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Biomedical subjects

Roberto Romero

Publications and source records attributed to Roberto Romero.

At least 55 records · Page 3Linked to original sources
PubMed2006

Solutes in maternal circulation and gestational sac compartments during early human development.

OBJECTIVES: The aim of this study was to review previous work reporting the concentration of solutes measured in maternal circulation, extra-embryonic celomic fluid, and amniotic fluid, to gain insights into the mechanism that could lead to compartmentalization of fluid and solutes within the gestational sac prior to the 12th week of pregnancy. METHODS: We conducted a Medline and PubMed literature search from January 1990 through March 2004 using the key words amniotic fluid, celomic fluid, coelomic fluid, celocentesis, coelocentesis, amniocentesis, yolk sac and embryonic cavities. We selected those articles describing solutes that had been measured in the same patient in samples obtained prior to 12 weeks' gestation from maternal circulation, celomic fluid and amniotic fluid. Information extracted from these publications included: gestational age at sampling, number of samples evaluated, mean concentration of the solutes in each of the three fluids and bibliographic citation. RESULTS: We found 73 publications with the key words and selected 13 that met the inclusion criteria. The concentration of 31 solutes reported in each of the three compartments was documented and gradients among compartmental interfaces calculated. CONCLUSION: This study describes the concentration of solutes measured in maternal circulation, extracelomic fluid and amniotic fluid early in human development. Analysis of calculated gradients across the compartmental interfaces suggests that the shift of fluid may depend on the biophysical properties of the placenta and yolk sac and on graded changes in hydrostatic pressures across compartments.

Amniotic Fluid↗
PubMed2006

A sonographic short cervix as the only clinical manifestation of intra-amniotic infection.

OBJECTIVE: A sonographically short cervix is a powerful predictor of spontaneous preterm delivery. However, the etiology and optimal management of a patient with a short cervix in the mid-trimester of pregnancy remain uncertain. Microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation are frequently present in patients with spontaneous preterm labor or acute cervical insufficiency. This study was conducted to determine the rate of MIAC and intra-amniotic inflammation in patients with a cervical length < 25 mm in the mid-trimester. STUDY DESIGN: A retrospective cohort study was conducted of patients referred to our high risk clinic because of a sonographic short cervix or a history of a previous preterm birth. Amniocenteses were performed for the evaluation of MIAC and for karyotype analysis in patients with a short cervix. Fluid was cultured for aerobic and anaerobic bacteria, as well as genital mycoplasmas. Patients with MIAC were treated with antibiotics selected by their physician. RESULTS: Of 152 patients with a short cervix at 14-24 weeks, 57 had amniotic fluid analysis. The prevalence of MIAC was 9% (5/57). Among these patients, the rate of preterm delivery (< 32 weeks) was 40% (2/5). Microorganisms isolated from amniotic fluid included Ureaplasma urealyticum (n=4) and Fusobacterium nucleatum (n=1). Patients with a positive culture for Ureaplasma urealyticum received intravenous Azithromycin. Three patients with Ureaplasma urealyticum had a sterile amniotic fluid culture after treatment, and subsequently delivered at term. The patient with Fusobacterium nucleatum developed clinical chorioamnionitis and was induced. CONCLUSION: (1) Sub-clinical MIAC was detected in 9% of patients with a sonographically short cervix (< 25 mm); and (2) maternal parenteral treatment with antibiotics can eradicate MIAC caused by Ureaplasma urealyticum. This was associated with delivery at term in the three patients whose successful treatment was documented by microbiologic studies.

Adult↗
PubMed2006

Four-dimensional ultrasonography of the fetal heart using a novel Tomographic Ultrasound Imaging display.

OBJECTIVE: The objective of this study was to investigate the feasibility of examining the fetal heart with Tomographic Ultrasound Imaging (TUI) using four-dimensional (4D) volume datasets acquired with spatiotemporal image correlation (STIC). MATERIAL AND METHODS: One hundred and ninety-five fetuses underwent 4D ultrasonography (US) of the fetal heart with STIC. Volume datasets were acquired with B-mode (n=195) and color Doppler imaging (CDI) (n=168), and were reviewed offline using TUI, a new display modality that automatically slices 3D/4D volume datasets, providing simultaneous visualization of up to eight parallel planes in a single screen. Visualization rates for standard transverse planes used to examine the fetal heart were calculated and compared for volumes acquired with B-mode or CDI. Diagnoses by TUI were compared to postnatal diagnoses. RESULTS: (1) The four- and five-chamber views and the three-vessel and trachea view were visualized in 97.4% (190/195), 88.2% (172/195), and 79.5% (142/195), respectively, of the volume datasets acquired with B-mode; (2) these views were visualized in 98.2% (165/168), 97.0% (163/168), and 83.6% (145/168), respectively, of the volume datasets acquired with CDI; (3) CDI contributed additional diagnostic information to 12.5% (21/168), 14.2% (24/168) and 10.1% (17/168) of the four- and five-chamber and the three-vessel and trachea views; (4) cardiac anomalies other than isolated ventricular septal defects were identified by TUI in 16 of 195 fetuses (8.2%) and, among these, CDI provided additional diagnostic information in 5 (31.3%); (5) the sensitivity, specificity, positive- and negative-predictive values of TUI to diagnose congenital heart disease in cases where both B-mode and CDI volume datasets were acquired prenatally were 92.9%, 98.8%, 92.9% and 98.8%, respectively. CONCLUSION: Standard transverse planes commonly used to examine the fetal heart can be automatically displayed with TUI in the majority of fetuses undergoing 4D US with STIC. Due to the retrospective nature of this study, the results should be interpreted with caution and independently confirmed before this methodology is introduced into clinical practice.

Cardiac Volume↗
PubMed2006

Normal and abnormal transformation of the spiral arteries during pregnancy.

This article reviews the anatomy and physiology of the uterine circulation, with emphasis on the remodeling of spiral arteries during normal pregnancy, and the timing and anatomical pathways of trophoblast invasion of the spiral arteries. We review the definitions of the placental bed and basal plate of the placenta, their relevance to the study of the physiologic transformation of the spiral arteries, as well as the methods to obtain and examine placental bed biopsy specimens. We also examine the role of the extravillous trophoblast in normal and abnormal pregnancies, and the criteria used to diagnose failure of physiologic transformation of the spiral arteries. Finally, we comment on the use of uterine artery Doppler velocimetry as a surrogate marker of chronic uteroplacental ischemia.

Arteries↗
PubMed2006

What does 2-dimensional imaging add to 3- and 4-dimensional obstetric ultrasonography?

OBJECTIVE: The purpose of this study was to determine whether 2-dimensional (2D) ultrasonography adds diagnostic information to that provided by the examination of 3-dimensional/4-dimensional (3D/4D) volume data sets alone. METHODS: Ninety-nine fetuses were examined by 3D/4D volume ultrasonography. Volume data sets were evaluated by a blinded independent examiner who, after establishing an initial diagnostic impression by 3D/4D ultrasonography, performed a 2D ultrasonographic examination. The frequency of agreement and diagnostic accuracy of each modality to detect congenital anomalies were calculated and compared. RESULTS: Fifty-four fetuses with no abnormalities and 45 fetuses with 82 anomalies diagnosed by 2D ultrasonography were examined. Agreement between 3D/4D and 2D ultrasonography occurred for 90.4% of the findings (123/136; intraclass correlation coefficient, 0.834; 95% confidence interval, 0.774-0.879). Six anomalies were missed by 3D/4D ultrasonography when compared to 2D ultrasonography (ventricular septal defect [n = 2], interrupted inferior vena cava with azygous continuation [n = 1], tetralogy of Fallot [n = 1], horseshoe kidney [n = 1], and cystic adenomatoid malformation [n = 1]). There were 2 discordant diagnoses: transposition of the great arteries diagnosed as a double-outlet right ventricle and pulmonary atresia misinterpreted as tricuspid atresia on 3D/4D ultrasonography. One case of occult spinal dysraphism was suspected on 3D ultrasonography but not confirmed by 2D ultrasonography. When compared to diagnoses performed after delivery (n = 106), the sensitivity and specificity of 3D/4D ultrasonography (92.2% [47/51] and 76.4% [42/55], respectively) and 2D ultrasonography (96.1% [49/51] and 72.7% [40/55]) were not significantly different (P = .233). CONCLUSIONS: Information provided by 2D ultrasonography is consistent, in most cases, with information provided by the examination of 3D/4D volume data sets alone.

Female↗
PubMed2006

Applications of 2-dimensional matrix array for 3- and 4-dimensional examination of the fetus: a pictorial essay.

OBJECTIVES: Two-dimensional (2D) matrix array is a new technology for the performance of 3-dimensional and 4-dimensional (4D) ultrasonography. In this study, we report the use of a 2D matrix array transducer for examination of fetal structures including the fetal heart. METHODS: Thirty-four fetuses without abnormalities and 19 fetuses with congenital anomalies were examined with a 2D matrix array transducer (x3-1, IE-33; Philips Medical Systems, Bothell, WA). Median gestational age was 25 6/7 weeks (range, 13 0/7-40 1/7 weeks). RESULTS: (1) A 360 degrees rotation and examination of selected structures was possible in the second trimester. (2) Structures were examined by maintaining the transducer in a fixed position and rotating the volume using the system trackball. (3) Dorsal and ventral parts of the hands and feet were visualized in a single volume data set, in real time, without moving the transducer. (4) Real-time en face visualization of atrioventricular valves was possible from the ventricular or atrial chambers. (5) Four-dimensional images of bones were obtained by decreasing gain settings only, with no need for cropping. (6) Four-dimensional reconstruction of vascular structures was possible with color Doppler imaging. Two limitations were identified: (1) lower resolution than mechanical volumetric transducers, and (2) narrow volume display. CONCLUSIONS: Real-time direct 4D imaging with 360 degrees rotation for examination of fetal anatomic structures is feasible. This technology allows examination of fetal structures from multiple perspectives, in real time, without the need to move the transducer in the maternal abdomen. Further technological developments may overcome the limitations identified in this study.

Congenital Abnormalities↗
PubMed2006

A novel algorithm for comprehensive fetal echocardiography using 4-dimensional ultrasonography and tomographic imaging.

OBJECTIVE: Tomographic ultrasound imaging (TUI) is a new display modality that allows simultaneous visualization of up to 8 parallel anatomic planes. This study was designed to determine the role of a novel algorithm combining spatiotemporal image correlation and TUI to visualize standard fetal echocardiographic planes. METHODS: Volume data sets from fetuses with and without congenital heart defects (CHDs) were examined with a novel algorithm that allows simultaneous visualization of the 3-vessel and trachea view, the 4-chamber view, and outflow tracts. Visualization rates for these planes as well as the ductal arch and 5-chamber view were calculated. RESULTS: (1) Two hundred twenty-seven volume data sets from fetuses without (n = 138) and with (n = 14) CHDs were reviewed; (2) among fetuses without CHDs, the 4-chamber view, 5-chamber view, ductal arch, 3-vessel and trachea view, left outflow tract, and short axis of the aorta were visualized in 99% (193/195), 96.9% (189/195), 98.5% (192/195), 88.2% (172/195), 93.3% (182/195), and 87.2% (170/195) of the volume data sets, respectively; (3) these views were visualized in 85% (17/20), 80% (16/20), 65% (13/20), 55% (11/20), 55% (11/20), and 70% (14/20) of the volume data sets, respectively, from fetuses with CHDs; and (4) simultaneous visualization of the short axis of the aorta, 3-vessel and trachea view, left outflow tract, and 4-chamber view was obtained in 78% (152/195) of the volume data sets from fetuses without CHDs and in 40% (8/20) of those with CHDs. CONCLUSIONS: The 3-vessel and trachea view, the 4-chamber view, and both outflow tracts can be simultaneously visualized using a novel algorithm combining spatiotemporal image correlation and TUI.

Algorithms↗
PubMed2005

A role for TLRs in the regulation of immune cell migration by first trimester trophoblast cells.

Normal pregnancy is characterized by the presence of innate immune cells at the maternal-fetal interface. Originally, it was postulated that the presence of these leukocytes was due to an immune response toward paternal Ags expressed by the invading trophoblasts. Instead, we and others postulate that these innate immune cells are necessary for successful implantation and pregnancy. However, elevated leukocyte infiltration may be an underlying cause of pregnancy complications, such as preterm labor or preeclampsia. Furthermore, such conditions have been attributed to an intrauterine infection. Therefore, we hypothesize that first trimester trophoblast cells, upon recognition of microbes through TLRs, may coordinate an immune response by recruiting cells of the innate immune system to the maternal-fetal interface. In this study, we have demonstrated that human first trimester trophoblast cells constitutively secrete the chemokines growth-related oncogene, growth-related oncogene alpha, IL-8, and MCP-1 and are able to recruit monocytes and NK cells, and to a lesser degree, neutrophils. Following the ligation of TLR-3 by the viral ligand, poly(I:C), or TLR-4 by bacterial LPS, trophoblast secretion of chemokines is significantly increased and this in turn results in elevated monocyte and neutrophil chemotaxis. In addition, TLR-3 stimulation also induces trophoblast cells to secrete RANTES. These results suggest a novel mechanism by which first trimester trophoblast cells may differentially modulate the maternal immune system during normal pregnancy and in the presence of an intrauterine infection. Such altered trophoblast cell responses might contribute to the pathogenesis of certain pregnancy complications.

Chemokines↗
PubMed2005

Equilibrium sampling through membranes of freely dissolved copper concentrations with selective hollow fiber membranes and the spectrophotometric detection of a metal stripping agent.

A sensitive spectrophotometric method for the determination of freely dissolved copper concentrations in aqueous samples after preconcentration with hollow fiber membrane extraction has been developed. The method is based on the equilibrium sampling through a selective membrane into an acceptor solution containing 4-(pyridyl-2-azo)resorcinol (PAR), which serves as stripping agent and metal indicator. Negligible extraction of interferences and equilibrium enrichment of copper allowed for selective spectrophotometric determination of the Cu-PAR complex. Some important extraction parameters such as acceptor composition, shaking, equilibrium time, and sample volume were studied. The optimized methodology showed good linearity in the range of 5-100 microg/L, an enrichment factor of 93, good repeatability and reproducibility (RSDs < 6%, n = 6), and a detection limit of 4 microg/L. The cationic metals Ni2+, C(2+, Cd2+, Fe3+, Pb2+, Zn2+, and Mn2+ were shown not to interfere with the measurement of Cu2+. Measurements on samples containing mixtures of various ligands and cations were in good agreement with theoretically calculated concentrations, and the method was also applied to environmental samples. The developed technique requires less labor and less sophisticated equipment than conventional methods typically based on atomic absorption spectrometry or ICP.

Journal Article↗
PubMed2005

Identification of 9alpha,11beta-prostaglandin F2 in human amniotic fluid and characterization of its production by human gestational tissues.

CONTEXT: 9alpha,11beta-Prostaglandin F(2) (9alpha,11beta-PGF(2)) can contract uterine smooth muscle with a potency equal to PGF(2alpha). Its presence in the human uterus and production by human gestational tissues is unknown. OBJECTIVE: These studies were performed to determine whether the PGD(2)-derived 9alpha,11beta-PGF(2) is both present in human amniotic fluid and synthesized by human gestational tissues and if so, whether labor-related substances could regulate its production. RESULTS: Detectable concentrations of 9alpha,11beta-PGF(2) were found in amniotic fluid samples and appeared to increase in late gestation. All gestational tissues studied synthesized 9alpha,11beta-PGF(2), with the placenta having the highest basal production rate, followed by the amnion and then the choriodecidua. IL-1beta and TNFalpha caused concentration-dependent increases in 9alpha,11beta-PGF(2) production in human amnion and choriodecidual explants. Moreover, treatment of choriodecidual and placental explants with lipopolysaccharide resulted in a significant increase in 9alpha,11beta-PGF(2) production rates, reaching a maximum of 13-fold in the choriodecidua. Studies examining the effects of the addition of exogenous PGD(2) strongly indicated that the choriodecidua has significant ability to convert PGD(2) to 9alpha,11beta-PGF(2), whereas the amnion has little. CONCLUSIONS: These results demonstrate for the first time that 9alpha,11beta-PGF(2) is present in human amniotic fluid and that it is produced by human gestational tissues and up-regulated by bacterial cell wall components and proinflammatory cytokines. We suggest that this prostaglandin may play a part in the mechanisms of human labor at term and preterm.

Amniotic Fluid↗
PubMed2005

Determination of free copper concentrations in natural waters by using supported liquid membrane extraction under equilibrium conditions.

A method is described for measurement of freely dissolved copper concentrations in natural water samples using supported liquid membrane (SLM) extraction under equilibrium conditions, a technique denoted "equilibrium sampling through membranes" (ESTM). For this purpose, 1,10-dibenzyl-1,10-diaza-18-crown-6 as neutral carrier and oleic acid were used in the membrane phase. The main variables optimised were the carrier used to form the metal complexes, the organic solvent used in the membrane, the countercation, pH, the ligand used in the acceptor phase, the extraction time, and the flow rate of the donor phase. After the optimisation process an enrichment factor of 18.5 was obtained. Equilibrium conditions were reached after extraction for 60 min if a flow rate of 1.0 mL min(-1) or greater was used. When different ligands such as humic acids, phthalic acid, and EDTA were added to the sample solution, and sample pH ranged from 6 to 8, the results obtained for freely dissolved copper concentrations were in a good agreement with results from speciation calculations performed with Visual Minteq V 2.30, Cheaqs V L20.1, and WinHumic V. The developed technique was applied to analysis of stream and leachate water.

Journal Article↗
PubMed2005

Cervicovaginal fibronectin improves the prediction of preterm delivery based on sonographic cervical length in patients with preterm uterine contractions and intact membranes.

OBJECTIVE: The purpose of this study was to examine the diagnostic performance of ultrasonographic measurement of the cervical length and vaginal fetal fibronectin determination in the prediction of preterm delivery in patients with preterm uterine contractions and intact membranes. STUDY DESIGN: Ultrasound examination of the cervical length and fetal fibronectin determination in vaginal secretions were performed in 215 patients admitted with preterm uterine contractions (22-35 weeks) and cervical dilatation of </=3 cm. Outcome variables were the occurrence of preterm delivery within 48 hours, 7 days, and 14 days of admission, delivery </=32 and </=35 weeks, as well as the admission-to-delivery interval. Statistical analysis included chi-square test, receiver-operator characteristic (ROC) curve analysis, logistic regression, and survival analysis. RESULTS: The overall prevalence of preterm delivery </=35 weeks was 20% (43/215). The prevalence of spontaneous preterm delivery within 48 hours, 7 days, and 14 days of admission, and delivery </=32 and </=35 weeks were 7.9% (17/215), 13.0% (28/215), 15.8% (34/215), 8.9% (9/101), and 15.8% (34/215), respectively. ROC curve analysis and contingency tables showed a significant relationship between the occurrence of preterm delivery and both cervical length and fetal fibronectin results ( P < .01 for each). Both tests performed comparably in the prediction of spontaneous preterm delivery. However, when fetal fibronectin results were added to those of cervical length (<30 mm), a significant improvement in the prediction of preterm delivery was achieved. CONCLUSION: Fetal fibronectin adds prognostic information to that provided by sonographic measurement of the cervical length in patients with preterm uterine contractions and intact membranes.

Adult↗
PubMed2005

A short cervix in women with preterm labor and intact membranes: a risk factor for microbial invasion of the amniotic cavity.

OBJECTIVE: The purpose of this study was to determine whether there was a relationship between sonographic cervical length and the presence of culture-proven microbial invasion of the amniotic cavity in women with preterm labor and intact membranes. STUDY DESIGN: Ultrasonography and amniocentesis were performed in 401 patients admitted with preterm labor (22-35 weeks) and cervical dilatation of < or = 3 cm, as assessed by digital examination. Cervical length was determined by transvaginal ultrasound at admission. Outcome variables were the presence of microbial invasion of the amniotic cavity (defined as a positive amniotic fluid culture) and the occurrence of preterm delivery before 35 weeks. Contingency tables, chi2 test, receiver-operator characteristic (ROC) curves, and logistic regression were used for statistical analysis. RESULTS: The prevalence of microbial invasion of the amniotic cavity was 7% (28/401). Spontaneous preterm delivery (< or = 35 weeks) occurred in 21.4% (82/384) of patients. ROC curve analysis showed a significant relationship between the frequency of microbial invasion of the amniotic cavity and the length of the uterine cervix (area under the curve: 0.77; P < .005). Patients with a cervical length < 15 mm had a higher rate of a positive amniotic fluid culture than patients with a cervical length > or = 15 mm (26.3% [15/57] vs. 3.8% [13/344], respectively; P < .05). Moreover, patients with a short cervix (defined as < 15 mm) were more likely to deliver spontaneously before 35 weeks, 32 weeks, within 7 days, and within 48 hours of admission ( P < .05 for all comparisons). Forty percent of patients (161/401) had a cervical length > or = 30 mm. These patients had a very low risk of microbial invasion of the amniotic cavity (1.9% [3/161]), spontaneous delivery < or = 35 weeks (4.5% [7/154]), < or = 32 weeks (2.6% [2/76]), within 7 days (1.9% [3/154]), and within 48 hours (0% [0/154]) of admission. CONCLUSION: Endovaginal ultrasonographic examination of the uterine cervix in women with preterm labor identifies patients at increased risk for intrauterine infection.

Adult↗
PubMed2005

High levels of fetal cell-free DNA in maternal serum: a risk factor for spontaneous preterm delivery.

OBJECTIVE: This study was conducted to determine whether there is a relationship between the concentration of fetal cell-free DNA in maternal serum and the duration of pregnancy in women who are at high risk for preterm delivery because of either preterm labor or preterm premature rupture of the membranes. STUDY DESIGN: Sera were collected and frozen from 71 women with a male fetus. Maternal serum fetal cell-free DNA concentration was measured with the use of real-time polymerase chain reaction amplification of DYS1. Fetal cell-free DNA concentrations were converted to multiples of the median. The following groups were studied: group 1: women with preterm labor and intact membranes who were delivered at > or = 36 weeks of gestation (n = 21); group 2: women with preterm labor who were delivered at <36 weeks of gestation (n = 29); and group 3: women with preterm premature rupture of the membranes in labor (n = 20) or not in labor (n = 1) who were delivered prematurely (<36 weeks of gestation). Kaplan-Meier and Cox regression analyses were used to analyze the relationship between fetal cell-free DNA concentrations and the likelihood of preterm delivery. RESULTS: A cut-off value for fetal cell-free DNA of 1.82 multiples of the median was chosen for analysis. The cumulative rate of early preterm delivery (<30 weeks of gestation) was significantly higher for women with fetal cell-free DNA concentrations of > or = 1.82 multiples of the median than those with fetal cell-free DNA concentrations below this cut-off (45% [95% CI, 36%-74%] vs 18% [95% CI, 11%-25%]; P = .008]. The cumulative rate of preterm delivery (<36 weeks of gestation) was also significantly higher at > or = 1.82 multiples of the median (73% [95% CI, 52%-93%] vs 66% [95% CI, 54%-79%]; P = .02). After adjustment for covariates, Cox analysis showed that fetal cell-free DNA at > or = 1.82 multiples of the mechanisms of disease that are associated with a mean hazard rate of delivery of 1.57 (P = .005). CONCLUSION: High concentrations of fetal cell-free DNA in maternal serum are associated with an increased risk of spontaneous preterm delivery. This observation may have implications for the understanding of the mechanisms of disease that is associated with preterm labor.

Cross-Sectional Studies↗
PubMed2005

In utero cardiac fetal surgery: laser atrial septotomy in the treatment of hypoplastic left heart syndrome with intact atrial septum.

OBJECTIVE: The purpose of this study was to report a novel technique, laser atrial septotomy, for the in utero treatment of hypoplastic left heart syndrome with intact atrial septum. STUDY DESIGN: In utero atrial septotomy by Neodymium-YAG laser photofulguration in a fetus with hypoplastic left heart syndrome (HLHS) and intact atrial septum was performed at 30 4/7 weeks of gestation. Percutaneous fetal cardiocentesis was performed to guide a contact (Neodymium-YAG) laser fiber into the right atrium with the objective of creating an interatrial communication by photofulguration of the septal tissue. RESULTS: New onset of blood flow from the left to the right atrium was confirmed by color Doppler imaging during the procedure. The neoatrial septal defect remained patent until delivery. A 3400-g neonate was born by spontaneous vaginal delivery at 37 weeks of gestation. A first stage Norwood procedure was performed on the first day of life and surgical correction of an obstructed right pulmonary vein at 3 months. Although pulmonary vascular resistance was normal at cardiac catheterization at 2 months of age, the infant died at 5 months of age from multiple organ failure. An autopsy was declined. CONCLUSION: In utero laser atrial septotomy is feasible. Further experience is necessary to determine the risks and benefits of this technique for the treatment of fetuses hypoplastic left heart syndrome with intact atrial septum.

Adult↗