Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2020 | January-March | Volume 14 | Issue 1

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Nobuhiro Mori, Kenta Yamamoto, Kosuke Koyano, Takashi Kusaka

HDlive Flow with Spatiotemporal Image Correlation for Assessment of Fetal Goiter

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:3] [Pages No:1 - 3]

Keywords: 3D ultrasound, Fetal goiter, HDlive flow, Radiant flow, Spatiotemporal image correlation

   DOI: 10.5005/jp-journals-10009-1616  |  Open Access |  How to cite  | 


Case description: We present our experience of diagnosing fetal goiter using radiant flow and HDlive flow with spatiotemporal image correlation (STIC). A 39-year-old pregnant Japanese woman, gravida 3, para 1, with Graves\' disease was referred to our ultrasound clinic at 37 weeks and 1 day of gestation because of suspected fetal goiter. Two-dimensional (2D) sonography revealed enlarged thyroid glands (left lobe, 29.5 × 22 mm; right lobe, 32.9 × 21.2 mm). Radiant flow showed abundant blood flow on both lobes. HDlive flow with STIC clearly demonstrated spatial relationships of pulsatile dilated blood vessels in the fetal goiter. Our results suggest that HDlive flow with STIC shows precise spatial vascularity with pulsation of fetal goiter in utero.



Deeksha Pandey, Sri V Kummarapurugu, Gazal Jain, Keerthi Kyalakond, Priya Pai, MG Sayyad, Muralidhar V Pai

A Noninvasive Screening Tool for Abnormal Uterine Bleeding: An Attempt to Reduce Numbers of Endometrial Biopsies

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:7] [Pages No:4 - 10]

Keywords: Endometrium, Screening, Sonography, Uterine bleeding

   DOI: 10.5005/jp-journals-10009-1623  |  Open Access |  How to cite  | 


Introduction: Endometrial pathologies contribute to a large proportion of abnormal uterine bleeding (AUB). The aim of this study was to prospectively validate a novel scoring tool [diseases of endometrium–evaluation and risk scoring (DEERS)] as compared with the gold standard histology. Diseases of endometrium–evaluation and risk scoring is a scoring system based on patient characters and endometrial features that are visualized in gray scale transvaginal sonography (TVS). We hypothesized that this tool will help screen women who present with AUB for premalignant and malignant diseases of endometrium, in a noninvasive way. When performed routinely in women prior to subjecting them to endometrial sampling, it would reduce anxiety for the patient till the final histology report is awaited. It may also be used to help reduce the burden of unnecessary samplings to the clinicians as well as decrease the burden of histological slide review for the pathologist. Materials and methods: A total of 454 women were included. Patients with AUB in whom cervical, myometrial, ovarian, and endocrinal causes were ruled out and were planned for endometrial sampling were recruited for the study, as cases (n = 284). Women who were planned for hysterectomy for reason other than endometrial pathologies were taken as controls (n = 170). Preoperatively patient characteristics were noted, and TVS was performed to calculate DEERS for all. Results: In the study cohort, DEERS showed specificity of 100% for cancers, 88.12% for complex hyperplasia, 67.12% for benign lesions, and 76.35% for normal endometrium. However, the sensitivity of prediction was not encouraging. The 95% accuracy of the test for various lesions ranged from 60 to 97%. We noted a high efficacy (sensitivity of 72.2%, specificity of 92.1%) of DEERS in predicting malignant/premalignant diseases of endometrium, when coupled in one group. Conclusion: This scoring system looks promising for screening endometrial malignancy in women who present with AUB.



S Adelita Híjar, P Susy Ruiz, Saul Levy-Blitchtein

Fetal Massive Pericardial Effusion as a Sign of Bilateral Diaphragmatic Agenesis: A Case Report

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:3] [Pages No:11 - 13]

Keywords: Diaphragmatic, Fetal diaphragm agenesis, Fetal massive pericardial effusion, Fetal medicine, Fetal pericardial effusion, High risk pregnancies, Maternal fetal medicine, Perinatal outcome, Prenatal diagnosis, Ultrasonography

   DOI: 10.5005/jp-journals-10009-1622  |  Open Access |  How to cite  | 


Congenital diaphragmatic hernia (CDH) is an unusual fetal malformation that requires early diagnosis and treatment. Commonly, presentations are in the left side (85%), followed by right (13%) and only very few (2%) bilateral. The last one is a severe condition associated with high mortality rates, and very rarely these cases survive for surgical treatment. We describe the case of a 34-week male fetus with pericardial effusion in transabdominal ultrasound. Pericardiocentesis was performed, and the presence of liver was noticed at the thoracic cavity, confirming a diaphragmatic hernia. The newborn presented acute respiratory distress and died 1 hour after birth. Necropsy revealed complete diaphragmatic agenesis, pulmonary hypoplasia, and incomplete intestinal malrotation. Survival of these patients depends on cardiopulmonary function. Bilateral agenesis of the diaphragm associated with incomplete intestinal malrotation is a rare entity, and its significance requires further research.



Sally DE Mohammed, Mona AM Ali, Hassan Osman

Klippel–Feil Syndrome: A Rare Case Report

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:3] [Pages No:14 - 16]

Keywords: Cervical fusion, Klippel–Feil syndrome, Ultrasound

   DOI: 10.5005/jp-journals-10009-1624  |  Open Access |  How to cite  | 


Background: Klippel–Feil syndrome (KFS) is defined as a congenital fusion of two or more cervical vertebrae. The most common signs are short neck, low hairline at the back of the head, and restricted mobility of neck. Case description: A term, female child weighing 2,522 g was born to a 34-year-old, a third gravida mother with a previous history of two cesarean sections. She was delivered by an elective cesarean section and had Apgar scores of 4 and 6 at 1 and 5 minutes, respectively. Ultrasound done at 22-week gestational age showed a single, viable fetus with hydrocephalous, short broad neck, and extended limbs. After adequate obstetric, genetic counseling and given all the information about the risks involving this pregnancy, the parents opted for conservative management without any intervention. On examination, she had the typical triad of KFS, including very short neck, low occipital hairline, and reduced bilateral neck movements. The child died immediately due to respiratory distress. Her parents refused to consent for postmortem scanning. Conclusion: Although KFS is a rare syndrome encountered less commonly and a classical triad is present in almost 50% cases, one should closely investigate for other anomalies associated with it for better, early management and rehabilitation.



Cihat Sen, Frank Chervenak

Maternal Mortality: Tragedy for Developing Countries and Shame for Developed World

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:11] [Pages No:17 - 27]

Keywords: Maternal mortality rate, Millennium development goals report, Sustainable development, Under-five mortality, United Nations

   DOI: 10.5005/jp-journals-10009-1621  |  Open Access |  How to cite  | 


Aim: To present the data from United Nations 2005 and 2015 Millennium Development Goals (MDG) reports. Results: The World is faced with the increasing problem of inequality. That is why millennium declaration was signed in the year 2000. The United Nations millennium declaration embodies an agreement that developing countries will work to maintain sound economies, to ensure their own development and to address human and social needs. Developed countries, in turn, agree to support poorer countries through aid, trade, and debt relief. A meaningful partnership between rich and poor must also address developing countries\' need for technology, medicines, and jobs for their populations, particularly for the growing ranks of young people. In this paper, two MDG reports from 2005 to 2015 were presented with the analysis of the reasons for which the targets of MDG were not met and how World Association of Perinatal Medicine, International Academy of Perinatal Medicine, Ian Donald School of Medical Ultrasound and International Society Fetus as a Patient can help. Conclusion: More political efforts should be made in order to improve health of the mothers and infants in order to make this world sustainable.



How to Increase Resilience of Healthy Newborns in Underdeveloped Countries?

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:4] [Pages No:28 - 31]

Keywords: Infant health, Maternal health, Millennium Development Goals, Resilience, Salutogenesis

   DOI: 10.5005/jp-journals-10009-1619  |  Open Access |  How to cite  | 


Out of eight Millennium Development Goals (MDGs) derived from the Millennium Declaration, three (goals IV, V, and VI) were health related. High infant, under-five, and maternal mortality rates decreased in developing countries, but the rate was not satisfactory, because the preset targets were not achieved by 2015. The aim of this paper is to discuss whether the problems of neonatal health could be solved by the same approach as for the implementation of the MDGs or the paradigm should be changed. It is proposed to use Antonovsky's concept of salutogenesis, which is health oriented, meaning that it cares about conditions and mechanisms contributing to preserving health, opposing to pathogenesis aiming to investigate the pathogenesis of the disease with the semiology, symptoms, syndromes, and concepts of systemic, iatrogenic, or endogenous causes of disease. Besides that it is important to increase the resilience of mothers and neonates, understood as “the capacity, processes, or outcomes of successful adaptation in the context of significant threats to function or development.” Implementing Baby Friendly Hospital Initiative of the World Health Organization and UNICEF in developing countries can preserve health of healthy mothers and healthy newborn infants by increasing their resilience.



Milan Stanojevic

Health-dedicated Millennium Development Goals: What has been Done Wrong?

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:4] [Pages No:32 - 35]

Keywords: Child health, Maternal health, Millennium Development Goals, Newborn health, Reproductive health, Sustainable Development Goals

   DOI: 10.5005/jp-journals-10009-1620  |  Open Access |  How to cite  | 


Aim: To discuss the inequalities of maternal and infant health in developed and developing countries based on the United Nations Millennium Development Goals Report from 2015. Results: When almost 20 years ago United Nations General Assembly launched Millennium Development Goals (MDGs), there was a hope that inequalities in the world will be decreasing. Among the MDGs, there were goals 4 and 5 dedicated to the child and maternal health, mostly treating maternal, neonatal, and under-five mortality rates. The analysis of the achievement of MDGs revealed that time for developing countries to reach the same chance of neonatal survival as in 2012 for newborn babies in high-income countries, based on the average annual rate of reduction from 2000 to 2012, is for sub-Saharan Africa 110 years and for South Asia 99 years. These distressing data urged world leaders at United Nations Conference on Sustainable Development (Rio +20 Conference in 2012) to launch 17 Sustainable Development Goals (SDGs) to be implemented till 2030. Sustainable development goals differ from MDG because they cover all aspects of human life and development, such as environment, peace, justice, security, equality, education, and health, and SDGs apply to all countries not just to developing world. Most of the SDGs carry forward the matters not solved by the MDGs. In contrast to the MDGs, SDGs have been brought together within one framework as universal whole, with the interactions among them, which are brought into focus in the 2030 Agenda. Conclusion: There is a hope that approach offered by SDG can decrease existing gap in maternal and infant health in the world.



Frank Chervenak

Maternal Mortality in the USA

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:7] [Pages No:36 - 42]

Keywords: Hemorrhage, Maternal deaths, Maternal mortality, Preeclampsia, Thromboembolism, United states

   DOI: 10.5005/jp-journals-10009-1614  |  Open Access |  How to cite  | 


Maternal mortality is a major global concern. The time period of maternal death in the USA after delivery is extended for up to 1 year after pregnancy, while according to the World Health Organization (WHO) that period is only within 42 days after pregnancy termination, these two different definitions of maternal deaths, in the USA and by the WHO, make it impossible to precisely compare maternal death ratios between the USA and the remainder of the world. With this in mind, the USA is the only high-income country where maternal mortality rates seem to have increased over the last decades. The cause of the differences between the USA and other countries could be the reporting mechanism and the differences in maternal mortality definitions between the Centers for Disease Control and Prevention (CDC) and the WHO definition. The causes of the increase in maternal mortality in USA are unknown but could include the higher age of women having their first child, and the increase in the obesity and opioid epidemic. In the USA, about one third of maternal deaths happen during pregnancy, about one third happen at delivery or in the week after, and about one third happen 1 week to 1 year postpartum, and about 60% of maternal deaths are potentially preventable.



Vedran Stefanovic

Role of Obstetric Ultrasound in Reducing Maternal and Neonatal Mortality in Developing Countries: From Facts to Acts

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:7] [Pages No:43 - 49]

Keywords: Cesarean delivery, Low-income countries, Maternal mortality, Neonatal mortality, Sub-Saharan Africa, Ultrasound

   DOI: 10.5005/jp-journals-10009-1617  |  Open Access |  How to cite  | 


World Health Organization antenatal care recommendations include an ultrasound scan as a part of routine antenatal care. The impact of routine ultrasound imaging in terms of significantly improving the overall pregnancy outcome has been disputed by recent Cochrane review based on trials conducted mostly in developed countries. When ultrasound is used in high-risk pregnancies, its use becomes clearly beneficial. However, the fatal pregnancy outcomes (stillbirth, maternal, and early neonatal death) as end points are considerably rare in developed countries, while it must be highlighted that developing countries account for 99% of maternal and neonatal mortality. Also, considering the fact that there are no sufficient studies conducted in developing countries, particularly in rural settings and high-risk pregnancies, it is still unclear whether some positive impact as described in developed countries will produce similar results in low-income countries with specific problems and needs. This review not only provides further evidence of the promising potential of the use of ultrasound in resource-limited settings but also addresses some critical issues of maternity care in developing countries. Also, certain proposals and ideas about how to implement ultrasound in clinical practice to reduce maternal and neonatal mortality will be discussed.



Maternal Mortality: The Indian Story

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:4] [Pages No:50 - 53]

Keywords: Childbirth, Health, Moratality

   DOI: 10.5005/jp-journals-10009-1618  |  Open Access |  How to cite  | 


Maternal mortality is still a major problem of developing countries, and all the “so-called” developing countries have failed to achieve the Millennium Development Goal targets. Revised targets are given in Sustainable development goal (SDG) for maternal mortality rate (MMR) of 70. Due to multiple issues of women's health and empowerment and literacy, the targets have become different to achieve in India in the past few years. For the last 5 years, India has shown a new political will and a new multipronged drive to bring down MMR, and the results have been dramatic to bring the MMR down to 130. We are well on course to SDG-2030 goal of 70 MMR.



Abdel-Lateef Ashmaig, Mohammed Abdelmoneim

Improving the Quality of Training and Service in Obstetrics and Gynecology Practice

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:2] [Pages No:54 - 55]

Keywords: Obstetrics and gynecology, Task shifting, Training

   DOI: 10.5005/jp-journals-10009-1625  |  Open Access |  How to cite  | 


Improving the quality of training and service in obstetrics and gynecology practice starts at the community level [the patient and family, the midwife (MW), the community health worker (CHW)], goes through the higher levels of healthcare providers (doctors, nurses, secondary level healthcare facilities), and escalates to reach the government level. Both MWs and CHWs can play vital role in improving the quality of care provided. Task shifting, where responsibilities and tasks can be shifted from highly trained health workers to less highly trained health workers in order to maximize the efficient use of health workforce resources, needs to be appropriately addressed. Learning objectives: To acknowledge the importance of improving the quality of training and care. To acknowledge the vital role of MWs and CHWs. To acknowledge the importance of “task shifting”.



Orion Gliozheni, Elko Gliozheni

Some Solutions to Reduce Maternal Mortality

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:5] [Pages No:56 - 60]

Keywords: Antenatal care, Maternal morbidity, Maternal mortality, Skilled birth attendant, Unsafe abortion

   DOI: 10.5005/jp-journals-10009-1615  |  Open Access |  How to cite  | 


Background: Maternal mortality and morbidity remain an important public health priority and are key indicators of women's health worldwide. Data from the World Health Organization (WHO) show that about 295,000 women died during and following pregnancy and childbirth in 2017. About 13% of maternal deaths worldwide is due to unsafe abortions. The vast majority of these deaths (94%) occurred in low- and middle-income countries, and most could have been prevented. Severe maternal morbidity is nearly 100 times more common than maternal mortality and includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. Improving maternal health is one of the key priorities of WHO. Action to improve women's health includes safe obstetric access, skilled attendance at childbirth, adequate antenatal, postpartum and postabortion care in order to reduce maternal deaths, and severe pregnancy complications. Causes of maternal mortality and morbidity: The five most important direct causes of maternal mortality in developing countries that account for nearly 75% of all maternal deaths are severe bleeding, infections, unsafe abortion, high blood pressure during pregnancy, and complications from delivery. Some other factors also impact the poor maternal health outcomes such as the distance to facilities and, in some cases, inadequate and poor quality prenatal and maternity care services. Poor women in remote areas are the least likely to receive adequate healthcare. On the other side, adolescent girls face a higher risk of complications and death as a result of pregnancy than other complications. How can we reduce maternal mortality ratio? Delivery by skilled birth attendants is strongly recommended to reduce maternal and neonatal mortality. Skilled care before, during, and after childbirth can make the difference between life and death for the mother as well as for the baby. A good essential obstetric care should be accessible to address complications of childbirth. An adequate antenatal and postpartum care can significantly reduce maternal mortality and morbidity. To avoid maternal deaths, it is also very important to prevent unwanted pregnancies. Family planning is also very important for primary prevention of maternal mortality. Conclusion: Efforts to improve maternal outcomes could be done through programs of antenatal and postpartum care focused on the prevention and recognition of complications of pregnancy and childbirth. Substantial reduction in maternal mortality and morbidity will require long-term investment in community education and family planning and, ultimately, the empowerment of women. It is important to implement initiatives to understand the burden of severe maternal mortality and morbidity and to implement review processes for assessing potential preventability.



Abdallah Adra, Mariam Saad

Maternal Mortality among Refugees and in Zones of Conflict

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:3] [Pages No:61 - 63]

Keywords: Conflict zones, Maternal mortality, Refugees

   DOI: 10.5005/jp-journals-10009-1612  |  Open Access |  How to cite  | 


Every day, more than 500 women and girls in countries with emergency settings die during pregnancy and childbirth, due to the absence of skilled birth attendants or emergency obstetric procedures and unsafe abortion. Three chronologically ordered delays contribute to the increased maternal morbidity and mortality in conflict zones: (1) delay in recognizing the need to seek obstetrical care, (2) delay in reaching the medical facility, and (3) delay in diagnosing and receiving the proper care. When it comes to the causes of maternal mortality in states of conflict, the trends seem to be concordant with those seen in global estimations. Most common causes are preventable complications that could be avoided if proper care is given in the right time, including obstetrical hemorrhage, hypertensive disorders of pregnancy, and sepsis. Despite the apparent effects of war on interruption of access to reproductive healthcare, its direct consequences on pregnancy outcomes are less clear. Low birth weight, stillbirth, and prematurity were found to be consequences of conflict exposure. According to the World Health Organization, there are multiple evidence-based interventions that have been shown to reduce maternal morbidity and mortality, for which there is moderate- to high-quality evidence.



Aris Antsaklis

Maternal Mortality: What are Women Dying from?

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:6] [Pages No:64 - 69]

Keywords: Delivery, Maternal mortality, Pregnancy

   DOI: 10.5005/jp-journals-10009-1626  |  Open Access |  How to cite  | 


World Health Organization defines maternal death as the death of a woman while pregnant or within 42 days after delivery, irrespective of the duration and the location of pregnancy, and irrespective of the cause, as long as it is related to or aggravated by pregnancy or pregnancy's management, but not from accidental or incidental causes during pregnancy.1,2 Specifically for the year 2017, worldwide, every day, approximately 810 women died from possibly preventable causes related to pregnancy and childbirth. It is very important to highlight that of all maternal deaths, 94% occur in low- and lower middle-income countries, something that reveals the disparities of the quality of healthcare services that are provided in the different areas of the world. Another tragedy is that women are dying from preventable and treatable disorders such as hemorrhage, hypertensive disorders, sepsis, and abortions which still in some areas of the world are performed under very unsafe conditions. Because of these unacceptable reasons and percentages of maternal mortality, it was decided that actions must be taken to optimize world's future health, and the Sustainable Development Goals were decided by countries from all-around the world. These are 17 goals to be achieved by 2030 to decrease maternal mortality and improve the healthcare quality provided to these women. In this article, we will present the global, European and Greek trends about maternal mortality in line with the major causes that are responsible for maternal mortality. Additionally, the reasons why women mainly in low-income countries do not have timely and appropriate healthcare will also be discussed.



Ana Bianchi

Health System and Markers of Health in Uruguay

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:6] [Pages No:70 - 75]

Keywords: Health markers, Health system, Infant mortality, Maternal mortality, National sanitary goals

   DOI: 10.5005/jp-journals-10009-1627  |  Open Access |  How to cite  | 


We describe the implementation of a new National Health System in 2007 in Uruguay, South America, to improve the health for all the Uruguayan population and improve the markers of health. A health system for the private and public hospitals was set up under the strict control of the Ministry of Public Health. We identified 15 critical health problems unresolved, which were also considered important factors to improve and we control their improvement during the next years. The Integrated National Health System incorporated high-cost technology such as cardiac surgery, medication of high-cost chemotherapy, treatments for the burned, and programs of organ transplants completely subsidized by the health system.



Aliyu L Dayyabu, Mahmood K Magashi

From Safe Motherhood to Sustainable Development Goals: Unmet Targets; What are We Missing?

[Year:2020] [Month:January-March] [Volume:14] [Number:1] [Pages:3] [Pages No:76 - 78]

Keywords: Millennium development goals, Safe motherhood initiative, Sustainable development goals, Unmet targets

   DOI: 10.5005/jp-journals-10009-1613  |  Open Access |  How to cite  | 


Maternal mortality (MM) has been an important issue for years, but it is only within the last 50 to 100 years that the global health community has started focusing its attention on it. In an attempt to reduce MM, programs were formulated and implemented. Such programs include the safe motherhood initiative (SMI) of the 80s, the millennium development goals (MDGs: 2000 to 2015), and currently the sustainable development goals (SDGs). The SMI attempted to reduce MM but failed to do so as envisaged and to improve on it, the MDGs were implemented. Although the MDGs made significant inroads in reducing MM, like its predecessor, it failed to achieve 100% success. As we are on the verge of starting another attempt (SDGs), we must identify the impediments that limited the success of the two previous programs. We need to inject new innovations into the SDGs to make them a success. Emphasis should now be on information, access, and quality of care provided during the intrapartum and postpartum periods which are the times when most MM occur. New ideas such as setting up maternity clusters should be implemented for the hard-to-reach communities. This approach can be the panacea to reduce MM especially in the developing countries.


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