Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2021 | January-March | Volume 15 | Issue 1

PICTURE OF THE MONTH

Toshiyuki Hata, Riko Takayoshi, Aya Koyanagi, Takahito Miyake

Antenatal Diagnosis of Type-3 Vasa Previa

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:3] [Pages No:1 - 3]

Keywords: Transvaginal sonography, Type-3 vasa previa,Antenatal diagnosis, Color Doppler, Placenta previa

PDF  |  DOI: 10.5005/jp-journals-10009-1689  |  Open Access |  How to cite  | 

Abstract

Regarding type-3 vasa previa, some branches exit the placental surface and subsequently re-enter at the placental cotyledons. We present a case of type-3 vasa previa diagnosed at 32 weeks of gestation. A 38-year-old pregnant Japanese woman was re-examined using transvaginal color Doppler due to suspected vasa previa on previous routine obstetric examination. Color Doppler clearly showed a small velamentous artery near the internal cervical os. At 37 weeks and 6 days of gestation, a planned cesarean section was performed, resulting in a viable, single female newborn weighing 2,726 g. Placental examination showed peripheral insertion of the umbilical cord with one aberrant vessel.

ORIGINAL RESEARCH ARTICLE

Amandeep Singh, Gauravdeep Singh, Kamlesh Gupta

Estimation of Gestational Age by Using Fetal Kidney Length and Transcerebellar Diameter in Comparison with Other Biometric Indices

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:6] [Pages No:4 - 9]

Keywords: Fetal kidney length, Gestational age, Transcerebellar diameter

PDF  |  DOI: 10.5005/jp-journals-10009-1678  |  Open Access |  How to cite  | 

Abstract

Background: The knowledge of accurate estimation of gestational age (GA) for an obstetrician is first and foremost to date the pregnancy as early as possible during the antenatal period for proper management of all the pregnancies. Ultrasound parameters like BPD, HC, AC and FL in second and third trimesters are not very reliable for dating the pregnancy. Fetal kidney length (FKL) and transcerebellar diameter (TCD) have been studied and shown to strongly correlate with the gestational age. Materials and methods: A prospective observational study was conducted on 600 women with normal singleton pregnancies. Fetal kidney length and transcerebellar diameter were measured using Voluson E8 (Wipro GE) ultrasound machine. Statistical analysis was done using tests of correlation and simple linear regression. All analysis was done by using SSPS statistics 24.0. Results: The result indicates that the fetal kidney length and transcerebellar diameter in the present study correlated well with the assigned gestational age. A positive linear relationship of gestational age with fetal kidney length and transcerebellar diameter was found. Correlation of gestational age with fetal kidney length and transcerebellar diameter was 0.875 and 0.975 respectively. Conclusion: The present study reveals that fetal kidney length and transcerebellar diameter can be used as parameters in estimating gestational age, especially in later trimesters, where biometric indices may not be much reliable.

REVIEW ARTICLE

Asim Kurjak, Milan Stanojevic, Panagiotis Antsaklis

Recent Results and Future Challenges in the Assessment of Fetal Brain Function

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:28] [Pages No:10 - 37]

Keywords: Structure and function of fetal brain,Cerebral palsy, KANET test, Prenatal neurology

PDF  |  DOI: 10.5005/jp-journals-10009-1682  |  Open Access |  How to cite  | 

Abstract

Clinical and epidemiological studies have revealed that cerebral palsy (CP) most often results from prenatal rather than perinatal or postnatal causes. Currently, although the momentous advances in prenatal and perinatal care, there is no mean to identify or expect the development of these disorders. Therefore, the development of diagnostic strategies to avoid and condense the saddle of perinatal brain damage has to turn into one of the most imperative tasks of contemporary perinatal medicine. The application of the new neurobehavioral test KANET might improve our understanding of prenatal neurodevelopmental events and possibly antenatal detection of CP and other neurological diseases.

REVIEW ARTICLE

Simona Vladareanu, Mihaela Boț, Anca Burnei, Ioana Calo, Radu Vladareanu

The KANET Test in Twin Pregnancies

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:5] [Pages No:38 - 42]

Keywords: Neurodevelopment,Behaviour, Neurological disorders, Cerebral palsy, Review, Dichorionic twin, Twin pregnancies, Fetal movements, Ultrasonography, Four-dimensional ultrasound, KANET test, Monochorionic twin

PDF  |  DOI: 10.5005/jp-journals-10009-1680  |  Open Access |  How to cite  | 

Abstract

The revolution of ultrasonography in obstetrics has enabled us to assess the neurological development of the fetus in utero. The KANET test has proven to be a useful tool in identifying neurological anomalies and might have the potential to early on diagnose pathologies that nowadays can be diagnosed only postpartum. Studies have shown a strong correlation between antepartum evaluation using four-dimensional ultrasonography for the assessment of the fetal behavior and postpartum neurodevelopment. Studying twin pregnancies can offer us even more insight into fetal development, as they are considered high-risk pregnancies with a higher incidence of lower-weight newborns predisposed to neurological disorders such as cerebral palsy. As neurological disorders are frequently identified in high-risk pregnancies, we reviewed the latest studies on twin pregnancies. We also studied KANET integration in a routine fetal assessment and observed its role in reducing the complications and even in treating neurological disorders prenatally. Along with our personal experience in applying the KANET test in the evaluation of twin pregnancies with a 2-year postnatal follow-up, we hope that a better understanding of fetal neurodevelopment should be reached.

REVIEW ARTICLE

Aris Antsaklis

Obesity in Pregnancy: A New Chapter in Obstetrics

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:6] [Pages No:43 - 48]

Keywords: Obesity epidemic,Cesarean section, Diabetes, Macrosomia

PDF  |  DOI: 10.5005/jp-journals-10009-1679  |  Open Access |  How to cite  | 

Abstract

Obesity is a worldwide health problem affecting more than 35% of the adult population in the USA. Obesity is the greatest epidemic ever experienced by humans and resulting from increasing population increasing lifespan, urbanization, plentiful food and physical inactivity. The rate of obesity has doubled over the past decade. Percentage of women who are overweight or obese has increased by 60% over the past 30 years. The mean BMI has increased over the past 20 years leading to adverse metabolic effects on blood pressure, cholesterol and triglyceride concentration and insulin resistance, thereby increasing the risk: (1) for coronary disease and ischemic stroke, (2) for type 2 diabetes, and (3) for polycystic ovary syndrome (PCOS). Maternal obesity in pregnancy (MOP) has been associated with fertility implications both genders pregnancy complication, such as preterm delivery, shoulder dystocia, and adverse outcome including hypertensive disorders, gestational diabetes and need for operative delivery (cesarean section and instrumental vaginal delivery). Maternal obesity also has a significant impact on fetal development on neonatal period and overall on childhood development. Modification to routine prenatal care has been suggested for this population such as screening for diabetes in early pregnancy, limiting gestational weight gain, routine ultrasound for gestational age, fetal anatomic survey and antenatal surveillance with NST and BPP scoring and fetal echocardiography, screening for fetal aneuploidy. Obesity can affect screening test performance. Cell-free fetal DNA screening is more likely to result in test failure, low-dose aspirin to reduce the risk of preeclampsia and evaluation by anesthesiologist. Delivery timing and indications for labor induction should not be altered based on maternal obesity. For women undergoing cesarean delivery, prophylactic antibiotics should be administered based on maternal weight.

REVIEW ARTICLE

Zorán Belics, Zoltan Papp

Ultrasonographic Assessment of the Cervix for Prediction of Spontaneous Preterm Birth in Singleton Pregnancies

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:15] [Pages No:49 - 63]

Keywords: Digital examination, Perinatal morbidity, Perinatal mortality, Pregnancy, Prematurity, Transabdominal ultrasound, Transvaginal ultrasound

PDF  |  DOI: 10.5005/jp-journals-10009-1683  |  Open Access |  How to cite  | 

Abstract

Spontaneous preterm birth remains a major cause of neonatal morbidity and mortality across the world. Hence, there is an urgent need to find and implement diagnostic methods and interventions that can reduce this public health treat. The ultrasonographic assessment of the cervix is one tool that can be utilized to identify women at increased risk who may be candidates for preventive interventions. There are three main characteristics of the cervix, which can be evaluated during the ultrasound examination of the cervix: cervical length (CL), funneling and cervical gland area. Cervical shortening is one of the first steps in the processes leading to labor and can precede labor by several weeks. Because shortening begins at the internal cervical os and progresses caudally, it is often detected on ultrasound examination before it can be appreciated on physical examination. This is equally true for funneling and cervical gland area (CGA), which cannot be assessed with the physical examination. Based on previous experiences, the timing and frequency of ultrasonographic assessment of the cervix is primarily based on the patient\'s prior obstetric history (low-risk women are screened once at 18–24 weeks of gestation; high-risk population usually begins screening at about 16 weeks of gestation and the frequency depends on the measurement result). Classically the diagnosis of short cervix is defined when the CL is less than or equal to 25 mm at these gestational weeks, with the best prediction for PTB obtained at 16–24 weeks of gestation. The CL measurement, evaluation of funneling and CGA together increased the sensitivity of cervical screening for PTB and appeared to be powerful predictor of PTB before 32 weeks gestation. Generally, the importance of positive test is to try to recognize cervical changes on time, to plane the adequate therapy, to prepare for sufficient intrauterine transport, and to administered course of antenatal corticosteroid therapy to women at risk for PTB reduced the incidence and severity of respiratory distress syndrome (RDS) and mortality in offspring. Many interventions (bed rest, lifestyle intervention, cervical cerclage, pessary, progesteron, indomethacin, antibiotics, etc.) have been proposed in an attempt to prevent PTB depending on risk classification.

REVIEW ARTICLE

Orion Gliozheni, Elko Gliozheni

Congenital Uterine Anomalies: Impact on Perinatal Outcomes

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:17] [Pages No:64 - 80]

Keywords: Congenital anomalies, Miscarriage, Mullerian anomalies, Perinatal outcome, Preterm delivery, Uterine anomalies

PDF  |  DOI: 10.5005/jp-journals-10009-1685  |  Open Access |  How to cite  | 

Abstract

Congenital anomalies of the female reproductive system are defined as deviations from normal anatomy, and present a diagnostic challenge because of the variety of morphologic presentations. They are the result of abnormal development of the Müllerian ducts during embryogenesis. These anatomic disorders occur frequently and may result from genetic mutation, developmental arrest or acquired defects. Disorders range from congenital absence of the vagina and uterus, to defects in lateral or vertical fusion of the Müllerian ducts. A variety of anatomic defects may also be found in the urinary system. These anomalies are often asymptomatic and unrecognized. The true prevalence of uterine anomalies in the population is unknown. A recent major study indicated the prevalence of uterine anomalies (including minor anomalies, such as hypoplastic or arcuate uteri) about 7–8% in the normal fertile population and >25% in women with recurrent spontaneous abortions. Less than half, have clinical symptoms. Provided there is no obstruction to menstrual flow, these uterine anomalies present few problems in the absence of pregnancy. In the presence of pregnancy there is an increased incidence of miscarriage, poor fetal growth and malpresentation or placental adherence. The risk of spontaneous abortions in this group, during the first-trimester is 28–45%, while in the second-trimester is 5%. There are different uterine anomalies. A complete failure of fusion between the ducts results in a didelphic uterus. A partial failure results in an arcuate or bicornuate uterus. A failure of septal resorption results in variants ranging from a subseptate to a septate uterus. Atresia of one of the paramesonephric ducts results in a unicornuate uterus with a single tube. A differential diagnosis is very important, because of prognosis for reproduction and the choice of the most suitable surgical approach. Women with uterine anomalies are known to have a higher incidence of infertility, pelvic pain, recurrent pregnancy loss, preterm labor, fetal mortality, fetal growth restriction, preterm rupture of membranes, abnormal fetal presentation, retained placenta, and increased cesarean delivery rate. US is often the first imaging modality chosen because of its availability, short scan time, and low cost, several limitations are encountered during imaging. Transvaginal imaging, although superior to the transabdominal approach, may not always be possible, as in young girls or patients with vaginal septa. Detection of uterine anomalies by 3D ultrasound or MRI has really increased the accurate diagnosis of these anomalies. Several studies have examined pregnancy outcomes for each specific uterine anomaly. Women with an arcuate uterus have a similar reproductive outcome to women with a normal uterus. The unicornuate uterus has the poorest overall reproductive outcome, and the septate uterus has an increased miscarriage rate. The didelphic uterus, also has poor obstetrical outcomes. Didelphic, bicornuate, unicornuate, and septate uteri have also lower pregnancy rates in ART. Conclusion: Women with congenital uterine malformation usually have poorer reproductive outcomes and higher incidence of complications during pregnancy and delivery. Early diagnosis and treatment can improve obstetric outcomes.

REVIEW ARTICLE

Aleksandar Ljubic, Dušica Ljubić, Tatjana Bozanovic

Implantation and the Fetal Health

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:6] [Pages No:81 - 86]

Keywords: Endometrium, Gametes, Oocyte, Semen,Dysfunctional implantation, Embryo

PDF  |  DOI: 10.5005/jp-journals-10009-1684  |  Open Access |  How to cite  | 

Abstract

Dysfunctional implantation and the formation of the placenta can endanger life and health of both the fetus and the mother, during prenatal life and decades after delivery. The changes that lead to the insufficient implantation should be sought in the preimplantation period, in relation between the embryo and the endometrium. Prepregnancy approaches such as weight management, blood pressure and blood sugar control, smoking cessation, and optimization of the pregnancy interval may improve implantation and placentation, and lead to better pregnancy outcomes. Gametes: The birefringence properties of the meiotic spindle and the zona pellucida are indicative of good health of the oocyte. Very useful data can be obtained from the application of studying gene expression from cumulus cells, using microarrays, as biomarkers for oocyte viability. The metabolomic profiling of oocyte spent culture media by mass spectroscopy has shown differences related to oocyte maturation, embryo development and implantation success. Oocyte quality can be assessed by the measurement of oocyte oxygen consumption. The role of the number and function of mitochondria in the development of quality oocytes is surely very important. The correction of the gene signaling, or autologous tissue genetic bioengineering is certainly a step forward in obtaining the quality gametes. The stem cells can be influenced by the stem cell therapy in order to obtain the intracellular communication with existing ovarian primordial oogonia. The sperm chromatin and DNA integrity are necessary to ensure normal embryo development. Magnetic-activated cell sorting technology for sperm could improve obstetric and perinatal outcomes. Embryo: The invasive technology means preimplantation genetic testing (PGT), the aneuploidy screening or diagnosis of specific genetic disorders of the embryo before the transfer by using next-generation sequencing (NGS). Noninvasive time-lapse embryo monitoring allows continuous embryo observation without the need to remove the embryo from optimal culturing conditions. Recently, the developed strategies including the genomic, transcriptomic, and proteomic approaches, have been applied in assisted reproduction. Their goal is to identify a “molecular profile” of embryo development by detecting the chemical components in the oocyte, granulosa cells, follicular fluid, and embryo culture medium. Endometrium: The medical treatment with estrogens, vasodilators, sildenafil citrate has neither led to significant improvements of morphological parameters nor to the results in terms of increasing of implantation and reduction of the number of miscarriages. There have been reports of trials with immunoglobulins and anticoagulants in pregnancy complication prevention, as well as the intrauterine administration of autologous peripheral blood mononuclear cells (PBMCs), especially when pretreated with corticotropin-releasing hormone (CRH) that acts by regulating apoptosis of activated T-lymphocytes at the implantation site. The quality of endometrial thickness, implantation rate and pregnancy success, and the reduction of the complications, miscarriage rate, is attempted by flushing uterus cavity with autologous platelet-rich plasma (PRP) in preparation for the implantation during IVF process.

REVIEW ARTICLE

Radu Vlădăreanu, Simona Vladareanu, Mihaela Bot

Fetal Arrhythmia and Related Fetal and Neonatal Outcome

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:10] [Pages No:87 - 96]

Keywords: Doppler mode, echocardiography, Fetal cardiac arrhythmia, M mode

PDF  |  DOI: 10.5005/jp-journals-10009-1687  |  Open Access |  How to cite  | 

Abstract

The evolution of fetal echocardiography (Motion and pulsed Doppler modes) has made possible the antenatal diagnosis of cardiac rhythm anomalies. Fetal cardiac arrhythmias are common anomalies, 20% of which are potentially dangerous. M-mode (motion-mode) echocardiography recording of the fetal heart cannot identify electrical events in the heart, but does depict the mechanical events that succeed them. Pulsed Doppler echocardiography identifies possible arrhythmias over a period of time, allowing for the measurement of these time intervals, a parameter absolutely necessary for the classification of various types of cardiac arrhythmias. Irregular cardiac rhythm (premature atrial contraction, premature ventricular contractions) is the most common disorder seen in practice in specialized fetal echography. These anomalies are usually benign and resolve spontaneously until delivery, thus do not require treatment. Fetal tachyarrhythmia (increased heart rate of 160–189 bpm) is detected by echocardiography, with a wide range of rhythm disorders. It is imperative to understand the mechanism of tachyarrhythmia, so that an accurate and rational management strategy can be formulated in each case. Fetal bradyarrhythmia is characterized by frequent irregular rhythm, low sustained heart rate (10 seconds–few minutes), below 110 bpm, or a combination of both. The diagnosis of the specific bradycardia depends on the echocardiogram findings and the atrioventricular conduction pattern.Once fetal bradycardia is noted, a quick fetal ultrasonographic examination should be performed to assess the normal fetal movements, fetal tone, thus contributing to the diagnosis of fetuses in distress, who require emergency delivery by cesarean section. This paper is an update of the diagnostic approaches in the current practice for different types of fetal heart rhythm disorders, the impact on the fetus and the newborn and their management.

REVIEW ARTICLE

Apostolos Zavlanos, Ioannis Tsakiridis, Ioannis Chatzikalogiannis, Apostolos Athanasiadis

Early- and Late-onset Intrauterine Growth Retardation

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:12] [Pages No:97 - 108]

Keywords: Complications, Small-for-gestational-age, Delivery, Ultrasound, Diagnosis, Fetal growth restriction, Intrauterine growth retardation, Management, Other, Prevention

PDF  |  DOI: 10.5005/jp-journals-10009-1686  |  Open Access |  How to cite  | 

Abstract

Aim and objective: The scope of this literature review was to synthesize the available evidence on the diagnosis and management of early and late-intrauterine growth retardation (IUGR). Background: Intrauterine growth retardation is a common obstetric complication affecting about one out of 10 pregnancies and may be associated with both short- and long-term adverse outcomes. Review results: Risk factors for IUGR include maternal, fetal and placental parameters like smoking, chromosomal abnormalities and placental mosaicism. Early-IUGR, usually correlated with preeclampsia, is difficult to manage, while late-IUGR may not be promptly diagnosed, but is associated with lower mortality. In addition, both entities follow different patterns of progression. For each case, ultrasound growth evaluation at 2-weeks intervals and regular Doppler monitoring are needed, along with cardiotocography. Moreover, a normal umbilical artery Doppler pattern in the third trimester endorses a normal pregnancy in the early-IUGR, but as for the clinical follow-up of late-IUGR fetuses, cerebroplacental ratio is the appropriate parameter for monitoring. Thus, timing of delivery is usually affected by these factors. Finally, the combined first-trimester screening might help in the prediction of IUGR. Conclusion: The diagnosis of fetal hypoxia in the third trimester remains a challenge for modern obstetrics. Hence, all fetal-maternal units should adopt and follow their own protocol for the management of IUGR. Clinical significance: IUGR remains a major problem in both developing and developed countries and several causes have been identified. More research in the field of prevention and the appropriate timing of delivery would probably improve perinatal outcomes of the affected fetuses.

PROSPECTIVE COHORT STUDY

Mohamed S Sweed, Gasser A El-Bishry, Amgad E Abou-Gamrah, Mohamed M AbdEl-Hamid, Eman A NasrEl-Din, Gihan E El-Hawwary

First-trimester 3D Power Doppler of Uteroplacental Circulation and Placental Volume for the Prediction of Preeclampsia: A Prospective Cohort Study

[Year:2021] [Month:January-March] [Volume:15] [Number:1] [Pages:5] [Pages No:109 - 113]

Keywords: Three-dimensional, Ultrasonography,Cohort studies, Doppler, Duplex, Imaging, Placenta, Preeclampsia

PDF  |  DOI: 10.5005/jp-journals-10009-1681  |  Open Access |  How to cite  | 

Abstract

Aim and objective: To evaluate the role of first-trimester 3D power Doppler of placental circulation and placental volume in the prediction of poor pregnancy outcomes. Materials and methods: This prospective cohort study included 375 pregnant women. 3D scans for the determination of placental volume and vascularization indices were performed. The primary outcome was the occurrence of preeclampsia (PE). Results: Placental 3D power Doppler indices were significantly lower in women who developed PE [vascularization index (VI) = 3.13 ± 2.1, flow index (FI) = 14.9 ± 9.3, vascularization flow index (VFI) = 0.1 ± 0.9] and fetal growth restriction (FGR) (VI = 4.5 ± 2.4, FI = 15.3 ± 7.9, VFI = 0.3 ± 0.6) compared with those who did not (VI = 9.7 ± 1.9, FI = 28.9 ± 4.6, VFI = 1.8 ± 1.4) (VI = 10.9 ± 1.6, FI = 30.9 ± 7.6, VFI = 1.9 ± 0.9), respectively (p < 0.001). The cutoff values for the prediction of PE were VI ≤ 3.22, FI ≤ 17.73, and VFI ≤ 0.5, while those for the prediction of intrauterine FGR were VI ≤ 4.12, FI ≤ 15.93, and VFI ≤ 0.3. Conclusion: First-trimester evaluation of placental bed vasculature with 3D power Doppler can be used as a good predictor of PE. Clinical significance: First-trimester 3D power Doppler of placental bed vasculature can help early prediction of PE and FGR allowing early intervention giving opportunity for better pregnancy outcomes.

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