Ethics is an essential component of obstetric ultrasound, an area in which the authors have collaborated for the past 25 years. The authors describe their collaboration. They then present one of the core ethical concepts of obstetric ultrasound: The ethical concept of the fetus as a patient. Next, they present one of the clearest clinical applications of ethics to obstetric ultrasound: Autonomy-enhancing strategies. The authors hope that these two paradigms will convince the reader that ethics is an essential dimension of obstetric ultrasound and stimulate further interest.

Maturation of the central nervous system (CNS) is reflected in fetal behavior. Modern technology, such as four-dimensional (4D) sonography improved assessment of fetal behavior in all three trimesters of pregnancy. After summing our own experiences and experiences of the leading authors in the field of fetal and neonatal neurology, new prenatal screening test for assessment of fetal behavior has been suggested. Test was named Kurjak antenatal neurodevelopmental test (KANET). Up to now results of KANET are encouraging and they have been published in several prominent journals. Nevertheless, potential of KANET in the assessment of integrity of the fetal central nervous system needs to be confirmed by studies that are in progress in several world university centers.

Transvaginal high-resolution ultrasound and three-dimensional (3D) ultrasound have been establishing sonoembryology as well as neurosonography in the first trimester. Fetal brain is rapidly developing and changing its appearance week by week during pregnancy. The most important organ, but it is quite hard to observe detailed structure of this organ by conventional transabdominal sonography. It is possible to observe the whole brain structure by magnetic resonance imaging in the post half of pregnancy, but it is difficult in the first half gestation, and transvaginal high-resolution 3D ultrasound is the most powerful modality. As for brain vascularization, main arteries and veins have been demonstrated and evaluated in various CNS conditions. Transvaginal high-resolution 3D ultrasound can demonstrate cerebral fine vascular anatomy, such as medullary vessels and it is greatly expected to estimate neurological prognosis relating with vascular development during fetal period.

Investigations of the fetal behavior in comparison with morphological studies led to the conclusion that fetal behavioral patterns directly reflect developmental and maturational processes of fetal central nervous system. Four-dimensional (4D) ultrasound has remarkably improved the assessment of the quality of fetal spontaneous movements, and enabled a better evaluation of fetal behavior. Recently, new prenatal screening test for assessment of fetal behavior, based on 4D ultrasound, has been published. We present you review of literature on fetal behavior in normal and high-risk pregnancies, and summarized results of new promising prenatal neurological screening test.

Understanding the relation between fetal and infant behavior and developmental processes of the brain in different periods of gestation may make achievable the distinction between normal and abnormal brain development as well as the early diagnosis of various structural or functional abnormalities. As the development of the brain is unique and continuing process throughout the gestation and after birth, it is expected that there is also continuity of fetal and neonatal behavior, which is the best functional indicator of developmental processes of the brain.

The aim is to present continuity of the general and other movements from prenatal to postnatal life in fetuses and newborns from low- and high-risk pregnancies.

Epidemiological studies revealed that many neurologically impaired infants belong to low-risk population, which means that they seemed to be developmentally normal as fetuses and as infants, while later in childhood neurological disability was diagnosed. Dyskinetic cerebral palsy (CP) is the dominant type of CP found in term-born, appropriate-for-gestational-age children with severe impairments who have frequently experienced adverse perinatal events. As neuroprotective methods of treatment are available for some infants, simple screening methods could be helpful to detect impaired fetuses early enough in order to avoid developmental catastrophe. It has been clear from postnatal assessment of Prechtl's neonatal general movements (GMs) that it is a better predictor of neurodevelopmental disability than neurological examination. Introduction of two-dimensional (2D) and four-dimensional (4D) ultrasound enabled introduction of GMs assessment to the prenatal period. Kurjak et al conducted a study by 4D ultrasound and confirmed earlier findings made by 2D ultrasonography, that there is behavioral pattern continuity from prenatal to postnatal life. New antenatal neurological screening test has been introduced by Kurjak et al (KANET), which was postnatally followed by postnatal neurological screening assessment according to Amiel-Tison (ATNAT). Although many fetal behavioral studies have been conducted in low- and high-risk pregnancies and KANET has been recently standardized, it is still questionable whether the assessment of continuity from fetal to neonatal behavior could improve ability for early detection of brain pathology.

Mild ventriculomegaly (VM), also defined as “borderline”, is a condition characterized by an atrial width between 10 and 15 mm independently from gestational age.

Fetuses with mild ventriculomegaly require an accurate morphological examination to rule out for associated neural and extraneural anomalies. The percentage of this association is 41%. However, in almost 13% of cases, the associated anomaly is not recognized at the time of the initial presentation. It is important to monitor the atrial width during the third trimester because in 15% of the cases it increases. Most of the cases missed at the first examination have a late onset diseases (migrational disorders, parenchimal damage, hemorrhage, etc). For these conditions MRI may play a useful role.

Maternal serum tests for congenital infections should be performed, since infections may be the cause of mild VM in 1.5% of the cases.

Fetal karyotype should also be evaluated, since chromosomal abnormalities may be associated in 2.8% of the cases of isolated VM.

The counseling in cases of apparently isolated mild VMs focuses on the possibility of neurodevelopmental delay in the surviving infants. The average percentage of neurodevelopmental delay reported in the literature is 10.9%. The possibility of late onset brain anomalies must be considered.

In conclusion, the most important prognostic factors are the association with other abnormalities not detected at the first examination and the progression of the ventricular dilatation.

Quantitative analysis of the quality of nuchal translucency (NT) measurements.

This is a retrospective single-center study. NT was measured according to the Fetal Medicine Foundation (FMF) criteria by 20 trained obstetricians (October 2003-November 2009). The performance of NT measurements was analyzed with regard to several quality control standards. Accuracy according to experience, professional profile, crown-rump length (CRL) values and FMF certification was statistically tested.

A total of 14,978 NT measurements were assessed. (1) The mean operator-specific median NT-MoM values was 0.98. (2) Mean percentage of cases >95th and <5th percentiles were 5.0 and 4.2% respectively. (3) Logarithmic mean and SD of the NT-MoM values were 0.00 and 0.13 respectively. (4) The DR for trisomy 21 at screening time was 90.7% for a FPR of 6.7% for standard screening strategy. (5) According to cumulative SUM (CUSUM) figures, the performance was more acceptable in FMF-certified operators. Operator experience, exclusive dedication to FM, FMF certification and a range of CRL values > 60 mm had a statistical impact improving these standards.

Overall quality standards show optimal NT measurements in our unit. Experience a dedicated profile to fetal medicine ultrasound, CRL over 60 mm and FMF certification has a significant positive impact on the quality standards.

Ultrasound screening has advantages over maternal serum screening. These include confirmation of embryo viability, accurate assessment of gestational age, early diagnosis of multiple pregnancies and identification of chorionicity, the detection of major structural abnormalities, major defects of the heart and great arteries, skeletal dysplasias and genetic syndrome and measurement of NT thickness in assessing the risk for Down's syndrome. Nuchal translucency (NT) has emerged as the most sensitive ultrasound marker for detection of chromosomal anomalies in the first trimester. However, the use of ultrasound in routine screening still faces problems with reliability and quality control. Combination of maternal age, NT and first and biochemical second-trimester markers is known as the integrated test. A major goal of screening tests is to achieve high detection rate and low false-positive rate at a low cost. The integrated test best meets these criteria. It could achieve a detection rate of 85% for a false-positive rate of 1.2%. It has a much better positive predictive value and, therefore, fewer amniocentesis and fewer losses of normal fetuses. Only screen-positive cases could be taken for invasive testing.

There is a wide range of noninvasive screening methods that aim to identify the subgroup of fetuses that are in a high risk of chromosomal defects. Invasive procedures should be offered to women in the high-risk group identified with the highest possible detection rate and the lowest false-positive rate.

The method of choice at 11 + 0 - 13 + 6 weeks is chorionic villus sampling. An early amniocentesis is much more dangerous and should be abandoned. CVS should be performed not earlier than at 11 + 0 weeks of pregnancy. Amniocentesis should be performed no earlier that at 15 + 0 weeks. Earlier procedure is associated with significantly higher rate of talipes equinovarius, amniotic fluid leakage and miscarriage. The umbilical cord insertion is a preferable site for fetal blood sampling. Care must be taken to distinguish between the vein and the artery, and the vein must be sampled, not the artery.

The operator's experience is very important issue. It has been postulated that to achieve a reasonable experience one should perform a minimum of 100 chorionic villus samplings, and a reasonable number of invasive procedures should be performed yearly.

Ductus venosus is a tiny vessel with a central role in fetal circulation. Combining B-mode with color and pulsed Doppler is feasible to identify this vessel and evaluate the blood flow waveform at 11 to 13 weeks. The higher prevalence of abnormal A-wave in fetuses with abnormal karyotype and/or cardiac defects turned DV evaluation into a useful marker for chromosomal abnormalities and cardiopathies. Even when combined with nuchal translucency (NT) or biochemical markers, DV blood flow evaluation contributes to an increase in sensitivity and reduces false-positive rate. Abnormal ductal flow is also related to a worse fetal and perinatal outcome. In monochorionic twin pregnancies, in addition to NT measurement at 11 to 14 weeks, the Doppler assessment of DV blood flow increases relevantly the performance of screening for those at higher risk of developing twin-to-twin transfusion syndrome. This story of 14 years surely contributed to change the way first trimester screening is being implemented.

US equipment became more and more important for the practicing obstetricians, and the demands for practicing US as part of the antenatal care becomes sometimes routine in certain areas. A lot of US workshops are practiced trying to put the guidelines for using the US in this domain, and every now and then new markers and US signs are added that could have some significance in relation to the fetal outcome.

Here a problem now exists, which is the gap between the ability to detect and the understanding of the significance of these findings, and this of course creates a great deal of improper counseling which leads to anxiety and confusions.

The aim of my lecture is to shed some light on some controversial US signs, like echogenic bowel, renal pyelectasis, cardiac echogenic foci, choroid plexus cyst, club foot, polydactyly, single umbilical artery and mild ventriculomegaly.

First I shall discuss the epidemiology–the pathophysiology, underlying risk for associated chromosomal anomalies and the most important is the significance of these signs, if present alone, so trying to suit out an evidence-based approach to their management and to provide the clinician with all the data that enables him to properly counsel the parents and eliminates the confusion created by the mere detection of these findings.

This review aims to provide the reader with an update on the present and potential clinical applications in Doppler ultrasound in perinatal medicine. Umbilical artery Doppler plays an important role in the management of intrauterine growth restriction (IUGR) and pre-eclampsia and aids in twin-to-twin transfusion syndrome management while notching in the waveform is a predictor of umbilical cord abnormalities. Middle cerebral artery Doppler reliably detects fetal anemia and may be useful in the assessment of IUGR as well. Abnormal uterine artery Doppler may play a role in predicting growth restriction, hypertensive disorders of pregnancy and preterm delivery. Abnormal ductus venosus waveforms can also be used to predict adverse fetal outcome and may allow for better timing of delivery while umbilical venous pulsations may be a sensitive marker for fetal heart failure in hydropic pregnancies. 3D power Doppler allows better small vessel visualization that is not affected by angle of insonation and has been used to diagnose placental and cord abnormalities. Significant improvements have recently occurred, improving the visualization and evaluation of placental vascularity, resulting from enhancements in delineation of tissue detail through electronic compounding and harmonics as well as enhancements in signal processing of frequency- and/or amplitude-based color Doppler ultrasound. Spatial representation of vascularity can be improved by utilizing 3D processing. Greater sensitivity of 3D Doppler ultrasound to macro- and microvascular flow has provided improved anatomic and physiologic assessment throughout pregnancy. The rapid development of these new ultrasound techniques will continue to enlarge the scope of clinical applications in placental studies. As clinical experience with these new technologies increases and as the technology improves further, it is reasonable to expect that 3D Doppler and 4D ultrasound will be complementary addition to well-established 2D Doppler ultrasound imaging.

Ultrasonic Doppler actocardiogram was simultaneous tracing of FHR and fetal movement signals on the monitoring chart, created in 1984 by Maeda. Fetal behavior was easily studied, false-positive nonreactive FHR and physiological sinusoidal FHR were differentiated, the severity of fetal CNS lesion and common fetal disorders were determined, short and long-term outcomes were diagnosed in multiple grades

It is clinical tissue characterization by common ultrasonic B-mode apparatus. Placental tissue was characterized and grade-3 placenta was detected. Placental origin of FGR was diagnosed and meconium stained turbid amniotic fluid was differentiated from clear fluid. Fetal periventricular echodensity preceding neonatal PVL was analyzed; 96% of fetal lung immaturity was noninvasively detected endometrial; benign hyperplasia, carcinoma, benign ovarian mass and malignancy were differentiated.

Before discovering genetic rules, genetic counseling was based on empirical observations. In this process, it was important to recognize that certain diagnoses were more frequent in certain couples’ descendants. The 20th century witnessed revolutionary progress in the science of genetics that coincided with increasing societal demands and therefore became an integral part of modern genetic counseling.

Genetic screening is changing from Mendelian disease ascertainment to predictive testing. We are also learning that the phenotypes of even simple Mendelian disorders are influenced by complex genetic and environmental factors. Moreover, developing knowledge about genotype/phenotype associations and many other aspects of genetic epidemiology will increasingly require referral to clinical geneticists.