Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2023 | April-June | Volume 17 | Issue 2

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Marina Vainder, Dan Farine

Late Prematurity

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:2] [Pages No:107 - 108]

   DOI: 10.5005/jp-journals-10009-1973  |  Open Access |  How to cite  | 



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

Superb Microvascular Imaging Generation 4 for Demonstration of Placental Microvasculature

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:3] [Pages No:109 - 111]

Keywords: Firsttrimester, Placental microvasculature, Secondtrimester, Superb Microvascular Imaging Generation 4, Thirdtrimester

   DOI: 10.5005/jp-journals-10009-1978  |  Open Access |  How to cite  | 


Objective: To present placental microvasculature using superb microvascular imaging generation 4® (SMI Gen4). Material and methods: A total of 20 healthy pregnancies were studied to describe placental microvasculature using transabdominal SMI Gen4 at 13–36 weeks of gestation. Results: Superb microvascular imaging generation 4® (SMI Gen4) clearly depicted primary, secondary, as well as tertiary stem villous vessels late in the first trimester of pregnancy. Volcanic eruption-like spiral artery jet flow (SAJ) was noted early in the second trimester of pregnancy. Increased placental vascularity was noted after the second trimester of pregnancy. Conclusion: SMI Gen4 may become a new diagnostic tool for the observation of placental microvasculature late in the first trimester of pregnancy. This modality may provide unique information on the prediction of fetoplacental insufficiency and hypertensive disorder during pregnancy.


Original Article

Toshiyuki Hata, Aya Koyanagi, Takahito Miyake, Mohamed AM AboEllail

Decreased Placental Perfusion Assessed by Three-dimensional Power Doppler Ultrasound in Pregnancies with Gestational Diabetes Mellitus

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:5] [Pages No:112 - 116]

Keywords: Gestational diabetes mellitus, Normal pregnancy, Placental perfusion, Placental vascular sonobiopsy, Three-dimensional power Doppler ultrasound

   DOI: 10.5005/jp-journals-10009-1977  |  Open Access |  How to cite  | 


Objective: To assess placental perfusion in pregnancies with gestational diabetes mellitus (GDM) using placental vascular sonobiopsy (PVS). Methods: Three-dimensional power Doppler ultrasound (3D PD US) assessment of placental perfusion with virtual organ computer-aided analysis (VOCAL) histogram analysis was performed in 49 normal pregnancies (control) at 18–21 + 6 and 28–31 + 6 weeks of gestation, and 10 diet-controlled GDM pregnancies at 28–31 + 6 weeks gestation. 3D PD indices such as the vascularization index (VI), flow index (FI), and vascularization FI (VFI) were generated for each placenta. Results: Flow index (FI) values [35.5 (mean) ± 3.5 standard deviations (SD)] at 28–31 + 6 weeks gestation were significantly higher than those [32.3 (mean) ± 4.1 (SD)] at 18–21 + 6 weeks (p < 0.0001), whereas there were no significant differences in VI or VFI values between 18–21 + 6 and 28–31 + 6 weeks of gestation in the control group. FI values [31.9 (mean) ± 3.9 (SD)] in the GDM group were significantly lower than those [35.5 (mean) ± 3.5 (SD)] in the control group at 28–31 + 6 weeks gestation (p = 0.0056), whereas between control and GDM groups no significant differences were found in VI and VFI values. Discussion: Our findings suggest that placental perfusion is reduced in diet-controlled GDM pregnancies. The lower FI in GDM pregnancies may be interpreted as placental vascular vasoconstriction, indicating placental hypoperfusion.



Toshiyuki Hata, Tomomi Kawahara, Takahito Miyake, Kei Hayata

Fetal Cardiac Tumor: HDlive Flow Silhouette with Spatiotemporal Image Correlation and HDlive Features

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:4] [Pages No:117 - 120]

Keywords: Fetal cardiac tumor, HDlive, HDlive flow, HDlive flow silhouette, Tortuous ductus arteriosus, Spatiotemporal image correlation

   DOI: 10.5005/jp-journals-10009-1969  |  Open Access |  How to cite  | 


We present HDlive flow silhouette with spatiotemporal image correlation (STIC) and HDlive features of multiple fetal cardiac tumors at 28 weeks and 2 days of gestation. Fetal echocardiography showed multiple cardiac tumors in four chambers. Tortuous ductus arteriosus was also noted. HDlive flow revealed the spatial relationship between the tortuous ductus arteriosus and aorta. HDlive flow silhouette with STIC and HDlive clearly revealed intraventricular tumors and spatial blood flow dynamics of cardiac chambers and great vessels. HDlive depicted intraventricular tumor movements in real-time. There was no manifestation of cardiac failure. Fetal cardiac rhabdomyoma was strongly suspected. Cardiac tumors resolved 2 months later after delivery with the use of everolimus.



Toshiyuki Hata, Aya Koyanagi, Tomomi Kawahara, Aya Itoh, Riko Takayoshi, Takahito Miyake, Yasuo Nakahara

Fetal Intrathoracic Cyst at 9 Weeks of Gestation

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:3] [Pages No:121 - 123]

Keywords: Cystic hygroma, Early gestation, Fetal intrathoracic cyst, HDlive Flow, HDlive silhouette, Pericardial cyst

   DOI: 10.5005/jp-journals-10009-1967  |  Open Access |  How to cite  | 


We present the case of a fetal intrathoracic cyst (2.8 x 1.7 mm) detected at 9 weeks and 2 days of gestation. At 11 weeks and 2 days of gestation, cystic hygroma (nuchal translucency = 5.8 mm) with generalized skin edema was identified. HDlive silhouette clearly revealed the location of the intrathoracic cyst. HDlive Flow with HDlive silhouette clearly showed the spatial relationships between the fetal heart and intrathoracic cyst at 13 weeks and 2 days. Cystic hygroma with generalized skin edema was resolved at this time. Chromosome analysis with amniocentesis revealed a normal karyotype (46XY) at 16 weeks and 4 days. The cyst disappeared at 22 weeks and 2 days. The mother delivered a viable, healthy male newborn at 40 weeks and 2 days of gestation. To the best of our knowledge, this is the first report of diagnosing a fetal intrathoracic cyst at 9 weeks of gestation.


Case Report and Literature Review

Zorancho Petanovski

Uterine Leiomyoma Variants: Case Reports and Literature Review

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:8] [Pages No:124 - 131]

Keywords: Ultrasound morphology, Uterine leiomyoma variants, Three-dimensional/Four-dimensional ultrasound, Three-dimensional power Doppler

   DOI: 10.5005/jp-journals-10009-1976  |  Open Access |  How to cite  | 


According to the World Health Organization (WHO) criteria for uterine smooth muscle, tumors have historically been distinct in benign leiomyomas, leiomyomas variants, and malignant leiomyosarcomas based on cytological atypia, mitotic rate, and presence or absence of tumor cell necrosis. Ultrasound, especially new techniques such as three-dimensional (3D)/four-dimensional (4D) ultrasound and 3D/4D color Doppler, is an excellent tool in the hands of ultrasonographers in the detection of atypical myomas and potential malignancy in uterine fibroids. Preoperative detection of malignancy in leiomyoma is a challenge for the ultrasonographer. It is very important to define an atypical leiomyoma by ultrasound examination because of its specificity, this type of leiomyoma can mimic leiomyosarcomas and can be precursors for the development of leiomyosarcoma.



Frank A Chervenak, Laurence B McCullough

Professionalism: An Essential Role in Caring for the Fetus as a Patient

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:4] [Pages No:132 - 135]

Keywords: Beneficence, Ethics, Preventive ethics, Professionalism, Public trust, Respect for autonomy, Viability

   DOI: 10.5005/jp-journals-10009-1968  |  Open Access |  How to cite  | 


The ethical obligations of the obstetrician to both the fetal patient and pregnant patient originate in the ethical concept of medicine as a profession. Obstetricians have beneficence-based and autonomy-based obligations to the pregnant patient and beneficence-based obligations to the fetal patient, which need to be carefully balanced in different clinical situations. The important roles of directive and nondirective counseling are explained, as well as the sometimes neglected role of preventive ethics.



Snezana Crnogorac, Aleksandra Vuksanovic Bozaric

Carcinoma in Pregnancy: What is the Impact on Fetus?

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:7] [Pages No:136 - 142]

Keywords: Pregnancy, Malignant disease, Treatment

   DOI: 10.5005/jp-journals-10009-1972  |  Open Access |  How to cite  | 


Cancer association with pregnancy (CAP) is defined as cancer diagnosed from the 1st day of childbearing to 1 year postpartum. Malignant disease in pregnancy is rare, 1:1000 pregnancies, but it represents an important therapeutic and ethical problem for both, the patient and the physician. The most important goals in curing are—treating the patient with the optimal anticancer regimen as soon as possible in order to preserve the mother's health, without harming the developing fetus. Until recently, the pregnancy had to be either terminated or cancer treatment delayed until after the birth. Nowadays, state-of-art treatment should be provided for this vulnerable population to preserve maternal and fetal prognosis. When suspicion of malignant disease in pregnancy is grounded, it is necessary to prove the same. It is recommended to apply standard methods, if possible. With some malignant tumors, some protocols for establishing diagnosis are changing sensitivity and specificity in pregnancy. Ultrasound examination is a method of choice for the breast, abdomen, and pelvis. If necessary, chest X-ray and mammography can be done safely with abdominal shielding. Magnetic resonance imaging (MRI) may be conducted if there is any unclarity in the analysis or suspicion of brain or bone metastasis. The main challenge in managing cancer in pregnancy is treating the patient with an optimal anticancer regimen without harming the developing fetus. Cancer during pregnancy is associated with a significantly increased risk of planned preterm birth, induction of labor, and a cesarean section. Women with CAP need psychological support during the pregnancy and after delivery.



Dan Farine, Prakeshkumar Shah, Kellie E Murphy

Antenatal Corticosteroids for Late Preterm Labor

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:6] [Pages No:143 - 148]

Keywords: Corticosteroids, Gestational diabetes, Late preterm labor, Preterm labor

   DOI: 10.5005/jp-journals-10009-1975  |  Open Access |  How to cite  | 


This article reviews several different aspects of corticosteroids in preterm labor (PTL). After a short review of the history of the administration of corticosteroids for preterm labor, we review the overall data on PTL. The next paragraph is on repeated courses of corticosteroids in PTL. Most of the literature does not show benefits from such repeated dosages. Furthermore, some like the large multiple courses of antenatal corticosteroids (MACS) study showed that repeated dosages resulted in smaller babies. What was probably more important was that it resulted in small head conferences, most likely reflecting smaller head sizes. There is ample literature on the effect of corticosteroids on different organ systems. We do not have good data on the long-term outcomes of this effect. A very long-term study on the original study of Liggins showed some effect on glucose tolerance but no effect on frank diabetes. It is difficult to use these issues in determining the need for corticosteroids as there is always a concern that a long-term effect may be found years later (look at the ORACLE study mentioned here). There is limited information on the effect of corticosteroids in the late preterm labor. The data is summarized in a table. Two of these papers are on administrating corticosteroids prior to a cesarean section (CS) and are discussed separately. Of the studies on the administration of corticosteroids for late PTL, one stands out. It was done by the maternal fetal medicine (MFM) network in the US, it is large and well-designed. It showed a decrease in both respiratory distress syndrome (RDS) by close to 50% and shortened the stay in the neonatal intensive care unit (NICU) by an average of 8 days. The price was an increase in GDM. These were the reasons that both the society of maternal fetal medicine (SMFM) and American College of Obstetricians and Gynecologists (ACOG) recommended the use of corticosteroids in late preterm. No other society came forward with such recommendations probably because of the concern for long-term effects.



Rubén A Quintero, Eftichia V Kontopoulos, Ramen H Chmait

Laser Treatment of Twin-twin Transfusion Syndrome

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:9] [Pages No:149 - 157]

Keywords: Laser photocoagulation, Outcome, Treatment, Twins monochorionic, Twin-to-twin transfusion syndrome

   DOI: 10.5005/jp-journals-10009-1974  |  Open Access |  How to cite  | 


Objective: Laser ablation of all placental vascular anastomoses is the optimal treatment for twin-twin transfusion syndrome (TTTS). This requires proper endoscopic identification of the anastomoses and adequate photocoagulation. However, two important controversies have recently become apparent—(1) a gap between concept and performance and (2) a question as to whether all the anastomoses can indeed be identified endoscopically and therefore, whether blind lasering of healthy placental tissue between anastomoses is justified. The purpose of this paper is to address the potential source of the gap between concept and performance and to discuss the optimal surgical technique. Materials and methods: Laser surgery for TTTS can be broken down into two fundamental steps—(1) endoscopic identification of the placental vascular anastomoses and (2) laser ablation of the anastomoses. Regarding the endoscopic identification of the laser targets, the nonselective technique is based upon lasering all vessels crossing the dividing membrane, whether anastomotic or not. The selective technique identifies all anastomoses and occludes only such vessels. The Solomon technique involves lasering healthy areas of the placenta between lasered anastomoses, as it assumes that not all anastomoses are endoscopically visible. Regarding the actual laser ablation process, successful achievement of complete surgical ablation (i.e., lasering all the anastomoses) can be measured by how often the selective technique can be performed, by the rate of postoperative persistent or reverse TTTS (PRTTTS) or postoperative twin anemia-polycythemia sequence (TAPS), and by the rate of residual patent placental vascular anastomoses (RPPVAS) on surgical pathology analysis of the placenta. Articles representing the different techniques are discussed. Results: The nonselective technique is associated with the lowest double survival rate (35%), compared with 60–75% of the Solomon or the Quintero selective techniques. The Solomon technique is associated with a 20% rate of RPPVAS, compared to 3.5–5% for the Quintero selective technique (p < 0.05). Both the Solomon and the Quintero selective techniques are associated with a 1% risk of PRTTTS. Adequate placental assessment is highest with the Quintero selective technique (99%) compared with the Solomon (80%) or the “Solomon standard” (60%) techniques (p < 0.05). A surgical performance index is proposed. Conclusion: The gap between concept and performance responsible for suboptimal clinical results gave rise to the Solomon technique. Unfortunately, The Solomon technique actually represents a historical backward step in the performance of the surgery, given that it is based on assuming that not all of the anastomoses are visible endoscopically. Furthermore, the Solomon technique is associated with a higher rate of residual patent vascular communications than the Quintero selective technique. The Quintero selective technique is associated with the highest rate of successful ablation of placental vascular anastomoses and with the lowest rate of persistent or reverse TTTS. The reported outcomes of the Quintero selective technique do not lend support to the existence of anastomoses beyond those that can be seen endoscopically that would justify lasering healthy placental tissue.



Eberhard Merz, Sonila Pashaj

Three-dimensional/Four-dimensional Ultrasound: The Key for the Precise Assessment of Fetal Malformations

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:7] [Pages No:158 - 164]

Keywords: Prenatal diagnosis, Fetal malformations, Three-dimensional ultrasound, Four-dimensional ultrasound, Visualization modes

   DOI: 10.5005/jp-journals-10009-1971  |  Open Access |  How to cite  | 


Three-dimensional/four-dimensional (3D/4D) ultrasound has a high diagnostic potential in the detection and visualization of fetal malformations. Compared to two-dimensional (2D) ultrasound, which only allows the demonstration of individual planes, 3D/4D ultrasound allows the storage of volumes that can be examined using different visualization modes. As a result, fetal structures can be represented in controlled reformatted planes, in multiple parallel (tomographic) planes, or in rendered surface or transparent images. Fetal malformations can thus be demonstrated with the optimal visualization mode and from the best viewing angle. In the case of a presumed fetal malformation during a 2D ultrasound examination, or in the case of an increased recurrence risk of a certain fetal malformation, the different viewing modes, in particular the surface mode, can be used to convincingly show the parents the absence of such a malformation.



Panos Antsaklis, Asim Kurjak

KANET Test in Clinical Practice: Lessons Learned and Future Challenges

[Year:2023] [Month:April-June] [Volume:17] [Number:2] [Pages:16] [Pages No:165 - 180]

Keywords: Cerebral palsy, Early diagnosis, Fetal neurology, Fetal neurological profile, Fetal assessment, Kurjak's antenatal neurodevelopmental test

   DOI: 10.5005/jp-journals-10009-1970  |  Open Access |  How to cite  | 


Assessing fetal neurobehavior during pregnancy has been challenging due to limited evaluation methods. Conditions such as cerebral palsy, often misattributed to labor incidents, actually originate during fetal development. This highlights the poor understanding and diagnosis of neurological problems. Recent advancements, such as Kurjak's antenatal neurodevelopmental test (KANET) test utilizing four-dimensional (4D) ultrasound technology, offer a way to study fetal neurobehavior in utero, define normal profiles, and identify abnormalities. Multicentric studies have demonstrated the utility of KANET, which has been standardized and successfully integrated into clinical practice for both high and low-risk cases, in understanding fetal neurology, particularly in uncertain cases like ventriculomegaly, providing comprehensive assessment and counseling for affected couples. KANET exhibits good sensitivity, specificity, predictive values, and acceptable variability among observers. With proper training and access to 4D ultrasound machines, ultrasound specialists can easily learn and apply KANET. This method has the potential to identify fetuses at risk for neurological impairment, enabling timely interventions, and improved outcomes through early diagnosis and appropriate follow-up.


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