Foreword

It gives me great pleasure to write the foreword for the new edition of Structural Fetal Abnormalities. The book has an interesting history. In 1970, I joined the Johns Hopkins Department of Radiology as an instructor, on a 1-year leave of absence from my UK position at Oxford, and was put in charge of genitourinary imaging. Within a month, the hospital's woman's board announced the donation of a bistable ultrasound imaging system for use in the women's clinic. With minimal experience in ultrasound, I was asked to develop the use of the system and welcomed the opportunity to travel around the USA for training and machine selection. I started imaging fetuses, crudely assessing growth by measuring the biparietal diameter and the femur length, counting fetal number, and discovering fetal lie. I even attempted to diagnose placenta previa by imaging a fluid-filled pessary placed around the cervix after a "double setup." Fetal anomaly detection seemed a remote possibility because the images were so rudimentary. I soon became fascinated by the technique and decided to stay on when my year away from the United Kingdom was complete.

Since that time there has been steady improvement in imaging quality. Grayscale imaging became available in 1975, but the acquirement of images was tedious and technically difficult using the B-scan technique, which involved carefully dragging a transducer suspended from a gantry around the maternal abdomen. Slowly, starting with Stuart Campbell's observation of the absent cranium in anencephalus (1972) and the spinal deformity in spina bifida (1975), the ultrasonic spectrum of fetal malformations began to be revealed. It soon became apparent that a team approach, involving consultation with obstetricians, pediatric surgeons or urologists, geneticists, neonatologists, genetic counselors, and individuals in other specialties was important in pregnancy management and in discussions with anxious patients when a fetal abnormality was discovered on a sonogram. For the most part, these anomalies were an incidental finding at the time of the ultrasound study rather than the result of referral because of familial or teratogenic issues; quality sonography was the doorway into the fetal world.

Fetal anomaly management discussions, such as the one that I and colleagues started at Johns Hopkins and subsequently at the University of Maryland, became an important feature of fetal malformation management. Each week, the fetal abnormalities revealed by sonography were shown, and the representatives of the various specialties commented on the aspects of fetal care that related to their specialty. These management conferences were the stimulus for the first two editions of this book, which were developed at the University of Maryland with collaboration from authors at Johns Hopkins. I am delighted that Allen Hogge, who has been involved since the first edition, has taken on the task of editing a new edition of the book.

What is the point of these management discussions? The discovery of a fetal abnormality poses difficult ethical and management dilemmas for the sonographic examiner, the parents, and the obstetrician. What sort of difficulties with delivery, and later life, will the anomaly present? Is the anomaly lethal, or is there such a poor prognosis that cesarean section and resuscitative care are to be avoided? Has the anomaly been discovered early enough that termination is an option? This is a difficult question because termination limits vary by state. Do the parents wish to pursue in utero surgery with all the uncertainty that approach brings? Sonologists, whether radiologists or now predominantly perinatologists, and referring obstetricians are frequently faced with many questions when a possible anomaly is discovered. This book attempts to answer these questions. In addition, support staff, such as sonographers, nurses, and genetic counselors, also play a significant role in diagnosis and care, and it is hoped this book will be of help to them. This book, in a succinct and well-illustrated fashion, attempts to provide complete coverage of all the problems the affected fetus may have so that the patient is ensured a comprehensive compassionate care plan.

There are thousands of conditions and syndromes that cause fetal deformities in utero. The conditions selected for presentation in this book were chosen because they are relatively common or have distinctive features that allow definitive recognition, such as the hitchhiker thumb of diastrophic dwarfism. Some of the more common sonographic findings that sometimes indicate underlying fetal problems, such as cord cysts, are also considered. Each is presented in a standardized fashion from the viewpoint of the geneticist, sonologist (whether radiologist or perinatologist), obstetrician, neonatologist, and surgeon. A consistent format is used for each entity. Numerous high-quality ultrasound images and photographs of the fetus or infant are included. Although the book is modeled on Smith's Recognizable Patterns of Human Malformations, there has been no attempt to be as comprehensive. The material in this book is targeted at sonographically visible abnormalities and does not include abnormalities not discoverable by sonography. I congratulate the new team led by Allen Hogge and Lyndon Hill on the quality of the new edition.