Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2019 | January-March | Volume 13 | Issue 1

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Megumi Ishibashi, Chiaki Tenkumo, Tomoya Yamashita

HDlive Flow for Diagnosis of Invasive Mole

[Year:2019] [Month:January-March] [Volume:13] [Number:1] [Pages:3] [Pages No:1 - 3]

Keywords: HDlive flow, HDlive flow silhouette, HDlive silhouette inversion mode, Invasive mole, Radiant flow

   DOI: 10.5005/jp-journals-10009-1579  |  Open Access |  How to cite  | 


Our experience of using HDlive flow or HDlive flow silhouette to diagnose invasive moles is presented. In the first case, a large ill-defined hypervascular mass occupying the entirety of fundal and anterior lesions of the uterus was identified using HDlive flow silhouette. The patient was successfully treated with methotrexate. In the second case, a circumscribed hypervascular tumor of the uterus was identified with HDlive flow. This patient was refractory to methotrexate and actinomycin-D and was successfully treated with etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine (EMA/CO). Based on ultrasound features, the difference in drug susceptibility between chemosensitive and refractory invasive moles may be due to the vascularity of the mass in the uterus.



Gabriella Minneci, Giuseppe Cali, Francesco Forlani

Three-dimensional Ultrasonography and Three-dimensional Power Doppler in the Evaluation of Placenta Accreta Spectrum

[Year:2019] [Month:January-March] [Volume:13] [Number:1] [Pages:6] [Pages No:4 - 9]

Keywords: Diagnosis, Four-dimensional ultrasonography, Impaired placentation, Placenta, Three-dimensional power Doppler

   DOI: 10.5005/jp-journals-10009-1580  |  Open Access |  How to cite  | 


Due to the increased rate of cesarean sections in the last decades, the anomalies of placental implantation and invasion have become an emerging pathology. Undetected prenatally, severe forms of invasive placentation can lead to dramatic consequences such as a uterine rupture in labor, peripartum hemorrhage, necessity of hysterectomy and massive blood transfusions. That is the reason why the prenatal diagnosis of impaired placentation plays a key role to detect patients at risk, who should be referred to tertiary perinatal centers. If the diagnosis of abnormal placentation is confirmed, the next step should be to define the degree of placental invasion. Twodimensional ultrasonography (2D-US) is the technique mainly used to diagnose the placenta accreta spectrum (PAS), but its accuracy could be possibly increased by the complementary use of the three-dimensional (3D) US and 3D power Doppler. Only a few prospective studies are available on the role of 3D US in the detection of PAS without establishing objective, universally acceptable ultrasonographic diagnostic criteria. Moreover, diagnosis is subjective with accuracy depending on the experience of the operator. 3D power Doppler technique seems to have a good intraoperator but low interoperator reproducibility, because it needs a rigorous standardization of predetermined machine settings. Multicentric studies are needed to identify common and objective 3D US and 3D power Doppler diagnostic criteria for PAS, to reduce interoperator variability.



HDlive Flow Silhouette Mode for Fetal Heart

[Year:2019] [Month:January-March] [Volume:13] [Number:1] [Pages:13] [Pages No:10 - 22]

Keywords: Congenital heart anomaly, Fetal heart, HDlive flow, HDlive flow silhouette mode, Prenatal diagnosis

   DOI: 10.5005/jp-journals-10009-1581  |  Open Access |  How to cite  | 


The HDlive flow silhouette mode is the latest technology to demonstrate vitreous-like clarity of blood flow and can preserve and delineate the outline and borders of the blood flow while showing its core as semitransparent. Therefore, holographic visualization of the fetal cardiac blood flow can be achieved. We can choose the combination of the HDlive flow or HDlive flow silhouette mode with glass-body rendering mode or HDlive silhouette mode for evaluation of the fetal heart. We can also evaluate the fetal heart from any direction, especially using five special views (frontal, spatial three-vessel, panoramic, posterior, and right lateral views). In this paper, HDlive flow silhouette mode characteristics of the normal fetal heart and congenital heart anomalies are shown using various images. The HDlive flow silhouette mode may help evaluate the normal fetal heart and diagnose congenital heart anomaly during pregnancy as an adjunctive diagnostic tool.



4D in Functional Studies of the Fetus

[Year:2019] [Month:January-March] [Volume:13] [Number:1] [Pages:11] [Pages No:23 - 33]

Keywords: Fetal behavior, Four-dimensional ultrasonography, KANET test, Neurodevelopmental impairment

   DOI: 10.5005/jp-journals-10009-1582  |  Open Access |  How to cite  | 


Assessing fetal neurobehavior has been a great challenge since the first steps of fetal medicine. The introduction of three-dimensional (3D) and four-dimensional (4D) ultrasound technology offered the opportunity to not only examine the fetus anatomically with explicit detail but also to observe the fetus directly and examine its behavior in real time, as one would examine a neonate. The development of the fetal central nervous system (CNS) follows a very structured path and these developmental steps are reflected by the behavior of the fetus in utero for each corresponding week or trimester. Which fetal movements develop during each month and which fetal behavioral patterns are normal or abnormal have been identified. In the same way that a neonatologist can understand by its motoric function if a neonate is premature or not. Similarly, we can now understand which fetal movements-behavioral pattern corresponds to each trimester of pregnancy. Structural and functional impairment of the brain can develop at any time during pregnancy. The structural anomaly of the brain is much easier to detect than functional. Delayed diagnosis of a neurological problem will make the possibility of timely treatment is rather doubtful. It is clear that the assessment of fetal neurological status is of utmost importance, and should be practiced both as a screening test for low- and high-risk pregnancies. The most complete method so far for the assessment of fetal neurobehavior, that relays on real time observation of the fetal behavior with 4D ultrasound and its efficacy has been tested through many multicentric studies is Kurjak's antenatal neurodevelopmental test (KANET). KANET has been introduced in everyday clinical practice and aims to assess the fetal behavior in a similar way that a neonate is assessed postnatally, through 4D ultrasound technology. The KANET has been introduced into systematic training and already ultrasound specialists have been certified to perform this test. Hopefully, application of KANET on larger populations, both high and low risk, will give more knowledge regarding early detection of fetuses at risk for neurological impairment, to allow accurate diagnosis prenatally, and as a consequence prompt intervention that could improve the outcome of some of these neonates postnatally.



Eberhard Merz, S Pashaj

Anomalies of the Fetal Face

[Year:2019] [Month:January-March] [Volume:13] [Number:1] [Pages:7] [Pages No:34 - 40]

Keywords: Congenital anomalies, Fetal face, Three-/Fourdimensional ultrasonography

   DOI: 10.5005/jp-journals-10009-1583  |  Open Access |  How to cite  | 


Visualization of the fetal face with three- and four-dimensional (3D/4D) ultrasound is a unique experience for both, the parents-to-be and the operator. While the future parents are primarily interested in seeing the surface of the fetal face and facial movements, the operator uses the different display modes for a precise fetal malformation check. The multiplanar mode with a simultaneous display of the three perpendicular planes allows an accurate demonstration of a normal or an abnormal fetal profile. Even if an image of the fetal face is acquired in an oblique position, the stored volume can be rotated by the rotational controls in all three directions, until the face is seen precisely in the median plane. The different surface modes enable the operator to detect abnormal protuberant structures or surface defects, while the transparent mode (maximum mode) reveals ossification defects. During a targeted ultrasound examination of the fetal face, five different regions have to be assessed: the forehead, orbits and eyes, nose, mouth, and chin. With 3D ultrasound the following fetal anomalies can be detected: anomalies including the forehead (anencephaly, protuberant forehead, abnormal metopic suture, frontal encephalocele/meningocele), anomalies of the orbits and the eyes (orbital hypoplasia/ microphthalmia, hypertelorism, hypotelorism, cataract, nasolacrimal cyst/dacryocystocele, cyclopia/proboscis), abnormalities of the nose (flat nose, absent nasal bone), abnormalities of the mouth (cleft lip/cleft palate, epignathus, macroglossia, chin anomaly (retrognathia/micrognathia). 3D ultrasonography allows a comprehensive evaluation of the fetal face with different display modes. In contrast to 2D ultrasound, 3D ultrasound enables a detailed demonstration of the soft tissue of the fetal face and thus contributes to a better understanding of the malformation by both the physician and the future parents.



Oliver Vasilj, Aida Saligahiæ Kadiæ, Anja Šurina

Fetal Cognitive Functions and 3D/4D Ultrasound

[Year:2019] [Month:January-March] [Volume:13] [Number:1] [Pages:13] [Pages No:41 - 53]

Keywords: Fetal behavior, Fetal cognitive function, Fetal stress, Four-dimensional ultrasonography

   DOI: 10.5005/jp-journals-10009-1584  |  Open Access |  How to cite  | 


In the past decades, advances in modern imaging methods, especially three-dimensional/four-dimensional ultrasound (3D/4D US), functional magnetic resonance imaging (fMRI) and fetal magnetoencephalography (fMEG), enabled the studies of the important neurodevelopmental events and opened the field of the investigation of fetal cognitive functions. Prenatal structural, functional and behavioral development, including the development of the central nervous system (CNS) and cognitive functional developments, are nowadays accessible to a better assessment due to the implementation of these methods. 3D/4D ultrasound imaging provides much important information about the fetus. It can detect various malformations and clarify suspicious findings, improve diagnostic accuracy, display fascinating fetal activity and also, it supports the advancements in fetal neurobehavioral and cognitive science. In this paper, a brief review of 3D/4D US assessed insights in the field of fetal neurodevelopment, particularly the development of fetal cognitive functions: sensory perception, motor action, emotions, learning, and memory, as well as the role of the fetal stress in cognitive development are discussed. Investigation of fetal cognitive functions is still in its beginning, but it is certain that future advances in the application of new imaging methods, such as different 3D/4D US modes and fMRI, will enable a better understanding of the cognitive abilities and functions of the fetus.


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