Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2022 | October-December | Volume 16 | Issue 4

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Toshiyuki Hata, Tomomi Yamanishi, Tomomi Kawahara, Aya Koyanagi, Riko Takayoshi, Takahito Miyake

HDlive Flow Features of Transposition of Great Arteries with Ventricular Septal Defect, Pulmonary Stenosis, and Persistent Left Superior Vena Cava

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:3] [Pages No:263 - 265]

Keywords: HDliveFlow, Persistent left superior vena cava, Prenatal diagnosis, Pulmonary stenosis, Spatiotemporal image correlation, Transposition of great arteries, Ventricular septal defect

   DOI: 10.5005/jp-journals-10009-1950  |  Open Access |  How to cite  | 


Objective: We present HDlive Flow features of transposition of great arteries (TGA) with ventricular septal defect (VSD), pulmonary stenosis (PS), and persistent left superior vena cava (PLSVC) at 21 weeks and 2 days of gestation. Case description: HD-flow suggested parallel positioning of great arteries exiting the right ventricle, VSD, and PLSVC. HDlive Flow (Silhouette) clearly revealed an aorta exiting the right ventricle and a small pulmonary artery (PS) exiting the left ventricle in parallel. Pulmonary valvar stenosis was also suspected. A blood vessel (PLSVC) on the left side of the small pulmonary artery was noted. HDlive Flow Silhouette with spatiotemporal image correlation clearly showed a shunt flow stream from the right to left ventricle through VSD. Conclusion: HDlive Flow (Silhouette) may provide additional, useful information for the precise prenatal assessment of complex TGA.



Swati Yadav, Sonal Panchal, Chaitanya Nagori, Sushma Nadagouda, Manish Thakker

Comparative Study of Dual Trigger vs hCG Trigger in Intrauterine Insemination Cycles

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:6] [Pages No:266 - 271]

Keywords: Dual trigger, Follicle stimulating hormone surge, Gonadotropin-releasing hormone agonist, Human chorionic gonadotropin, Intrauterine insemination, Ovulation trigger

   DOI: 10.5005/jp-journals-10009-1944  |  Open Access |  How to cite  | 


Aim: The aim of this study was to assess if follicle-stimulating hormone (FSH) surge induced by gonadotropin-releasing hormone agonist (GnRHa), when given in addition to human chorionic gonadotropin (hCG) for triggering ovulation in intrauterine insemination (IUI) cycles, was beneficial and resulted in higher pregnancy rates. Background: Gonadotropin-releasing hormone agonist (GnRHa), when given as an ovulation trigger, causes a surge of both FSH and luteinizing hormone (LH) due to its “flare” effect mimicking the midcycle surge of gonadotropins in a natural cycle. The role of midcycle FSH surge in humans is not completely understood. But when GnRHa alone is used as an ovulation trigger, it causes luteolysis and luteal phase defect due to its shorter duration of action. In IUI cycles, GnRHa can be combined with hCG, which is responsible for only LH surge, and compared with cycles in which hCG alone is used as a trigger to analyze the impact of midcycle FSH on clinical pregnancy rates. Materials and methods: A total of 60 IUI cycles were analyzed that were divided into two groups. Group I received hCG alone and group II received hCG + GnRHa for ovulation trigger. In both groups stimulation protocol used was letrozole, which started from day 2 of the cycle for 5 days, and recombinant FSH (rFSH) from day 7. Follicular monitoring was done using two-dimensional (2D) ultrasound and color Doppler. Once follicles and endometrium attained functional maturity, an ovulation trigger was given. In group I, recombinant hCG and in group II, triptorelin acetate (0.2 mg) along with recombinant hCG was given. In both groups, IUI was done 34–36 hours after the trigger; luteal support was given with 800 mg micronized vaginal progesterone per day. Clinical pregnancy rates were compared in both groups. Results: There was a difference in pregnancy rates between the hCG group (26.7%) and GnRHa + hCG group (40%). Conclusion: It was concluded that though there was a difference in pregnancy rates in both groups, the difference was not statistically significant due to the small patient cohort (p = 0.273).



Toshiyuki Hata, Aya Koyanagi, Tomomi Kawahara, Miyu Konishi, Saori Bouno, Tomomi Yamanishi, Yasunari Miyagi, Takahito Miyake

Fetal Cardiac Structures, Shape, and Aortic Tortuosity at 15–17 + 6 Weeks of Gestation: HDlive Flow Study

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:6] [Pages No:272 - 277]

Keywords: Aortic tortuosity index, Early second trimester, Fetal aortic tortuosity, Fetal heart shape, HDlive Flow with spatio-temporal image correlation, Spatial global sphericity index

   DOI: 10.5005/jp-journals-10009-1951  |  Open Access |  How to cite  | 


Objective: To examine fetal cardiac structures at 15–17 + 6 weeks of gestation using HDlive Flow with spatio-temporal image correlation (STIC). Assessments of the fetal cardiac shape and tortuosity of the descending aorta (DAo) were also conducted. Methods: Transabdominal HDlive Flow with STIC was performed on 101 normal fetuses at 15–17 + 6 weeks of gestation to evaluate the feasibility of the spatial three-vessel and panoramic views (PaVs). Target structures were examined in both views. The following ratings were used: “good” when all structures were identified, “fair” when only one structure was missing, and “poor” when two or more structures were missing. The fetal cardiac circumference (FCC) was obtained with ellipse measurements in the spatial four-chamber view. The spatial global sphericity index (GSI) to assess the fetal cardiac shape and the aortic tortuosity index (ATI) to evaluate fetal aortic tortuosity were also calculated. Results: The rates of “good,” “fair,” and “poor” were 81.8, 16.2, and 2%, respectively, in the spatial three-vessel view (3VV) and 27.3, 64.6, and 8.1%, respectively, in the PaV. FCC was 3.59 (mean) ± 1.16 mm [standard deviation (SD)]. Spatial GSI was 1.15 (mean) ± 0.34 (SD). Posterior ATI was 0.97 (mean) ± 0.07 (SD). Lateral ATI was 0.988 (mean) ± 0.458 (SD). Conclusion: HDlive Flow with STIC has the potential as a useful diagnostic modality to assess fetal cardiac structures and aortic tortuosity in the early stages of the second trimester. Furthermore, spatial GSI and ATI may be applied to evaluations of the fetal cardiac shape and aortic tortuosity.



Toshiyuki Hata, Aya Koyanagi, Tomomi Kawahara, Tomomi Yamanishi, Aya Itoh, Riko Takayoshi, Takahito Miyake, Mohamed Ahmed Mostafa AboEllail

Normal Nuchal Translucency with Septations at Crown-rump Length below 45 mm

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:4] [Pages No:278 - 281]

Keywords: Cystic hygroma, Fetus, First trimester, Nuchal translucency, Pregnancy outcome, Septation

   DOI: 10.5005/jp-journals-10009-1943  |  Open Access |  How to cite  | 


Objective: To assess the clinical characteristics, pregnancy courses, and outcomes in fetuses showing normal nuchal translucency (NT) with septations at a crown-rump length (CRL) below 45 mm. Materials and methods: During a 33-month period from July 2019 to March 2022, nine fetuses showing normal NT with septations (CRL: 22.3–43.3 mm) (NNTS group) and six cystic hygromas (CRL: 27.7–42.8 mm) (CH group) were identified at 9+1–11+2 weeks of gestation. Their clinical characteristics, pregnancy courses, and outcomes were investigated and compared between the groups. Results: There were no significant differences in gestational age at examination, maternal age, parity, CRL, or prevalence of hydrops between NNTS and CH groups. There were significant differences in NT thickness between NNTS [1.66 (mean) ± 0.24 (standard deviation (SD)) mm] and CH [4.6 (mean) ± 0.93 (SD) mm] groups (p = 0.002). Good outcomes were noted in all cases (100%) in the NNTS group, whereas only two cases had healthy fetuses (33.3%) in the CH group (p = 0.004). In the NNTS group, seven fetuses (not determined in two fetuses) had normal ductus venous flow on first-trimester fetal ultrasound scan. Conclusion: Normal NT with septations at CRL below 45 mm may not be an ominous sign, whereas CH at CRL below 45 mm may still be associated with poor fetal outcomes. However, the data and its interpretation in our study should be taken with some degree of caution because of the small number of subjects studied in both groups. Further studies involving a larger sample size of normal NT with septations at CRL below 45 mm would be needed to ascertain whether nuchal septations are a benign or an ominous sign in clinical practice.



Zorancho Petanovski, Asim Kurjak

Uterine Fibroids (Leiomyoma, Myoma)

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:16] [Pages No:282 - 297]

Keywords: International Federation of Gynecology and Obstetrics, Three-dimensional saline infusion sonohysterography ultrasonography, Three-dimensional ultrasonography, Uterine fibroids (Leiomyomas, Myomas)

   DOI: 10.5005/jp-journals-10009-1948  |  Open Access |  How to cite  | 


Uterine fibroids (leiomyomas, myomas) are the most common tumor formations of the uterus. These are tumors with benign potential and the occurrence of malignancy or finding of leiomyosarcoma is rare. Fibroids can occur in any part of the uterus. They can appear on the cervix and the corpus in the broad ligament. The general classification of fibroids is based on their localization and is divided into intramural, submucosal, and subserosal fibroids. The appearance of uterine fibroids on ultrasound is determined by the structure of the tumor itself. Therefore, there are several types of classifications that aim to localize the tumor itself preoperatively. The most commonly used one now is by the International Federation of Gynecology and Obstetrics (FIGO) PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) classification. From what has been stated so far, it can be seen that ultrasound is essential in the detection of fibroids, their number, dimensions, and topography in terms of the body of the uterus, but also important information about the relationship between the tumor and the cavity of the uterus. Three-dimensional (3D) ultrasonography improves the image of leiomyoma, volume, and localization. With 3D saline infusion sonohysterography (SIS) ultrasonography, it is possible to make a solid presurgical score et sub mucous leiomyoma in terms of treatment choice and certainly a prognosis in terms of preserving the reproductive potential of the uterus.



Zorancho Petanovski, Asim Kurjak, Emilija Petanovska Kostova

Imaging of Acquired Uterine Lesions

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:6] [Pages No:298 - 303]

Keywords: Color Doppler sonography, Enhanced myometrial vascularity/arteriovenous malformation, Intrauterine adhesions (Asherman's syndrome), Nabothian cysts, The isthmocele, Transvaginal ultrasound, Three-dimensional ultrasonography

   DOI: 10.5005/jp-journals-10009-1946  |  Open Access |  How to cite  | 


In general, the group of acquired uterine lesions consists of enhanced myometrial vascularity (EMV)/arteriovenous malformation (AVM), the isthmocele, intrauterine adhesions (IUAs) (Asherman's syndrome), and nabothian cysts. Uterine AVMs can be congenital or acquired. These vascular lesions can cause severe hemorrhage that can be life-threatening for a woman, so it has been recently suggested that curettage should not be performed in a patient who presents with abnormal uterine bleeding after an abortion or a delivery when there is an ultrasound-detected hypervascular area with turbulent flow within the myometrium. Color Doppler sonography is the preferred method of diagnosing uterine EMV/AVMs. The isthmocele is a myometrial defect resembling a pouch on the anterior wall of the uterine isthmus over a previous cesarean scar. Transvaginal ultrasound (TVUS) is the initial and most usual method described to assess the integrity of the uterus wall in nonpregnant patients. IUAs are also known as intrauterine synechiae or endometrial sclerosis. The most common presentation of Asherman's syndrome is secondary infertility. Two-dimensional (2D)/three-dimensional (3D) TVUS is useful in measuring the thickness of the endometrial lining. Also, together with or without sonohysterography (injection of sterile saline into the uterine cavity) can show the adhesions that characteristically appear as “bridging bands” of tissue that distort the cavity. Nabothian cysts are a common occurrence on the cervix. These are retention cysts of the endocervical glands caused by chronic inflammation. 3D ultrasonography gives an excellent image and the possibility of detecting nabothian cysts.



Zorancho Petanovski, Asim Kurjak, Emilija Petanovska Kostova

Adnexal Masses

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:8] [Pages No:304 - 311]

Keywords: Ectopic pregnancy, Fallopian tube inflammatory disease, Positive pregnancy test, Transvaginal two-dimensional/three-dimensional ultrasound examination

   DOI: 10.5005/jp-journals-10009-1947  |  Open Access |  How to cite  | 


Fallopian tube inflammatory disease and tubal pregnancy are closely related. Inflammatory disease of the fallopian tubes leads to the inability for fertilization of the oocyte when the fallopian tube is completely closed; it also makes the path difficult for the gamete to transfer into the uterine cavity. The possibility of ectopic pregnancy is rising as a result of deformity and reduced mobility of the fallopian tubes. Most ectopic pregnancies occur in the fallopian tubes and rarely in other structures. It used to be difficult to diagnose an ectopic pregnancy, but now with two-dimensional (2D)/three-dimensional (3D) ultrasound and serum β human chorionic gonadotropin (hCG), the diagnosis is easy, and women with an ectopic pregnancy should no longer be in a situation where this pathological situation is a life-threatening diagnosis. Noninvasive transvaginal ultrasound (TVU) 2D/3D examination provides an opportunity for rapid selection of patients and candidates for direct laparoscopic (LPSC) access at the first examination in “everyday” practice. Due to the increased use of high-resolution TVU, around 80% of ectopic pregnancies are diagnosed on time, without severe abdominal hemorrhage. TVU identification of an adnexal mass, empty uterine cavity, and positive pregnancy test are the gold standard for diagnosis.



Sonal Panchal

Volume Ultrasound in Infertility

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:17] [Pages No:312 - 328]

Keywords: Duplication abnormalities, Endometrial volume, Sono AVC, Submucosal fibroids, Three-dimensional hystero-salpingo contrast sonography, Three-dimensional sonohysterography

   DOI: 10.5005/jp-journals-10009-1949  |  Open Access |  How to cite  | 


Introduction: Volume ultrasound (US) is an important complementary addition to the brightness (B) mode and Doppler transvaginal assessment of the reproductive organs in patients presenting with fertility problems. It has an important role in pretreatment assessment and also the monitoring of the treatment cycles and decision-making on the treatment protocols. Discussion points: Three-dimensional (3D) US is a modality of choice for differential diagnosis of Mullerian abnormalities. When used with Doppler and saline infusion sonohysterography (SIS), 3D US may almost eliminate the need for diagnostic hysteroscopy. It can be used to confidently diagnose polyps, hyperplasia, synechiae, chronic endometritis (CE), etc., all endometrial pathologies. A 3D US is considered a modality, at par with magnetic resonance imaging (MRI), for the assessment of endometrio-myometrial junction and so for the diagnosis of adenomyosis. It also enables the documentation of endometrial invasion in adenomyosis. In cases with submucosal fibroids, it is the 3D US that allows a clear assessment of the extent of endometrial invasion or distortion. The 3D US also has a role in uterine scar and cervical assessment. A 3D hystero-salpingo contrast sonography (HyCoSy) is an excellent modality for the assessment of tubal patency. Virtual organ computer-aided analysis (VOCAL) and sonography-based automated volume count (SonoAVC) are volume calculation software and are very useful for the assessment of ovarian volume, stromal volume, follicular, and endometrial volume, and for the accurate calculation of antral follicle count (AFC). When combined with power, Doppler can give a precise assessment of the global vascularity of these structures that can be all used to improve the assisted reproductive technology (ART) results. A 3D US can also be used to predict and diagnose the complications of ART, like ovarian hyperstimulation syndrome (OHSS) and ectopic pregnancies.


Images in Obstetrics

Toshiyuki Hata, Tomomi Kawahara, Aya Koyanagi, Riko Takayoshi, Takahito Miyake

Superb Microvascular Imaging Generation 4 for Depiction of Fetal Peripheral Microvessels

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:6] [Pages No:329 - 334]

Keywords: Anterior auricular artery, Digital artery, Fetal peripheral microvessel, Popliteal artery, Superb microvascular imaging generation 4, superficial temporal artery

   DOI: 10.5005/jp-journals-10009-1945  |  Open Access |  How to cite  | 


Objective: To demonstrate fetal peripheral microvessels using superb microvascular imaging generation 4 (SMI Gen4). Materials and methods: A total of 20 healthy fetuses were studied to depict peripheral microvessels using SMI Gen4 with a transabdominal linear probe (5–18 MHz) at 13–36 weeks of gestation. Results: Fetal intracranial vessels were clearly identified early in the second trimester of pregnancy. Superficial temporal and anterior auricular arteries could be recognized. The adrenal microvasculature was also evident. Microvessels of the fingers could be noted. Moreover, microvessels of the thigh, knee, foot, and digital vessels of the toes could be clearly identified. Conclusion: Superb microvascular imaging generation 4 (SMI Gen4) will be a breakthrough approach for the depiction of fetal peripheral microvessels and organ microvasculature. Further studies involving a larger sample size are needed to ascertain the clinical relevance of SMI Gen4 in clinical fetal medicine and future fetal research.



Vedran Stefanovic, Milan Stanojevic, Ivica Zalud, Frank A Chervenak, Asim Kurjak

In Memoriam

[Year:2022] [Month:October-December] [Volume:16] [Number:4] [Pages:1] [Pages No:335 - 335]

   DOI: 10.5005/dsjuog-16-4-335  |  Open Access |  How to cite  | 


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