Donald School Journal of Ultrasound in Obstetrics and Gynecology

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Volume 15, Number 2, April-June 2021

PICTURE OF THE MONTH

Toshiyuki Hata, Riko Takayoshi, Takahito Miyake, Nobuhiro Mori, Kenji Kanenishi

Use of Transvaginal Superb Microvascular Imaging in Uterine Disorders

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:4] [Pages No:115 - 118]

Keywords: Cervical adenocarcinoma, Color Doppler, Missed abortion, Superb microvascular imaging, Three-dimensional SMI, Transvaginal probe, Uterine arteriovenous malformation

PDF  |  DOI: 10.5005/jp-journals-10009-1696  |  Open Access |  How to cite  | 

Abstract

Aim and objective: To present our first experience of using superb microvascular imaging (SMI) and three-dimensional SMI (3D-SMI) to assess the microvasculature of uterine disorders. Materials and methods: Three cases of uterine disorders [missed abortion, cervical adenocarcinoma (gastric-type mucinous carcinoma: GAS), and uterine arteriovenous malformation (AVM)] were studied to assess the microvasculature using the latest transvaginal SMI. Comparison between conventional color Doppler and SMI for detection of uterine vascularity was conducted in a postmenopausal woman. Results: Myometrial-rich microvasculature was clearly demonstrated using SMI compared with conventional color Doppler in the postmenopausal woman. In the case of missed abortion, tiny blood vessels could be clearly identified in the contents of the uterine cavity. Only a few tiny blood vessels were noted in the bulky tumor in the cervix of the GAS. In the case of uterine AVM, tortuous structures of AVM were clearly recognized using SMI and 3D-SMI. Conclusion: Superb microvascular imaging provides more detailed information regarding the microvasculature in uterine disorders, compared with conventional color Doppler. Transvaginal SMI can depict tiny uterine blood vessels without blooming. Further studies involving a larger sample size are needed to confirm the usefulness of SMI to assess the microvasculature in uterine disorders.

REVIEW ARTICLE

Frank A Chervenak, Laurence B McCullough

Moral Status of the Embryo in Professional Obstetric Ethics

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:5] [Pages No:119 - 123]

Keywords: Embryo, Ethical principle of beneficence, Ethical principle of respect for autonomy, Ethics, Moral status, Patient

PDF  |  DOI: 10.5005/jp-journals-10009-1691  |  Open Access |  How to cite  | 

Abstract

This paper addresses the moral status of the embryo based on the ethical concept of the embryo as a patient. This concept is explained by appealing to the ethical principles of beneficence and respect for autonomy and the professional virtue of integrity. The clinical implications of the ethical concept of the embryo as a patient are explored in both in vitro fertilization and nondirective counseling about a newly initiated pregnancy. The purpose of the counseling process should be to integrate beneficence with respect for autonomy to guide a professionally responsible counseling process that is designed to empower the woman to make informed decisions about initiating and continuing pregnancy.

REVIEW ARTICLE

Gwang J Kim

Ultrasonographic Evaluation of Embryonic Cardiac Development

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:10] [Pages No:124 - 133]

Keywords: Embryo, Heart, Ultrasound

PDF  |  DOI: 10.5005/jp-journals-10009-1701  |  Open Access |  How to cite  | 

Abstract

The heart is the first functional organ in the human embryo and starts to beat by 4 weeks of development. Recently, progressive advances in medical ultrasonography, especially high-frequency transvaginal ultrasonography and the color Doppler equipment allow access to the developing embryonic human heart. The anatomical and functional characteristics of the embryonic heart are different from those of the fetus and neonate. Embryo crown-rump-length (CRL) at 2 mm shows a discernible heartbeat. At this time, the embryonic heart is in the cardiac tube stage. Embryo CRL at 5 mm shows distinct differential movements of the ventricles and atria (13th Carnegie stage, 6+4/7 gestational weeks). At the 7th gestational weeks, an interventricular septum can be visualized in the embryonic heart. Although a heartbeat can be detected and gross cardiac structures are visualized early in gestation, visualization of some embryologically important intracardiac structures, such as the endocardial cushion, atrioventricular foramen, or atrioventricular valves are still limited, even with the latest high-end equipment. Cine function and color Doppler provide some valuable information about the morphology and function of the developing embryonic heart. For the evaluation of the embryonic heart using ultrasonography, keep the principle of “As Low As Reasonably Achievable” (ALARA) and the least use of color Doppler and pulsed Doppler.

REVIEW ARTICLE

Maria Carla Monni, Ambra Iuculano, Cristina Peddes, Giovanni Monni

Vanishing Twin Syndrome

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:9] [Pages No:134 - 142]

Keywords: First trimester, Multiple pregnancy, Ultrasound, Vanishing twin syndrome

PDF  |  DOI: 10.5005/jp-journals-10009-1693  |  Open Access |  How to cite  | 

Abstract

The vanishing twin syndrome (VTS) is defined as a spontaneous demise of one twin or one gestational twin sac in a multiple pregnancy in the first trimester. The incidence of VTS is increased in assisted reproduction techniques (ART) pregnancies, fundamentally due to the increased twin pregnancy rate rather than ART per se. Vanishing twin syndrome seems to be associated with adverse outcomes affecting the remaining survivor both in spontaneously conceived pregnancies and ART pregnancies. Vanishing twin syndrome can influence the measurement of invasive and noninvasive screening techniques. Conclusion: To date, the evidence of the short and long-term effects of VTS on the surviving fetus is discordant. We can reduce its incidence by correcting some predisposing factors. Early detection of VTS and meticulous ultrasound monitoring of the alive twin for the entire pregnancy is mandatory to identify possible adverse obstetric outcomes.

REVIEW ARTICLE

Miguel Pereira-Macedo, Nuno Montenegro, Alexandra Matias

Monochorionicity: Unveiling the Pandora Box

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:17] [Pages No:143 - 159]

Keywords: Chorionicity, Discordance, Genotype, Malformations, Mosaicism, Perinatal outcome, Phenotype, Placentation, Screening, Twins, Zygosity

PDF  |  DOI: 10.5005/jp-journals-10009-1697  |  Open Access |  How to cite  | 

Abstract

This article reviews the phenomenon of monozygosity by conducting an exhaustive literature review of this special type of twin pregnancies. An epidemiological update is presented showing the substantial contribution to perinatal morbidity and mortality as well as the increasing incidence associated with assisted reproductive techniques. Molecular mechanisms of zygosity and chorionicity are explored and the processes that lead to differences in monozygotic twin pairs are identified. A diagnostic sequence is proposed considering the modifications relative to singleton pregnancies as well as the pathology unique to this pregnancy type.

REVIEW ARTICLE

Bernat Serra, Alberto R Melcón, Mireia Gutierrez

Preconceptional and Antepartum Assessment of Patients with a Previous Cesarean Section

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:9] [Pages No:160 - 168]

Keywords: Cesarean scar pregnancy, Cesarean section, Placenta accreta, Placenta previa, Preconceptional counseling, Uterine rupture, Uterine scar defect, Vaginal birth after cesarean

PDF  |  DOI: 10.5005/jp-journals-10009-1698  |  Open Access |  How to cite  | 

Abstract

Cesarean section (CS) is the most frequently performed surgical procedure around the world and during the last decades, the incidence of CSs has continuously risen in both, developed and developing countries. Consequently, women with a previous CS becoming pregnant again is constantly growing. This article aims to clarify how women who have had a previous CS should be counseled and managed, either before getting again pregnant or during pregnancy with regard to the different complications related to this previous surgical procedure.

REVIEW ARTICLE

Giovanni Monni, Valentina Corda, Francesca Dessolis, Alba Piras

Invasive Diagnostic Procedures in Embryonic Period

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:6] [Pages No:169 - 174]

Keywords: Amniocentesis, Chorionic villous sampling, Fetal blood sampling, Invasive prenatal procedures, Preimplantation genetic diagnosis

PDF  |  DOI: 10.5005/jp-journals-10009-1692  |  Open Access |  How to cite  | 

Abstract

In the era of prenatal ultrasound and biochemical screening and also due to the increase of noninvasive prenatal testing and screening (NIPT, NIPS), invasive prenatal techniques are the most appropriate procedures for diagnosing chromosomal, metabolic, and genetic fetal anomalies. Chorionic villous sampling (CVS) in the first trimester of pregnancy is currently the technique of choice for women at high genetic risk. Amniocentesis is more frequently employed in the second trimester while fetal blood sampling (FBS) by cordocentesis is rarely used nowadays. Women who choose to avoid the termination of pregnancy (TOP) of an affected fetus can opt for preimplantation genetic diagnosis (PGD) by assisted reproductive techniques (ART) by transferring in utero only the microbiopsied non-affected embryos or blastocysts. All invasive prenatal diagnosis procedures are performed under continuous ultrasound monitoring and can be done both free-hand or by insertion of a spinal needle in the ultrasound probe. Chorionic villous sampling can be performed by transcervical or transabdominal route; this last one is preferred mostly because it can be employed in any trimester of pregnancy but also because it is simpler and therefore easier for hands-on training, faster, less invasive; it is also associated with lower risks of infections and fetal loss. In antenatal diagnosis, the first step is non-directive pretest counseling to explain the risks and efficacy and to provide information about the procedures and the disease. The new laboratory analysis techniques are in continuous progress and their efficacy and success are very high for chromosomal anomalies using traditional karyotype by direct analysis of cytotrophoblastic and cultured metaphases of chorionic tissue. Alternatively, quantitative fluorescent polymerase chain reaction (QF-PCR) and array comparative genetic hybridization (aCGH) can be utilized. DNA amplification by PCR and, recently, next-generation sequencing (NGS) have shown high sensitivity and specificity for single-gene diseases. Audit of clinicians and adequate training of fellows are of paramount importance to have the highest quality results. The authors of this manuscript would like to thank Fondazione di Sardegna; Sardinia Regional Department for Programming; Boyana Petrova Tsikalova, MA in English Philology.

REVIEW ARTICLE

Ali Sungkar

Preterm Birth in Low-resource Setting

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:4] [Pages No:175 - 178]

Keywords: Management, Morbidity and mortality, Preterm labor, Risk factor

PDF  |  DOI: 10.5005/jp-journals-10009-1695  |  Open Access |  How to cite  | 

Abstract

Preterm labor (PTL) is a global problem which is a complex disease with a high rate of morbidity and mortality, also has long-term consequences for the baby and the family. The well-known morbidities related to PTL are respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity, and anemia of prematurity. In a developing country, the management of PTL is limited by poor health systems, low education level of the mother, poor financial support, lack of facility and trained health personnel, and demographic barriers. This limitation leads to high morbidity and mortality of preterm birth, especially in developing countries. It is important to reduce the rate of preterm birth by preventing the event. Several risk factors have been identified and are avoidable and preventable, such as smoking, bacterial infection, poor nutritional status, and malnourished mothers. Strategies to prevent PTL have been proposed in primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth.

REVIEW ARTICLE

Ritsuko K Pooh, Nana Matsuzawa, Megumi Machida, Takako Nakamura, Hideaki Chiyo

Neurosonographic Approach to Malformations of Cortical Development

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:9] [Pages No:179 - 187]

Keywords: Fetus, Brain, Cortical development, Malformation, Proliferation, Migration, 3D ultrasound, Neurosonography, Imaging

PDF  |  DOI: 10.5005/jp-journals-10009-1699  |  Open Access |  How to cite  | 

Abstract

Malformations of cortical development (MCD) are disorders of cerebral cortex formation caused by various genetic mutations, infections, vascular abnormalities, or metabolic abnormalities. Malformations of cortical development are associated with abnormal cortical structure, ectopic gray matter, and odd brain size. It is hard to depict cortical development and its disorder by ultrasonography during the fetal period. The phenotype of cortical development does not appear until 8 months of gestation when gyrus/sulcus formation becomes apparent. Early detection of impaired cell migration and cortical maldevelopment is a challenge in the field of prenatal fetal neuroimaging. However, longitudinal neuroimaging throughout the embryological and fetal period, combined with the precise genetic investigation, fetal MCD has been diagnosed due to the development of neuroimaging and the remarkable development of the next-generation sequencing. Perhaps shortly, fetal MCD diagnosis will be possible more accurately and earlier. The combination of molecular genetics and detailed neurosonography has established “Neurosonogenetics”, a new field in multidisciplinary prenatal neurology, for prompt prenatal/postnatal management, care, prevention, and treatment in fetal and pediatric neurology.

REVIEW ARTICLE

Milan Stanojevic, Asim Kurjak, Aida Salihagic Kadic, Lara Spalldi Barisic, Miro Jakovljević

Fetal Awareness

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:7] [Pages No:188 - 194]

Keywords: Awareness, Consciousness, Fetal behavior, Fetal senses, Four-dimensional ultrasound

PDF  |  DOI: 10.5005/jp-journals-10009-1700  |  Open Access |  How to cite  | 

Abstract

Background: While studying fetal behavior using four-dimensional ultrasound (4D US), we have been speculating about the fetal awareness and fetal cognitive function, trying to become familiarized with fetal emotional life and its readiness to separate from the intrauterine environment and begin independent life as a new individual. Aim and objective: The aim and objective to see whether by observing the fetus by 4D US we are able to enter fetal behavior, emotions, mental status, consciousness, awareness, and other states connected with fetal mind and ability of self-regulation. Results: After 24–26 weeks, the fetus has the necessary connections to sense pain. Somatosensory evoked potentials can be registered from the cortex at 29 weeks, and they may provide evidence of pain processing in the somatosensory cortex. According to recent findings, the cortical pain response has been recorded by near-infrared spectroscopy from about 25 weeks. Fetal facial expressions like those of children sustaining pain have been noticed by 4D US. The fetus can alter the frequency, patterning, and coordination of movement in response to sensory challenges, while retention of information from motor experience and motor learning may contribute to normal prenatal motor development. Conclusion: We have learned from the research by 4D US that the fetus is capable of action planning and learning, meaning that probably the capability of being aware and conscious should proceed. Fetal life in utero is dramatic and rich in different experiences, which probably would not be possible without development of fetal awareness and consciousness.

REVIEW ARTICLE

Panagiotis Antsaklis, Maria Papamichail, Marianna Theodora, George Daskalakis, Asim Kurjak

Assessment of Fetal Neurobehavior in Special Cases

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:8] [Pages No:195 - 202]

Keywords: Fetal neurobehavior, Fetal neurology, KANET

PDF  |  DOI: 10.5005/jp-journals-10009-1694  |  Open Access |  How to cite  | 

Abstract

In utero life and particularly fetal brain development and fetal behavior and more specifically assessment and imaging of the fetal nervous system, is a field of great interest in perinatal medicine, with many unanswered questions. Human brain development is a very complex, but also extremely structured process commencing the first weeks after conception and continuing for a very long time, even throughout adult life. As already mentioned fetal neurobehavior can be affected by many parameters and can be altered by environmental, racial, and maternal factors, by maternal disease, administration of drugs and neurotrophic agents, and many other factors. We analyze some special circumstances that affect fetal neurobehavior.

REVIEW ARTICLE

Natalia Lesiewska, Maciej Bieliński

Cognitive Functions in Pregnant Women

[Year:2021] [Month:April-June] [Volume:15] [Number:2] [Pages:12] [Pages No:203 - 214]

Keywords: Brain function, Cognitive functions, Depression, Gestational diabetes, Obesity, Preeclampsia, Pregnancy

PDF  |  DOI: 10.5005/jp-journals-10009-1690  |  Open Access |  How to cite  | 

Abstract

Aim: This review aims to analyze current evidence about how pregnancy and pathologies which occur during pregnancy may affect the function of a woman\'s brain, and how those changes may influence cognitive functioning. Background: During pregnancy occur adaptive changes in a woman\'s body which are necessary for proper fetal development. Pregnancy also induces structural and functional alterations within the brain. Cognitive functions are the group of mental processes responsible for learning or information processing; hence, their proper function is essential in daily living and achieving set goals. Literature shows evidence of deleterious effects on cognitive functions caused by conditions such as diabetes mellitus, hypertension, obesity, or depression within the group on nonpregnant individuals. There are also studies evaluating cognitive functions in pregnancy complicated with various diseases (including pregnancy-related ones). Review results: Gathered publications show mixed results regarding cognitive functions in pregnancy and diseases associated with pregnancy. Results indicate a poorer function of cognitive domains in pregnant women, in contrast to nonpregnant ones, which may correlate with hormone levels. Regarding hypertensive disorders, data provide evidence of worse cognitive processing and greater risk of dementia in women with preeclampsia. The literature lacks evidence about the influence on cognition in women with gestational diabetes; however, diabetes mellitus show strong correlations with cognitive deterioration putatively associated with glucose metabolism dysfunction. Obese individuals show a decline in many cognitive domains, which may predispose them to further weight gain. Depression is associated with poorer cognitive performance; however, anxiety and depressive states may be responsible for subjective cognitive dysfunction during pregnancy. Conclusion: Research shows mixed results regarding the connection between cognition and both pregnancy-related diseases, which may stem from a lack of properly designed studies. Clinical significance: More research about cognitive functions and pregnancy is needed due to the growing prevalence of the abovementioned diseases and their harmful effect on brain function even long after delivery.

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