Artificial intelligence in obstetric ultrasound: A scoping review

The objective is to summarize the current use of artificial intelligence (AI) in obstetric ultrasound. PubMed, Cochrane Library, and ClinicalTrials.gov databases were searched using the following keywords “neural networks”, OR “artificial intelligence”, OR “machine learning”, OR “deep learning”, AND “obstetrics”, OR “obstetrical”, OR “fetus”, OR “foetus”, OR “fetal”, OR “foetal”, OR “pregnancy”, or “pregnant”, AND “ultrasound” from inception through May 2022. The search was limited to the English language. Studies were eligible for inclusion if they described the use of AI in obstetric ultrasound. Obstetric ultrasound was defined as the process of obtaining ultrasound images of a fetus, amniotic fluid, or placenta. AI was defined as the use of neural networks, machine learning, or deep learning methods. The authors’ search identified a total of 127 papers that fulfilled our inclusion criteria. The current uses of AI in obstetric ultrasound include first trimester pregnancy ultrasound, assessment of placenta, fetal biometry, fetal echocardiography, fetal neurosonography, assessment of fetal anatomy, and other uses including assessment of fetal lung maturity and screening for risk of adverse pregnancy outcomes. AI holds the potential to improve the ultrasound efficiency, pregnancy outcomes in low resource settings, detection of congenital malformations and prediction of adverse pregnancy outcomes.     

Routine fetal cardiac screening: what are we doing and what should we do?

In many countries, ultrasound examination is used in the second trimester to look for congenital malformations as part of routine prenatal care. While tertiary centres scanning high-risk pregnancies have reported a high degree of accuracy in the detection of congenital heart disease, many studies have shown that cardiac abnormalities are commonly overlooked during routine obstetric evaluation and there still remains a huge variation between centres. The majority of babies with congenital heart disease are born to mothers with no identifiable high-risk factors and so will not be detected unless there is widespread screening of the low-risk population. It is feasible to achieve widespread screening for fetal congenital heart disease in low-risk groups, but this does need commitment and effort from those performing the scans and those teaching them how to examine the heart. Staff performing routine obstetric ultrasound scans should learn a simple technique for examining the fetal heart and to use this in all patients. Links to a tertiary centre can provide support for checking scans of concern as well as for providing training and for obtaining feedback. In addition, an audit system needs to be established in each centre to trace false-positive and false-negative cases as well as to confirm true positives and true negatives. Copyright © 2004 John Wiley & Sons, Ltd.     

Open fetal surgery for myelomeningocele

Despite efforts at prevention through the use of preconception folic acid, spina bifida remains one of the most common congenital anomalies of the central nervous system that is compatible with life. It is, however, associated with a significant degree of lifelong morbidity. The development of open fetal surgery for myelomeningocele (MMC) has been a long process but one that serves as a model for how new procedures and technologies need to be properly evaluated before being brought into mainstream medical practice. Even so, risks and benefits need to be evaluated for each patient. The currently available studies have been carried out on a highly selected patient population where the fetal findings provided the maximum opportunity for benefit from prenatal closure of the MMC defect. There is the potential that as the surgery becomes more widely available, pressure will be brought to bear to perform surgery in cases where the likelihood for benefit is decreased and yet the risks are not. The only way to duplicate the results of the current studies is to follow the methodology and criteria that were used in the studies. This will mean that not every fetus with an MMC will be a candidate for in utero surgery. The balance of risk to benefit will continue to evolve as further technological advances are evaluated and more follow-up information is obtained. Copyright © 2011 John Wiley & Sons, Ltd.     

cfDNA screening and diagnosis of monogenic disorders – where are we heading?

Cell-free fetal DNA analysis for non-invasive prenatal screening of fetal chromosomal aneuploidy has been widely adopted for clinical use. Fetal monogenic diseases have also been shown to be amenable to non-invasive detection by maternal plasma DNA analysis. A number of recent technological developments in this area has increased the level of clinical interest, particularly as one approach does not require customized reagents per mutation. The mutational status of the fetus can be assessed by determining which parental haplotype that fetus has inherited based on the detection of haplotype-associated SNP alleles in maternal plasma. Such relative haplotype dosage analysis requires the input of the parental haplotype information for interpretation of the fetal inheritance pattern from the maternal plasma DNA data. The parental haplotype information can be obtained by direct means, reducing the need to infer haplotypes using DNA from other family members. The technique also allows the assessment of complex mutations and has multiplexing capabilities where a number of genes and mutations can be assessed at the same time. These advantages allow non-invasive prenatal diagnosis of fetal monogenic diseases to be much more scalable. These applications may drive the next wave of clinical adoption of cell-free fetal DNA testing. © 2018 The Authors Prenatal Diagnosis Published by John Wiley & Sons Ltd     

The influence of prenatal diagnosis on postnatal outcome in patients with structural congenital heart disease

Examination of the fetal heart has become an established part of mid-trimester anomaly scanning. Along side this has emerged the ability to diagnose congenital heart disease in the fetus with accuracy. Despite this, the development of screening programmes to look for fetal cardiac disease has only been partially successful. Furthermore, when detected, there seems to be little survival advantage associated with prenatal diagnosis. Demonstrating such an advantage is complicated by the nature of fetal cardiac disease, which tends to be severe and is often associated with extra-cardiac abnormalities. More selective studies, mostly involving small numbers of cases, are now beginning to demonstrate both improved survival and reduced morbidity in prenatally diagnosed infants presenting to cardiac intensive care units compared to those with a postnatal diagnosis. Copyright © 2004 John Wiley & Sons, Ltd.     

Environmental impact assessment taxonomy providing comprehensive coverage of midpoints,endpoints, damages,and areas of protection

Before conducting a comprehensive impact assessment, such as a life cycle impact assessment (LCIA), there is a need to discuss the range of impacts which could and should be included. Up to this point of time, there has not been a comprehensive list of impacts for potential inclusion available. This research builds upon previous work which surveyed a large component of the comprehensive impact assessment field for cataloging and analysis in greater detail and then expanded it to include those midpoints, endpoints, and damages which could be covered in a more comprehensive impact assessment. In this paper, a seminal effort in the form of a meta-model is presented to facilitate an expanded discussion of the taxonomy of this field. Upon using existing models it was apparent the taxonomy needed to be structured to represent midpoint, endpoint, damage, and weighted levels as they relate to areas of protection for the impact assessment phase. Contrary to recent use in the LCIA field, a distinction will be made between an endpoint measure (which is more of a “count” of impacts) and a damage measure (which is a value-weighted aggregation of two or more endpoints). The authors present a representation of all four levels of impact assessment: midpoint, endpoint, damage, and weighted. This taxonomy was developed to include the existing impacts found in LCIA literature, and then expanded to be more comprehensive and include a larger set of impacts than are normally included within LCIA. The authors recognize this is the first of many steps necessary to capture all potential impacts that should be considered when conducting a comprehensive environmental assessment. The intent is to propose a taxonomy that would greatly facilitate the accumulation and communication of empirical and theoretical knowledge gained by offering a standard vocabulary and structure.     

The environmental cost of pesticide usage in the United Kingdom

Organic pesticides have been used for more than 50 years, and have made a major contribution to the profound alteration of agricultural practice which has occurred during this period. Among the many effects arising from these developments in agriculture, various environmental changes have been identified, which have been the subject of considerable public debate and disagreement. Attention has focussed particularly on the popularly assumed adverse influence of pesticides on the natural flora and fauna. This review examines the position in the United Kingdom where interest in wildlife has always been extensive and where many amateur observations and professional scientific studies have been brought to bear on the problem. It differentiates between ‘direct’ effects which may be attributed to particular uses of certain compounds and ‘indirect’ effects normally arising from changes in habitat or food supply brought about by pesticides. The approach adopted has been to assess the effects of pesticide use on populations rather than attempting to place a financial estimate on any adverse environmental effect attributed to pesticides. Systems of surveillance are described and their ability to detect adverse effects is assessed. The difficulty of correlating such effects with pesticide use is examined. In general, it is concluded that other than for insects the levels of surveillance have been adequate to detect adverse effects on fauna and flora arising from pesticide use. Where direct effects have been discerned in the past, action has, where possible, been taken to rectify the position and it is suggested that this will continue. Overall there is little evidence that the survival of individual species is threatened by the direct effects of pesticides. Indirect effects are neither simple to delineate nor readily corrected and it is recommended that more research be carried out to develop the ability to assess their influence.     

Diagnosis of cardiac defects: where we've been,where we are and where we're going

There has been tremendous development in the field of prenatal diagnosis of cardiac disease in the last 30 years. Early work centered on the technical aspects of providing an accurate assessment of cardiac structure and function. Techniques of fetal cardiac screening have been developed and utilized throughout the world. More recently, investigators have begun to explore the ramifications of fetal cardiac diagnosis by assessing measures of outcome. In this article, the field of fetal echocardiography, as a screening tool for identifying congenital heart disease, and its impact on disease outcome is reviewed. Copyright © 2002 John Wiley & Sons, Ltd.     

1961—2014年中国干燥度指数的时空变化研究

论文采用中国1961—2014年530个气象站数据,运用FAO-56 Penman-Monteith公式计算潜在蒸散发量,并结合降水量计算中国1961—2014年干燥度指数（Aridity index,AI）,然后采用Mann-Kendall趋势检验、突变检验和小波分析对其进行时空变化分析。结果表明：1）1961—2014年中国整体、西北地区、青藏地区的干燥度指数均呈显著减小趋势,而南方地区干燥度指数呈微弱减小趋势,北方地区干燥度指数呈不显著增加趋势。中国干燥度指数的突变发生于1986年,而各个分区的突变时间有所差异。2）1961—2014年中国整体、北方地区和西北地区干燥度指数变化主周期均为28 a,南方地区稍晚1 a,青藏地区提前2 a,所有地区均在主周期上经历了变大—变小—变大的过程。同时所有地区也存在不同时间尺度的次周期变化。3）整个中国、西北地区和南方地区潜在蒸散发量的减少和降水量的增加,共同引起了干燥度指数的减小。在北方地区,年降水量的显著减小和潜在蒸散发减小引起干燥度指数呈现微弱增加趋势。在青藏地区,潜在蒸散发的微弱增加和降水量显著增加引起干燥度指数呈现显著减小趋势。4）中国干燥度指数在空间格局上和降水的分布相反,呈现出西北大、东南小的特征。北方地区整体干燥度指数偏小,但中部区域降水相对减少,蒸发能力增强,导致干燥度指数相对偏大。南方地区气温较高,蒸发能力强,但雨量充沛,是我国干燥度指数最小的区域。西北地区较为干燥,降水少,蒸发强,是我国干燥度指数最大的区域。青藏地区由于青藏高原的阻挡作用以及东部地区较为丰富的降水量,使得干燥度指数由东向西逐渐增加,呈现西干东湿的格局。     

Exome sequencing for gene discovery in lethal fetal disorders – harnessing the value of extreme phenotypes

Massively parallel sequencing has revolutionized our understanding of Mendelian disorders, and many novel genes have been discovered to cause disease phenotypes when mutant. At the same time, next-generation sequencing approaches have enabled non-invasive prenatal testing of free fetal DNA in maternal blood. However, little attention has been paid to using whole exome and genome sequencing strategies for gene identification in fetal disorders that are lethal in utero, because they can appear to be sporadic and Mendelian inheritance may be missed. We present challenges and advantages of applying next-generation sequencing approaches to gene discovery in fetal malformation phenotypes and review recent successful discovery approaches. We discuss the implication and significance of recessive inheritance and cross-species phenotyping in fetal lethal conditions. Whole exome sequencing can be used in individual families with undiagnosed lethal congenital anomaly syndromes to discover causal mutations, provided that prior to data analysis, the fetal phenotype can be correlated to a particular developmental pathway in embryogenesis. Cross-species phenotyping allows providing further evidence for causality of discovered variants in genes involved in those extremely rare phenotypes and will increase our knowledge about normal and abnormal human developmental processes. Ultimately, families will benefit from the option of early prenatal diagnosis. © 2014 John Wiley & Sons, Ltd.     

Fetal exsanguination following intrauterine angiographic assessment and selective termination of a hydrocephalic,monozygotic co-twin

Selective termination by intracardiac potassium chloride injection was performed in twins discordant for hydrocephaly at 20 weeks' gestation. Because of the potential for vascular anastomoses to exist between the twins, fetal angiography was performed prior to the selective termination procedure. Determination of vascular connections between the fetuses was hindered by fetal bradycardia following intracardiac administration of contrast material. Selective termination was performed without difficulty using intracardiac potassium chloride (KCl) to produce asystole in the twin with hydrocephaly. The unaffected fetus appeared active and had a normal heart rate during and immediately after the procedure. However, both twins were found to have died the following day. Pathologic examination documented several vascular anastomoses between the monochorionic, diamniotic fetuses. A likely cause of death was exsanguination of the normal twin into the abnormal one. This case illustrates the difficulties encountered in selective termination of monozygotic twins and, to our knowledge, represents the first reported use of intrauterine fetal angiography.     

Factors affecting the clinical use of non-invasive prenatal testing: a mixed methods systematic review

Non-invasive prenatal testing has been in clinical use for a decade; however, there is evidence that this technology will be more widely applied within the next few years. Guidance is therefore required to ensure that the procedure is offered in a way that is evidence based and ethically and clinically acceptable. We conducted a systematic review of the current relevant literature to ascertain the factors that should be considered when offering non-invasive prenatal testing in a clinical setting. We undertook a systematic search of relevant databases, journals and reference lists, and from an initial list of 298 potential papers, identified 11 that were directly relevant to the study. Original data were extracted and presented in a table, and the content of all papers was analysed and presented in narrative form. Four main themes emerged: perceived attributes of the test, regulation and ethical issues, non-invasive prenatal testing in practice and economic considerations. However, there was a basic difference in the approach of actual or potential service users, who were very positive about the benefits of the technology, compared with other research participants, who were concerned with the potential moral and ethical outcomes of using this testing method. Recommendations for the appropriate use of non-invasive prenatal testing are made. © 2013 John Wiley & Sons, Ltd.     

Methods for prenatal assessment of fetal cardiac function

Fetal cardiac function is increasingly recognized as a marker of disease severity and prognosis in selected fetal conditions. Magnetic resonance imaging (MRI) has been used in experimental (animal) fetal cardiology but the lack of a noninvasive fetal electrocardiogram (ECG) to trigger image acquisition remains a major limiting factor precluding its application in humans. Fetal medicine specialists are therefore limited to ultrasound to evaluate human fetal cardiac function. In this review, we aim to provide a complete overview of the different ultrasound techniques that can be used for fetal cardiac function assessment and we discuss their (theoretical) strengths and shortcomings. Conventional methods include M-mode assessment of ventricular contractility and Doppler assessment of the precordial veins and cardiac output (CO). More recent techniques such as the measurement of the myocardial performance index (MPI), myocardial motion analysis with tissue Doppler, speckle tracking and three-dimensional (3D) ultrasound techniques are also discussed. Copyright © 2009 John Wiley & Sons, Ltd.     

The 5 principles of “Design for Safer Nanotechnology”

Nanoparticles have been incorporated in hundreds of different types of products, and the novel properties of nanomaterials offer great promise to provide new technological breakthroughs. However, nanotechnology is an emerging technology which has potential health and safety risks throughout its product life cycle. The health risk of a nanoparticle is a function of both its hazard to human health and its exposure potential. It is prudent for companies to try to mitigate the potential risks of nanoparticles during the design stage rather than downstream during manufacturing or customer use. The intent of this paper is to propose five design principles for product designers to use during the design stage for products that contain nanoparticles. By using these design principles, the health risk of the nanoparticle may be mitigated by potentially lowering the hazard and/or the exposure potential of the nanoparticle. These proposed design principles are largely untested and are offered as an initial framework that will require more testing, validation, and refinement.     

土地利用改造规划的多因子空间分析

以福清市土地利用分布为例 ,在完成土地利用状况和土地适宜性参评因子空间数据库基础上 ,集成土地适宜性综合指数模型和地块紧凑度模型 ,开发了基于地理信息系统的土地适宜性评价和土地利用控制决策支持系统。通过土地适宜性多因子空间分析 ,模拟大农业 (耕地、林地、园地 )各目标用地条件下各地块土地使用适宜度 ,并结合土地利用现状 ,得到单目标土地改造方案 ;再经模型优化和综合比较得出多目标土地利用改造规划可选方案。计算结果表明 ,福清市土地资源中开发改造为新耕地的潜力极有限 ,而用于开发改造新林地和园地的土地尚有226 80km₂ 和36 34km₂ ,为福清市土地利用改造规划和总体规划的制定和调整提供了定量依据。     

Cover Image

Over recent years, technical developments resulting in the feasibility of fetal cardiovascular magnetic resonance (CMR) have provided a new diagnostic tool for studying the human fetal heart and circulation. During the same period, we have witnessed the arrival of several minimally invasive fetal cardiac interventions (FCI) as a possible form of treatment in selected congenital heart diseases (CHDs). The role of fetal CMR in the planning and monitoring of FCI is not yet clear. Indeed, high-quality fetal CMR is not available or routinely offered at most centers caring for patients with prenatally detected CHD. However, in theory, fetal CMR could have much to offer in the setting of FCI by providing complementary anatomic and physiologic information relating to the specific intervention under consideration. Similarly, fetal CMR may be useful as an alternative imaging modality when ultrasound is hampered by technical limitations, for example, in the setting of oligohydramnios and in late gestation. In this review, we summarize current experience of the use of fetal CMR in the diagnosis and monitoring of fetuses with cardiopathies in the setting of a range of invasive in utero cardiac and vascular interventions and medical treatments and speculate about future directions for this versatile imaging medium.     

The legal frameworks that govern fetal surgery in the United Kingdom,European Union,and the United States

The specialty of fetal surgery or fetal intervention is one of the most exciting emerging fields of modern medicine. It is made possible by decades of major developments in antenatal imaging, obstetric anaesthesia, fetal medicine, paediatric surgery, and of course by the bold and novel practitioners willing to take new steps to advance the field. Beginning in the 1970s, it has now reached a stage of maturity where there are several established in utero procedures and countless clinical trials and studies to develop more. But what is the legal situation that fetal surgeons find themselves in? What are the rights and legal protections for the fetus and the mother, both of which are arguably the patient? This article will address this question, discussing and summarising the current legal frameworks governing fetal surgery in the jurisdictions of the United Kingdom, European Court of Human Rights, and the United States of America as well as discuss what the future may hold and how researchers and physicians in the specialty can best navigate the legal environment.     

SARS-CoV-2 in the context of past coronaviruses epidemics: Consideration for prenatal care

Since December 2019, the novel SARS-CoV-2 outbreak has resulted in millions of cases and more than 200 000 deaths worldwide. The clinical course among nonpregnant women has been described, but data about potential risks for women and their fetus remain scarce. The SARS and MERS epidemics were responsible for miscarriages, adverse fetal and neonatal outcomes, and maternal deaths. For COVID-19 infection, only nine cases of maternal death have been reported as of 22 April 2020, and pregnant women seem to develop the same clinical presentation as the general population. However, severe maternal cases, as well as prematurity, fetal distress, and stillbirth among newborns have been reported. The SARS-CoV-2 pandemic greatly impacts prenatal management and surveillance and raise the need for clear unanimous guidelines. In this narrative review, we describe the current knowledge about coronaviruses (SARS, MERS, and SARS-CoV-2) risks and consequences on pregnancies, and we summarize available current candidate therapeutic options for pregnant women. Finally, we compare current guidance proposed by The Royal College of Obstetricians and Gynaecologists, The American College of Obstetricians and Gynecologists, and the World Health Organization to give an overview of prenatal management which should be utilized until future data appear.     

Normal fetal cardiac anatomy–a basis for the echocardiographic detection of abnormalities

Real-time examination of the fetal heart in 350 pregnancies has allowed a composite picture of normal fetal cardiac anatomy to be established and echocardiographic interpretation has been confirmed by anatomical studies. Two echocardiographic sections are readily obtainable and are suggested as applicable to routine scanning but the specialist nature of interpreting abnormalities is stressed. Six abnormalities have been suspected during the study and five confirmed anatomically or at cardiac catheterization. In view of the low incidence of congenital heart disease in a normal obstetric population, high risk groups should perhaps be selected for cardiac scanning at the present time. These include mothers of previously affected babies, diabetic mothers and certain abnormalities of pregnancy. Fetal ascites is particularly important, being present in three of the four proven cases of cardiac abnormality.     

Pregnancy-related pharmacokinetics and antimicrobial prophylaxis during fetal surgery,cefazolin and clindamycin as examples

Antimicrobial prophylaxis during surgery aims to prevent post-operative site infections. For fetal surgery, this includes the fetal and amniotic compartments. Both are deep compartments as drug equilibrium with maternal blood is achieved relatively late. Despite prophylaxis, chorio-amnionitis or endometritis following ex utero intrapartum treatment or fetoscopy occur in 4.13% and 1.45% respectively of the interventions. This review summarizes the observations on two commonly administered antimicrobials (cefazolin, clindamycin) for surgical prophylaxis during pregnancy, with emphasis on the deep compartments. For both compounds, antimicrobial exposure is on target when we consider the maternal and fetal plasma compartment. In contrast, amniotic fluid concentrations-time profiles display a delayed and much more blunted pattern, behaving as deep compartment. For cefazolin, there are data that document further dilution in the setting of polyhydramnios. Along this deep compartment concept, there is some accumulation during repeated administration, modeled for cefazolin and observed for clindamycin. The relative underexposure to antimicrobials in amniotic fluid may be reflected in the pattern of maternal-fetal complications after fetal surgery, and suggest that antimicrobial prophylaxis practices for fetal surgery should be reconsidered. Further studies should be designed by a multidisciplinary team (fetal surgeons, clinical pharmacologists and microbiologists) to facilitate efficient evaluation of antimicrobial prophylaxis.