowed to continue >72 h. (c) 2018 S. Karger AG, Basel

Objective: To determine the frequency and distribution of chromosome abnormalities in women with early pregnancy failure (EPF) detected by cytogenetic testing on chorionic villus sampling. Method: Retrospective observational cohort study of chromosomal analysis from transvaginal chorionic villus sampling (CVS) or reflex products of conception (POC) karyotype. CVS was offered as a training tool for Maternal Fetal Medicine fellows prior to manual vacuum aspiration for EPF 9-week gestation. POC were analyzed for cytogenetics if no results were obtained on CVS. Results: One hundred thirty samples were collected from December 2011 to April 2015. 33 (27.3%) cases had a normal karyotype and 88 (73.0%) cases had an abnormal karyotype. The most common group of abnormalities were trisomy, (n = 50, 41.3%), triploidy/tetraploidy, (n = 17, 14.0%), monosomy (n = 15, 12.4%), and structural rearrangements (n = 6, 5.0%). Nine (6.9%) samples were maternal decidua only. Abnormal karyotype in EPF was significantly increased in women by age group (p < .01) but not in women with a history of prior miscarriage (p = .5). Conclusion: Our cohort had a high detection rate of aneuploidy. The most common chromosomal abnormalities in EPF were: trisomy, followed by triploidy/tetraploidy, monosomy, and structural rearrangements. Maternal age had the strongest correlation with EPF associated with aneuploidy.

Massive fetomaternal hemorrhage (FMH) can cause devastating pregnancy outcomes. Perinatal prognosis may be improved by intrauterine transfusion, but the appropriate management for these pregnancies remains unclear. To determine the recurrence risk of FMH after intrauterine transfusion, we performed a systematic review of all case reports/series of patients with proven FMH treated with intrauterine transfusion and who had subsequent follow-up of at least 72 h until delivery. This revealed 13 cases, with 1 additional case from our institution. Ten patients (71.4%) had a second episode of FMH requiring a second intrauterine transfusion. Five patients (35.7%) required at least 3 intrauterine transfusions. The time interval between intrauterine transfusions was progressively reduced. The gestational age at the onset of signs/symptoms was 26.6 ± 2.1 weeks, and gestational age at delivery was 34.2 ± 4.2 weeks. Two cases of fetal demise (14.3%) and no neonatal deaths were recorded. Limited postnatal follow-up on 8 neonates was normal. The mean neonatal hemoglobin and transfusion rates were 13.2 ± 5.7 g/dL and 33.3%, respectively. Close fetal monitoring, likely daily, is necessary to recognize FMH recurrence. Several transfusions may be necessary once FMH is diagnosed if pregnancy is allowed to continue > 72 h.

To assess the correlation between fetal liver length and reticulocyte count in women undergoing percutaneous umbilical cord blood sampling (PUBS) for alloimmunization. This was a single-center retrospective study. All consecutive singleton gestations with complete data referred to the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University (Philadelphia, PA) from January 2001 to December 2013 for suspected fetal anemia due to maternal alloimmunization (Rh-isoimmunization) were included in the study. Women with suspected fetal anemia were managed with detailed scan, including MCA Doppler and liver length. Only women who underwent PUBS were analyzed. The primary outcome was the correlation between the reticulocyte count at the first PUBS and the liver length at the time of the first PUBS quantified as z-score for gestational age. All fetuses were measured for fetal liver length from the right hemidiaphragm to caudal tip of the right liver lobe on coronal image of the fetal abdomen, using high-resolution real-time ultrasound with a 2- to 4-MHz convex transducer (Voluson E8 or E10). Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) to assess Pearson linear regression and multiple regression analysis. 16 fetuses with red blood cell alloimmunization were analyzed. A positive correlation was found between fetal liver length and reticulocyte count (r = 0.70; p-value = 0.01; Figure 1), and liver length and fetal hemoglobin level (r = 0.67; p-value = 0.03). Liver length measurement may be a useful indicator of the degree of and physiologic response to fetal anemia in isoimmunized pregnancies. This may be useful in timing the need for invasive diagnosis and therapy. Further studies of subsequent PUBS and non-Rh fetal anemia may better elucidate this process.

Objectives: The aim of the paper was to assess nasal and oral amniotic fluid flows, with the use of color ultrasound and spectral Doppler, in normal fetuses. Material and methods: Forty-six fetuses of singleton gestations were studied prospectively. Spectrum imaging and maximal nasal fluid flow velocities were described. Episodes of regurgitation (external flow from the mouth), swallowing (internal flow at the level of oropharynx and then entrance to the esophagus) were evaluated in two groups: Fetuses < 27 weeks of gestation and 27 weeks of gestation and older. Statistical analysis was done using Fischer exact test and t-test at p = 0.05. Results: Twenty-one fetuses were < 27 weeks of gestational age and presented mean maximal both inspiratory and expiratory nasal fluid flow velocities significantly lower than twenty-five fetuses who were >= 27 weeks of gestational age (p = 0.035 and p= 0.031 respectively, t-test). Episodes of regurgitation were observed more frequently in group of"younger" fetuses (p = 0.006, Fischer exact test).There was no statistically significant relationship between irregular nasal flow spectrum by color Doppler and gestational age group (p = 0.264, Fischer exact test). Conclusions: Episodes of regurgitation occurred in normal fetuses < 27th week of gestation. Fast amniotic nasal fluid flows without episodes of regurgitation were observed more frequently in fetuses >= 27 weeks and it could be interpreted as an additional sonographic feature of prenatal maturation.

Objective: To evaluate whether the left myocardial performance index (MPI) changes in association with the fetal heart rate (FHR) tracing during labor. Study design: Women with term, singleton pregnancies, in labor were recruited to this prospective cohort study. Primary outcome: difference in left MPI between Category of fetal heart rate tracings. Secondary outcomes: differences in left MPI by FHR characteristics. Participants underwent ultrasound examination, during which fetal MPI was measured. Results: Twenty-four laboring patients were recruited. There were 13 patients with Category I FHR, 11 patients with Category II FHR, and 0 patients with Category III FHR. Demographics were similar between the groups. MPI was not significantly different between fetuses with Category I or Category II FHR (0.67 versus 0.65, p = .385). MPI was significantly higher in fetuses with accelerations versus those without (0.71 versus 0.59, p = .045). MPI was not significantly different for fetuses with or without decelerations (0.65 versus 0.68, p = .350), between deceleration type (0.50 versus 0.64 versus, 0.75, p = .421), or between variability type (0.56 versus 0.68, p = .113). Conclusions: MPI of fetuses in term, laboring patients did not vary with differing FHR characteristics except for the presence or absence of accelerations.

To evaluate the NIPT utilization in clinical setting as documented by the providers and NOT by the commercial laboratories. This is a retrospective study of data review. The NIPT Registry was established to collect and record the data on all patients that are referred for the NIPT testing. Prenatal units & centers located near Philadelphia area were invited to participate in this study. Each participating center has obtained the IRB approval. 1584 patients had NIPT and 380 cases were excluded due to no confirmatory testing or unknown baby outcomes. 1204 cases were eligible for the primary analysis. Ethnic background: Caucasian 52.7 %, African American 15.4 %, Asian: 3.2 %, Hispanic 24.3%, Others 4.4 %. Private health insurance 40.1%, Medicaid 57.1%, other payment options: 2.8%. Indications for the NIPT testing: AMA 49.6 %, abnormal ultrasound findings 25.8 %, abnormal serum test results 13.6 %, positive history: 5.6%, other indications: 0.2%, no indications: 0.2%, multiple indications: 13.8 %. 1155 cases were tested as NIPT negative. Among them, 987 babies were delivered normal (85.5%), 4 had major chromosomal abnormalities (0.3%), 159 cases had other birth defect (14.2%). 27 cases were tested as NIPT positive. Among them, 8 babies were delivered normal (29.6%), 11 had major chromosomal abnormalities (40.7%), 8 cases had other birth defect (29.6%). 22 cases had inconclusive NIPT results. Among them, 15 babies were delivered normal (68.2%), 7 cases had other birth defect (31.8%). The sensitivity, specificity, PPV and NPV of NIPT to detect major chromosomal abnormalities were 73.3%, 98.7%, 40.7%, and 99.7% respectively. The sensitivity, specificity, PPV and NPV of NIPT to detect all birth defect were 9.8%, 99.2%, 70.3%, and 85.1% respectively. Our data showed that despite of the accuracy of NIPT in detecting major chromosomal abnormalities, there were quite a few birth defect cases that were not screened by this test alone. Other prenatal screening options should be considered in addition to NIPT for prenatal care.

To examine population-based recurrence risk of fetal aneuploidy in invasive prenatal procedures performed for a history of fetal aneuploidy compared to those performed for advanced maternal age (AMA). This is a retrospective cohort of all pregnancies that have undergone invasive prenatal diagnostic testing, including chorionic villus sampling (CVS) or amniocentesis, between June 2002 and June 2014 in the Mainline Health System Hospitals in Pennsylvania. Incidence of fetal aneuploidy in women with prior fetal aneuploidy was compared to incidence of fetal aneuploidy in AMA women without any other indication for invasive testing. Method of invasive testing was also compared. Chi square test and t-test were used for statistical analysis. There were 6080 invasive procedures during the study period. 3896 amniocentesis and 2194 CVS were performed. 115 patients had an invasive procedure for a previous fetal aneuploidy. The mean maternal age was 37 years for this group compared to 39 years for the AMA group (p<0.01). The invasive procedure was done at a significantly earlier gestational age and CVS was more commonly used (p<0.01). The incidence of recurrent aneuploidy was 1.7%, not significantly different than in women having invasive procedures for the sole indication of AMA (2%) (p=0.52) (Table). The incidence of aneuploidy is similar in women that had a prior fetal aneuploidy compared to women with AMA only. Women with prior fetal aneuploidy were more likely to have a CVS performed. This information may be helpful to inform early pregnancy care and counseling.

INTRODUCTION: To determine if children with a known diagnosis of Klinefelter Syndrome (KS) had a fetal anatomy ultrasound demonstrating long femur length (FL). METHODS: Case series of males with Klinefelter Syndrome (KS) receiving medical care in the pediatric endocrinology division at Thomas Jefferson University Hospital (TJUH) in 2014. We invited the mothers of these male children to participate in our study. Women who agreed to participate signed a medical records release form, which was sent to the delivering obstetrician requesting prenatal and delivery records. Records were reviewed for demographics, biometric measurements from the 18-22 week anatomy ultrasound, and delivery outcomes. Primary outcome was FL (calculated percentile based on Hadlock) from the anatomy ultrasound. RESULTS: In 2014, there were 100 males with KS being cared for at TJUH. 52 women agreed to participate in the study. We received medical records on 40 of these women (77%); of these, 30 records had the anatomy ultrasound report and delivery information. Mean gestational age at the time of the anatomy ultrasound 19.71 weeks (SD ± 1.29 weeks). 41% of women had an amniocentesis and a known prenatal diagnosis of KS. Femur length percentile was computed based on gestational age at the time of the ultrasound; mean FL percentile was 51.6% (SD ± 14.7%, range 8.7%-77.6%). CONCLUSION: The phenotype of males with Klinefelter Syndrome commonly results in tall stature, with a disproportionately long femur from early childhood. However, fetal femur length does not appear to predict an increased risk for Klinefelter Syndrome at the time of anatomy ultrasound.

AbstractInternational Prenatal Cardiology Collaboration Group (IPCCG) links specialists from prenatal cardiology all over the world. In this recommendation we would like to focus on the fetal/prenatal echocardiography official report. So far many recommendations focused mainly on technical aspects of the fetal heart examination.

1 Department of Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Łodź, Poland 2 Department for Prenatal and Gynecological Sonography, Division of Prenatal Medicine, University of Giessen and Marburg, Germany 3 Department of Perinatal Medicine University of Montevideo, Uruguay 4 Department of Obstetrics, Federal University of Sao Paulo, Brazil 5 Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel 6 Department of Obstetrics and Gynecology, Izmir Katip Celebi University, Izmir, Turkey 7 Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI; Detroit Medical Center, Hutzel Women’s Hospital, Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA 8 Division of Pediatric Cardiology, Fetal Cardiology Program, Children’s Hospital Los Angeles, USA 9 Department of Obstetrics and Gynecology, University of Rome Tor Vergata, Roma, Italy 10 Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Rochester School of Medicine and Dentistry, Rochester, USA 11 Department of Pediatric Cardiology, UCLA Medical Center, Santa Monica Mattel Children’s Hospital UCLA, Santa Monica, USA 12 Fetal Medicine Department Obstetrics, Gynecology University Hospitals Leuven, Belgium 13 Division of Reproductive Imaging and Genetics, Jefferson University Hospitals, Philadelphia, USA 14 Department of Obstetrics and Gynecology, Weill Cornell Medical Center, New York, USA 15 Centro Hospitalar Lisboa Central, Maternidade Dr Alfredo da Costa, Lisboa, Portugal 16 Fetal Cardiology Unit, Ukrainian Children’s Cardiac Center, Kyiv, Ukraine 17 Obstetrics and Gynecology Department, Polish Mother Memorial Hospital Research Institute, Łodź, Poland Correspondence: Maciej Slodki, Department of Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, ul. Rzgowska 281/289; 93-338 Łodź, Poland; tel.: +48 42 271 15 56, e-mail: maciejslodki@op.pl

Abstract Progress in the fields of fetal cardiology and fetal surgery have been seen not only in singleton pregnancies but also in multiple pregnancies. Proper interpretation of prenatal echocardiography is critical to clinical decision making, family counseling and perinatal management for obstetricians, maternal fetal medicine specialists, neonatologists and pediatric cardiologists. Fetal echocardiography is one of the most challenging and time-consuming prenatal examinations to perform, especially in multiple gestations. Performing just the basic fetal exam in twin gestations may take an hour or more. Thus, it is not practical to perform this exam in all cases of multiple gestations. Therefore our review and recommendations are related to fetal echocardiography in twin gestation.

Abstract BACKGROUND: The Myocardial Performance Index (MPI) is a Doppler derived myocardial function tool and can be used to evaluate systolic and diastolic function in fetuses. The objectives of this study were to investigate the MPI during labor and compare it to values in non-laboring women. METHODOLOGY: 40 women with uncomplicated, term, singleton pregnancies were recruited to this prospective observational study at Thomas Jefferson University Hospital. Controls were a retrospective cohort of women > 34 weeks who underwent third trimester fetal echocardiography. Fetal left and right sided isovolumic contraction time, isovolumic relaxation time and ejection time were recorded before, during and after contractions. Right and left sided MPI was then calculated. RESULTS: Laboring patients and non-laboring patients were comparable for age, race, gravidity and parity. During labor the average left MPI was 0.63 ± 0.17 and the average right MPI was 0.62 ± 0.20. The coefficient of correlation between MPI and cervical dilation was 0.15 for left MPI Index and 0.14 for right MPI. When comparing non-laboring to laboring women, the average left MPI for non-laboring women was 0.34 ± 0.04, p = <0.001. CONCLUSIONS: Myocardial Performance Index is a non-invasive, easily attainable measure of cardiac function that can be obtained during labor and does not change with cervical dilation. MPI is significantly different between laboring and non-laboring women. The fetal MPI may help define fetal status in labor.

Congenital heart defects are among the most common congenital defects and contribute substantially to the mortality of newborns and young infants, in spite of well-developed medical and surgical treatments.

INTRODUCTION: Current ACOG technical bulletin #144, 2014 states “Women with monoamniotic twin gestations should undergo cesarean delivery to avoid an umbilical cord complication of the nonpresenting twin at the time of the initial twin's delivery.” To assess feasibility of vaginal delivery, we compared neonatal outcomes after attempted VD versus planned cesarean delivery (CD). METHODS: This retrospective cohort study from 2 tertiary-care centers, reviewed all viable MoMo twin pregnancies beyond 24 weeks gestation, delivered over last 15 years. Independent T test and Fisher exact test were used for statistical analysis. RESULTS: Of 29 women with MoMo twins, 15 underwent planned CD and 14 attempted VD. Of the 14 women who attempted VD: 6 underwent IOL; 10 successfully delivered both neonates vaginally with median interval of 3 minutes between the twins; 3 underwent CD for non-reassuring fetal tracing; 1 required CD for the 2nd twin. Despite similar GA at delivery (32.7 vs 33.3 weeks; P=.5) and fetal loss rate (2/15 vs 1/14; P=NS), incidence of intracranial hemorrhage was significantly lower in the vaginally delivered neonates (0 vs 8; P=.006); lower trends were also noted in neonatal length of stay (18 vs 25, P=.09) and respiratory complications. Entangled cords were noted in 28/29 pregnancies at birth. Women with prior CD more often chose repeat CD. Composite maternal outcomes were similar in the 2 groups. CONCLUSION/IMPLICATIONS: VD appears to be safe in appropriately identified MoMo twins. Current practice and recommendations are based on theoretical risks. This study, though small, provides valuable data on option of vaginal delivery for MoMo twins.

To evaluate whether the left myocardial performance index (MPI) changes in association with characteristics of fetal heart tracings (FHT). Women with term, singleton pregnancies in labor were recruited to this prospective cohort study at a single academic medical center. Exclusion criteria were cardiac abnormalities, multiple gestations, intrauterine growth restriction, and non-cephalic presentation. The primary outcome was the difference in left MPI between category I and category II FHT. Secondary outcomes were the differences in left MPI between fetal heart rate characteristics including presence or absence of accelerations, presence or absence of decelerations, deceleration type and class of variability. All participants underwent an ultrasound examination, during which fetal left sided isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), and ejection time (ET) were recorded during labor. MPI was calculated from the formula MPI = (ICT+IRT)/ET. X2, student t-test and analysis of variance tests were used. A p value of 0.05 was considered statistically significant. 24 laboring patients were recruited from March 2014 through May 2015. There were 13 patients with category I and 11 patients with category II FHT. Demographics were similar between groups (Table). MPI was not significantly different between fetuses with category I or category II FHT (0.67 vs 0.65, p = 0.385). MPI was significantly higher in fetuses with accelerations on their FHT versus those without (0.71 vs 0.59, p = 0.045). The MPI was not significantly different for fetuses with or without any type of deceleration (0.65 vs 0.68, p = 0.350), between deceleration type (0.50 vs 0.64 vs 0.75, p = 0.421), or between different classes of variability (0.56 vs 0.68, p = 0.113) (Figure). MPI of fetuses in term, laboring patients did not vary with differing FHT characteristics except for the presence and absence of accelerations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: To examine trends in the incidence and method of invasive prenatal diagnosis due to the impact of sequential screening and noninvasive prenatal testing. Methods: This is a retrospective review of all pregnancies that have undergone invasive prenatal diagnostic testing between June 2002 and June 2014, divided in 3 periods: period 1 from June 2002 to October 2006, period 2 from November 2006 to December 2011, and period 3 from January 2012 to June 2014. The main outcome measures were trends in the incidence and method of each procedure. Results: There were 88,135 deliveries and 6,080 invasive procedures during the study period. In period 1, 2,755 (8.8%) procedures were carried out, in period 2 2,820 (7.3%), and in period 3 505 (2.5%; p < 0.01). In period 1, there were 1,990 (6.3%) cases of amniocentesis, 1,646 (4.3%) in period 2, and 254 (1.2%) in period 3 (p < 0.01). In addition, in 765 (2.5%) cases, chorionic villus sampling (CVS) was performed in period 1, compared to 1,174 (3.0%) cases in period 2 and 251 (1.3%) cases in period 3 (p < 0.01). Advanced maternal age as the sole indication for invasive procedures decreased significantly over time, while the indication of abnormal serum screening and abnormal ultrasound findings increased (p < 0.01). Conclusion: There was a significant decline in the incidence of invasive prenatal testing over the 12 years of the study. The decrease in amniocentesis was more marked than that in CVS.

Congenital heart defects are among the most common congenital defects and contribute substantially to the mortality of newborns and young infants, in spite of well-developed medical and surgical treatments. It is estimated that the mortality of children with congenital heart defects in developing countries is as high as 20%, whereas the incidence of congenital heart defects is approximately 1/100 live births(1). Currently, there is an emphasis on early fetal screening for chromosomal abnormalities and neural tube defects, despite the fact that congenital heart defects are four times more frequent than chromosomal abnormalities and six times more frequent than neural tube defects(2). It should be noted that basic in-utero screening for heart defects is possible as early as the first trimester, which in some cases prompts further work-up and treatment(3). Throughout the world, second trimester screening remains the mainstay of prenatal diagnosis of cardiac anomalies. However, a comprehensive work-up for fetal heart defects can be associated with substantial psychological burden on the mother and her family. Moreover, the prevalence of misdiagnosis can be as high as 36%, thus prompting the need for further training and multidisciplinary team work(4). Furthermore, 33% of heart defects are accompanied by other anomalies(5). In 2006, the Polish Ministry of Health established a Register of Fetal Heart Defects (RFHD). The aim of this initiative was to enable cooperative gathering of data on fetal heart diseases, such as heart defects, significant cardiac arrhythmias, heart failure, heart ectopy and other significant heart conditions. RFHD is an internet database where the user can attach images, movies and other information to a given patient's file. Proofreading is performed by pediatric cardiologists from level C institutions – those that register at least 100 cases of heart defects annually. The data gathered so far have shown that heart defects are the weakest link in prenatal diagnosis. However, as physicians performing prenatal screening gain more experience, the number of diagnosed cases of congenital heart disease has grown steadily, both in Poland and worldwide(6). Analysis of data from Polish institutions confirms the need for multi-center and multidisciplinary collaboration in order to further develop screening for fetal heart defects, as well as to set goals for development of cardiac surgery of newborns. This type of collaboration contributes to both coordinated patient care and complex medical treatment, and is a scientific trend for the 21st century, helping to solve complicated scientific problems(7). Fortunately, the availability of current information and communication technologies allows partnership between different scientific centers around the world to be feasible(8). Therefore, we have established the International Prenatal Cardiology Collaboration Group (www.prenatalcardiology.org) with the aim of bringing together physicians of various specialties who are involved directly in the treatment of pregnant women and their fetuses, for further development of prenatal diagnosis. The IPCCG was established to join current worldwide efforts to improve the standard of care, management and outcomes for fetuses and neonates affected by congenital heart disease. The aim of our group is to establish research studies on a more expansive assembly of patients from different parts of the world. We plan to share our experience and create study protocols. Research to be conducted includes both retrospective and prospective studies, as well as metaanalyses. Through the IPCCG it may also be possible to gather a substantial amount of information on severe and very rare fetal heart defects, such as atrial aneurysms, ventricular aneurysms or coronary fistulas. This can enrich knowledge about these diseases, which can consequently improve patient outcome and contribute to the ever developing field of prenatal cardiology. Collaboration across centers and disciplines is also needed for other reasons. As published recently(9), treatment costs for rare heart conditions have been growing. Furthermore, it has been stressed that multidisciplinary cooperation can help decide which patents should be treated(9, 10). So far, there have been several established multi-center prenatal cardiology programs in Canada and the USA(11). Our aim was to create a similar program of collaboration among not only leading centers worldwide, but also with hospitals that want to further develop the fields of prenatal cardiology and prenatal diagnosis. The perspectives of each specialty are important in creating future standards of practice. We invite all physicians and non-physicians who are involved in prenatal care to collaborate with the IPCCG.