Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2018 | April-June | Volume 12 | Issue 2

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Tamaki Tanaka, Chiaki Tenkumo, Yuko Fukuda

HDliveFlow Silhouette Mode with HDlive Silhouette Mode for Diagnosis of Sclerosing Stromal Tumor of the Ovary

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:4] [Pages No:85 - 88]

Keywords: HDlive silhouette mode, HDliveFlow silhouette mode, Laparoscopic surgery, Ovary, Sclerosing stromal tumor

   DOI: 10.5005/jp-journals-10009-1555  |  Open Access |  How to cite  | 


We present our experience of using the HDliveFlow silhouette mode with HDlive silhouette mode to diagnose sclerosing stromal tumor (SST) of the ovary. Two-dimensional (2D) sonography showed an echogenic solid tumor with some anechoic areas inside the mass. Two-dimensional power Doppler depicted peripheral vascularity with a few central vessels inside the mass. HDliveFlow clearly showed abundant peripheral vascularization with several penetrating vessels (scrubbing-brush appearance). The HDliveFlow silhouette mode with HDlive silhouette mode revealed numerous peripheral vessels with some penetrating vessels and a few cysts inside the mass. Magnetic resonance imaging (MRI) was highly suggestive of SST. Laparoscopic right salpingo-oophorectomy was performed, and the histopathologic diagnosis was SST of the right ovary. The HDliveFlow silhouette mode with HDlive silhouette mode may facilitate the preoperative diagnosis of SST as an additional diagnostic tool along with conventional 2D power Doppler sonography.



Katika Nawapun, Nisarat Phithakwatchara, Tuangsit Wataganara, Kriengkrai Iemsawatdikul, Preeyacha Pacharn, Suparat Jaingam

Current Status and Future Prospects of Magnetic Resonance Imaging in Perinatal Medicine

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:5] [Pages No:89 - 93]

Keywords: Fetal magnetic resonance imaging, Fetal neuroimaging, Fetal therapy, Functional magnetic resonance imaging, Placental perfusion

   DOI: 10.5005/jp-journals-10009-1556  |  Open Access |  How to cite  | 


Fetal magnetic resonance imaging (MRI) has become an important adjuvant to high-quality ultrasound once fetal structural anomaly is identified. There are recently developed advanced techniques such as provision of volumetric data, spectroscopy, and functional MRI. Changes in local susceptibility caused by blood breakdown products, echo-planar imaging (EPI) sequences [i.e., diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC)] are especially sensitive to hemorrhage and edema. These novel sequences are particularly useful for assessment of fetal ischemic and hemorrhagic brain lesions. Prenatal MRI has been increasingly adopted in assessment and follow-up after in utero surgeries of twin–twin transfusion syndrome, congenital diaphragmatic hernia, lower urinary tract obstruction, and myelomeningocele. Development of guidelines to better define the role of fetal MRI in relation to prenatal diagnostic ultrasound can reduce the variation of sequence protocols, magnetic field intensity, as well as the use of gadolinium performed in different centers. Novel sequences may be used for research purposes, but safety concerns of obstetric MRI cannot be overlooked. The current utilities and future prospects of MRI in perinatal medicine are updated in this article.



Eberhard Merz

1989–2019: 30 Years of 3D Ultrasound in Obstetrics and Gynecology

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:5] [Pages No:94 - 98]

Keywords: Four-dimensional ultrasound, HDlive mode, Silhouette mode, Three-dimensional ultrasound

   DOI: 10.5005/jp-journals-10009-1557  |  Open Access |  How to cite  | 


Three-dimensional (3D)/four-dimensional (4D) ultrasound has profited greatly from the developments in computer and 3D probe technology. It has become such a sophisticated technique in the fields of prenatal diagnosis, gynecology, and breast diagnosis that it is indispensable for the skilled ultrasound operator. It represents a problem-solving tool in different circumstances, not only in the demonstration of pathological findings, but also in the verification of normal findings. This is particularly important in obstetrics in patients with an increased risk for a specific fetal malformation. In such a situation, the parents-to-be can easily be reassured by being shown the normal fetal anatomy. On the contrary, with the ability to demonstrate the fetus to the parents-to-be as in a photograph, there may be a risk that they believe 3D ultrasound to be able to detect any possible defect and can thus guarantee the “perfect baby.” However, this would definitively be the wrong conclusion.



Genzo Marumo, Junko Noguchi

Singleton and Twin Fetal Movements before 20 Weeks of Gestation

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:5] [Pages No:99 - 103]

Keywords: Fetal movement, First half of pregnancy, Fourdimensional ultrasound, Singleton pregnancy, Twin pregnancy

   DOI: 10.5005/jp-journals-10009-1558  |  Open Access |  How to cite  | 


Objective:To assess the change in the frequency of singleton and twin fetal movements with advancing gestation and compare the total number of fetal movements among singleton, active, and quiet twin fetuses at 12 to 19 weeks of gestation using four-dimensional (4D) ultrasound. Materials and methods: The 4D ultrasound was used to examine fetal movements in 58 singleton and 48 normal twin fetuses at 12 to 19 weeks of gestation. The frequencies of eight fetal movements were assessed through 15-minute recordings. The correlation between the frequency of each fetal movement in singleton and twin fetuses and gestational age was analyzed. The total number of fetal movements among singleton, active, and quiet twin fetuses was compared at 12 to 13 and 14 to 19 weeks respectively. Results: Frequencies of hand-to-face and leg movements were significantly increased with advancing gestation, whereas the frequencies of general movements significantly decreased at 12 to 19 weeks in singleton fetuses. Frequencies of body rotation and general movements were significantly decreased with advancing gestation, whereas the frequencies of mouthing movement significantly increased at 12 to 19 weeks in twin fetuses. The total number of fetal movements in singleton fetuses was significantly higher than that in quiet twins at 12 to 13 weeks of gestation, and there were significant differences in the total number of fetal movements between singleton fetuses and active or quiet twins at 14 to 19 weeks. Conclusion: Our results suggest that the characteristics of fetal movements in singleton and twin fetuses are different before 20 weeks of gestation. However, the data and their interpretation in the present study should be taken with some degree of caution because of the small number of subjects studied. Further studies involving a larger sample size are needed to draw the hard conclusions regarding the difference in fetal movements between singleton and twin pregnancies before 20 weeks’ gestation.



Raham Bacha, Syeda Khadija, M Athar A Shams

Umbilical Artery Doppler Waveform Indices at Term

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:4] [Pages No:104 - 107]

Keywords: Doppler indices (systolic/diastolic ratio, pulsatility index), Term, Umbilical artery

   DOI: 10.5005/jp-journals-10009-1559  |  Open Access |  How to cite  | 


Aim: This study was designed to evaluate umbilical artery Doppler indices [systolic/diastolic (S/D) ratio and pulsatility index (PI)] in normal fetus at term. Doppler ultrasound of umbilical arteries is widely accepted as a primary tool for quantitative analysis of fetoplacental and uteroplacental blood flow in highrisk pregnancies. Materials and methods: A total of 100 normal singleton pregnant women were recruited in this study from the Radiology Department Fatima Memorial Hospital (FMH) from August 3, 2012 to November 30, 2012. Their gestational ages were from 37 to 40 weeks. Results: A total of 100 Doppler indices measurements were performed. The values of S/D ratio were less than 3 and the values of mean PI were less than 1 from 37 to 40 weeks of gestation. Conclusion: Umbilical artery Doppler indices among normal pregnant women in our population are similar to most published reference values from other parts of the world. Clinical significance: This normative data will serve as a basis for the evaluation of the umbilical artery circulation in our population.



Alvaro Ruiz-Zambrana, María Aubá, Begoña Olartecoechea, Matías Jurado, Stefano Guerriero, Juan L Alcázar, Tania Errasti, José Á Minguez

Evaluation of the Four-dimensional “Spatiotemporal Image Correlation” Technology with High-definition Color Doppler as Third Step for Preoperative Differential Diagnosis of Ovarian Tumors: A Prospective Study

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:8] [Pages No:108 - 115]

Keywords: Adnexal masses, Power Doppler, Spatiotemporal image correlation, Two-dimensional, Ultrasound

   DOI: 10.5005/jp-journals-10009-1560  |  Open Access |  How to cite  | 


Aim: The purpose of this study is to analyze whether the addition of volumetric pulsatility indices (vPI) derived from spatiotemporal image correlation (STIC) assessment could improve the diagnostic performance of conventional two-dimensional (2D) ultrasound for discriminating benign from malignant adnexal tumors used as a third sequential step. Study design: Ours was an observational prospective cohort study between September 2014 to September 2016. Women diagnosed as having a persistent ovarian tumor evaluated at our center were included in this study. All women underwent transvaginal ultrasonography before surgery to assess the ultrasonographic characteristics of the lesion by gray-scale morphological analysis classifying the lesion as benign or suspicious based on “pattern recognition”. In benign lesions, no further test was conducted. For those tumors regarded as suspicious, assessment of the vascularization was performed by using conventional 2D high-definition flow color Doppler (2D-HDF), classifying the lesion as suspicious if vascularization within solid component was detected. In those lesions with intratumoral vascularization, four-dimensional (4D)-STIC technology with HDF was applied for calculating vPI. We used two reference standards: Definitive histology when the mass was surgically removed and in case the mass was not removed, those with spontaneous resolution or persistent without change and follow-up longer than 12 months were considered as benign. We compared diagnostic performance of conventional approach (pattern recognition followed by 2D-HDF) vs pattern recognition followed by 2D-HDF followed by 4D-STIC. Results: A total of 214 patients were included; 175 had a benign tumor and 39 a malignant tumor. We observed that vPI was significantly lower in malignant masses as compared with benign masses when 4D-STIC was used. Sensitivity and specificity of B-mode + 2D-HDF were 0.95 [95% confidence interval (CI): 0.83–0.98] and 0.92 (95% CI: 0.87–0.95) respectively. Sensitivity and specificity of B-mode + 2D-HDF + 4D-STIC were 0.95 (95% CI: 0.83–0.98) and 0.94 (95% CI: 0.90–0.96)respectively. No significant differences by adding the STIC were observed (McNemar test p > 0.05). Conclusion: The 4D-STIC does not improve the diagnostic performance of conventional ultrasound in the differential diagnosis of ovarian tumors as compared with conventional assessment using 2D ultrasound. However, a low vPI increases significantly the probability of malignancy in questionable masses.



Mandy Abushama, Ramez Rawhani, Amal Abdellatif

Antenatal Diagnosis of Fetal Skeletal Malformation

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:8] [Pages No:116 - 123]

Keywords: Antenatal ultrasound, Fetal skeletal dysplasia, Prenatal diagnosis

   DOI: 10.5005/jp-journals-10009-1561  |  Open Access |  How to cite  | 


Skeletal dysplasia encompasses a heterogamous group of disorders. In this disorder, there are abnormalities involving primarily the fetal skeleton and it may involve other fetal organs. These changes can be lethal or nonlethal. Over 300 types of this abnormality have been described in the literature. The incidence of this condition in the general population is small; however, it contributes significantly to prenatal mortality and morbidity. The etiology and mechanism leading to skeletal dysplasia are not fully understood. Skeletal dysplasia can be inherited as autosomal recessive, dominant, or ever as X-linked disorder and some are of somatic origin. Exposure to external teratogenic factors is a very rare cause of skeletal dysplasia. Antenatal diagnosis of this condition is not easy because of the large number of skeletal dysplasia and the ultrasound finding can overlap between different types of skeletal dysplasia. The newer technology in two-dimensional and three-dimensional ultrasound allows more meticulous studies. In this article, we will be discussing the most common lethal and nonlethal dysplasia, common methods of evaluating and diagnosing these malformations, and the new technique of noninvasive prenatal diagnosis (NIPD), which can play a major role in prenatal diagnosis of skeletal dysplasia.



Selma Porovic, Sonal Panchal

Fetal Behavior in Normal Pregnancy and Diabetic Pregnancy

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:13] [Pages No:124 - 136]

Keywords: Diabetic pregnancy, Fetal behavior, Kurjak's antenatal neurodevelopmental test, Normal pregnancy

   DOI: 10.5005/jp-journals-10009-1562  |  Open Access |  How to cite  | 


Ultrasound (US) has been the modality of choice for assessment of the development of the embryo and fetus in the womb. Threedimensional US has made the study of the fetal anatomy even more accurate and understandable. But fetal development is not only the development of the structures but also their functionality. The functionality of the kidneys, e.g., can be confirmed by urine production and filling of the bladder, the functionality of the bladder by its periodically emptying and filling, and that of the heart by fetal circulation. The function of the nervous system is the most complex and this can be studied by fetal movements and fetal expressions. The development of fetal motor behaviors can be studied by real-time US.1 The fetal activity observed or recorded with US equipment is fetal behavior.2 Study of the fetal movements has been found to be more correlating with the fetal central nervous system (CNS) development. Studies have shown that the development and maturation of the fetal nervous system is reflected by quality and quantity of fetal movements.3,4 On comparing the fetal movements with morphological studies, it was found that the fetal behavioral patterns directly reflected the development and maturation of fetal CNS. Therefore, assessment of fetal behavior in different periods of gestation can help to distinguish normal brain from abnormal during different phases of development.5 It also helps to make the diagnosis of functional and structural abnormalities earlier.6 B-mode or a two-dimensional (2D) US is impossible to understand the complexity of these movements and so till the invent of four-dimensional (4D) US it was not possible to correctly evaluate the fetal movements, especially fetal expressions. The details of fetal face and hands studied by 4D US have potential to generate information regarding fetal movement and behavior.7 There is a specific fetal behavioral pattern that corresponds to each week or trimester of fetal life and this pattern reflects the steps of human brain development and maturation.8-10



Placenta and Transvaginal Sonography

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:8] [Pages No:137 - 144]

Keywords: Low-lying placenta, Magnetic resonance imaging, Safety and accuracy of transvaginal sonography

   DOI: 10.5005/jp-journals-10009-1563  |  Open Access |  How to cite  | 


In recent years, transvaginal evaluation of the placenta has completely changed the way obstetricians need to perceive and assess a low-lying placenta. Additionally, the number of negative ultrasound examinations in morbid placental adherence has reduced. This article presents the evidence on the safety and accuracy of transvaginal placental evaluation and goes on to discuss the manner in which transvaginal findings should alter clinical protocols to optimize maternal and fetal outcomes. It also answers a very pertinent clinical question: How low is low?



Erasmo Huertas, Adelita Híjar, Igor Huerta, José C Elias, Armando Florez, Luis M Gomez

Successful Management of Fetal Hydrothorax associated with Hydrops

[Year:2018] [Month:April-June] [Volume:12] [Number:2] [Pages:3] [Pages No:145 - 147]

Keywords: Fetal hydrothorax, Hydrops, Pleural effusion, Prenatal treatment, Thoracoamniotic shunt

   DOI: 10.5005/jp-journals-10009-1564  |  Open Access |  How to cite  | 


We report a case of massive unilateral hydrothorax diagnosed at 18 weeks’ gestation in a fetus with normal karyotype. The fetus was affected severely by hydrops from 22 weeks. Initially, we performed a pleurodesis, but due to worsening hydrothorax evolving into hydrops, we proceeded with insertion of a transplacental thoracoamniotic shunt. Improvement was evident from 1 week after the procedure followed by resolution of hydrothorax for the remainder of the pregnancy. After a cesarean delivery at 37 weeks, the neonate required prolonged neonatal intensive care unit stay. He was discharged when he was 2 months old and has remained stable until the present time.


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