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\begin{document}

\title{Re: How often do we identify fetal abnormalities during routine
third-trimester ultrasound? A systematic review and meta-analysis.
(First comment on BJOG-20-0525.R1)}



\author[1]{Claudia Massarotti}%
\author[1]{Chiara Gaggero}%
\author[1]{Chiara Molinari}%
\author[1]{Diletta Marcolin}%
\author[1]{Pierangela De Biasio}%
\affil[1]{Ospedale Policlinico San Martino}%


\vspace{-1em}



  
  \date{June 02, 2024}


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Letter to the Editor, BJOG Exchange

\textbf{Re: How often do we identify fetal abnormalities during routine
third-trimester ultrasound? A systematic review and meta-analysis}

Sir,

Drukker et al.\textsuperscript{1} recently reviewed the existing
literature on prevalence and types of anomalies detected in the
3\textsuperscript{rd} trimester, finding that as much as 1:300
examinations led to a new diagnosis. This finding came as a reminiscence
of the first steps of the prenatal diagnosis\textsuperscript{2} and
stressed that we are not ready to dismiss the
3\textsuperscript{rd}trimester routine scan yet.

While the scaffolding of the fetus is formed by the time of the mid
pregnancy anatomy scan, during the last months of pregnancy, the fetus
grows considerably to reach its genetic determined potential, with a
process that is mostly hypertrophic, and prepares for the extrauterine
life with formation of reserves, like fat tissue deposition.

As discussed by Drukker et al., the national policies on the
3\textsuperscript{rd} trimester scan are heterogeneous and the utility
of such an examination has been questioned. Traditionally, it was
oriented to identify late FGR, preventing adverse neonatal outcomes.
However, a single estimation, even with the highest achievable accuracy,
is not enough to describe the complex and dynamic process of fetal
growth\textsuperscript{3}.

Re-discovering the 3\textsuperscript{rd} trimester scan (30-33 weeks of
gestation) as a screening point, allows us to befit of it at its best.
Indeed, it discloses many relevant information:

\begin{enumerate}
\tightlist
\item
  The detection of malformations not yet visible at 20 weeks, that
  become evident with fetal maturation. The prime example are the
  urogenital malformations, as described in the systematic review. These
  malformations usually have a benign prognosis, sometimes they require
  a corrective procedure and sometimes only follow up. Following the
  detection of these anomalies, the expectant parents have time to be
  educated on the diagnosis, to choose with the healthcare provider the
  better birth setting and to plan for interventions (if indicated)
  and/or for an adequate follow up.
\item
  The detection of malformations requiring medical procedures at birth,
  i.e. cardiac malformations not visible before, enabling a safe birth
  and tailored life-saving interventions.
\item
  The detection of abnormalities resulting from asymptomatic infections,
  from late-presenting neurological malformations or from other
  intercurrent rarer causes, such as a fetal cerebral hemorrhage. These
  findings frequently carry a poor prognosis with them. A 30 weeks
  diagnosis means starting a late referral pathway to prepare the
  expectant parents for birth (or 3\textsuperscript{rd} trimester
  abortion, where legal) at best.
\item
  The detection of FGR or a starting point of a reference curve to
  detect late FRG. The evaluation of the estimate fetal weight (EFW) is
  less accurate in the last weeks of gestation due to objective
  difficulties in performing ultrasound measurements, hence a greater
  discrepancy between fetal weight and neonatal birthweight. However,
  the most relevant information we can acquire is not the fetal weight
  per se but a slowed or accelerated growth curve compared to the 30
  weeks screening, essential to identify higher risk pregnancies to be
  monitored closely.
\end{enumerate}

All these findings are detectable only in the contest of an efficient
routine screening program, preferably performed by highly trained
individuals. One of the main purposes of the Obstetrician is to reduce
as much as possible the maternal and neonatal morbidity during pregnancy
and birth, but also to give to that newborn the best possible life after
birth, including appropriate care when indicated, building tailored
follow-up pathways in-utero and after birth. Thus, the
3\textsuperscript{rd} trimester routine scan is a precious arrow in our
quiver that, together with the other prenatal appointments, aims to
continuously improve our maternal and infant care.

Claudia MASSAROTTI\textsuperscript{1,2}*, Chiara Roberta
GAGGERO\textsuperscript{3,4}, Chiara MOLINARI\textsuperscript{4},
Diletta MARCOLIN\textsuperscript{1,2}, Pierangela DE
BIASIO\textsuperscript{3,4}

\begin{enumerate}
\tightlist
\item
  Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics
  and Maternal and Child Health (DINOGMI dept.), University of Genoa,
  Genoa, Italy
\item
  Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico
  San Martino, Genoa, Italy
\item
  Prenatal Diagnosis and Perinatal Medicine Unit, IRCCS Ospedale
  Policlinico San Martino, Genova, Italy.
\item
  Maternal and Child Health Department, IRCCS Ospedale Policlinico San
  Martino, Genova, Italy
\end{enumerate}

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Drukker L, Bradburn E, Rodriguez GB, Roberts NW, Impey L,
  Papageorghiou AT. How often do we identify fetal abnormalities during
  routine third-trimester ultrasound? A systematic review and
  meta-analysis. BJOG. 2020 Aug 13. doi: 10.1111/1471-0528.16468.
\item
  Jauniaux E, Prefumo F. Prenatal diagnosis of fetal anomalies from the
  third to the first trimester and back. BJOG. 2020 Oct 16. doi:
  10.1111/1471-0528.16523.
\item
  Caradeux J, Martinez-Portilla RJ, Peguero A, Sotiriadis A, Figueras F.
  Diagnostic performance of third-trimester ultrasound for the
  prediction of late-onset fetal growth restriction: a systematic review
  and meta-analysis. Am J Obstet Gynecol. 2019 May;220(5):449-459.e19.
  doi: 10.1016/j.ajog.2018.09.043.
\end{enumerate}

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