Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2009 | July-September | Volume 3 | Issue 3

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RESEARCH ARTICLE

Recent Advances in 3D Assessment of Various Fetal Anomalies

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:24] [Pages No:1 - 24]

Keywords: Three-dimensional ultrasound,fetus,anomaly

   DOI: 10.5005/jp-journals-10009-1017  |  Open Access |  How to cite  | 

Abstract

Recent advances of ultrasound technology including 3D/4D sonography have revealed embryonal/fetal morphology, intrauterine vascularity and fetal behavior from early gestation. Modern ‘sonoembryology’ allows the definition of in vivo anatomy including visualization of dynamic features, which cannot be characterized in fixed specimens after embryonic death in embryology. Furthermore, recent highresolutional ultrasound technologies have remarkably approached accurate prenatal diagnoses with vivid and distinct sonographic depiction. Nowadays, the antenatal diagnosis is no longer ‘maybe’ nor ambiguous, owing to progressive 3D/4D ultrasound which have contributed to the field of embryology, fetal physiology and pathology.

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REVIEW ARTICLE

Guillermo Azumendi, Kazuo Maeda, Ritsuko K Pooh, Iva Lausin

Advances in Visualization of the Early Human Development

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:14] [Pages No:25 - 38]

Keywords: First trimester,sonoembriology,placenta,three-dimensional ultrasound

   DOI: 10.5005/jp-journals-10009-1018  |  Open Access |  How to cite  | 

Abstract

The anatomy and physiology of placental and embryonic development is a field where medicine exerts its impact on early pregnancy and opens fascinating aspects of embryonic differentiation. The introduction of high frequency transvaginal transducers as well as three and four dimensional sonography has resulted in remarkable progress in ultrasonic visualization of early embryos and fetuses.

Ultrasound has been widely used in the field of early human development due to its safety, diagnostic accuracy and convenience. Normal fetal anatomy and development have been widely investigated using two-dimensional ultrasound and most of the knowledge regarding early human development were established through understanding of sectional images of fetal body and organs obtained by two-dimensional ultrasound. Usage of new techniques has produced more objective and accurate information of embryonal and early fetal development. For the first time parallel analyses of structural and functional parameters in the first 12 weeks of gestation become possible. This article deals with establishment of human life from ovum and sperm, though fertilization, detailed histological development and the establishment of the placenta, and early human development visualized by 2- and 3-dimensional ultrasonography.

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REVIEW ARTICLE

Alin Basşgül Yig¢iter, Zehra Nesşe Kavak

Cervical Length, Volume and Flow Indices During Pregnancy by Transvaginal 2D and 3D Ultrasonography

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:6] [Pages No:39 - 44]

Keywords: Three-dimensional ultrasound,VOCAL,cervical length measurement,volume,power Doppler

   DOI: 10.5005/jp-journals-10009-1019  |  Open Access |  How to cite  | 

Abstract

Recently, many researches suggested that 2D US is insufficient for defining the true sagittal plane of uterine cervix. When the cervix is bent or curved, it is difficult to get a perfect sagittal section but rather mid oblique image by 2D US. Only 3D US allows us to evaluate the cervix in the coronal section and reproduce images in many cut. Coronal section of the cervix is especially useful in evaluating cervical funneling. Diagnosing internal orifice dilatation, asymmetrical, flattened or fissure-like cervices is possible. 3D US favors a more detailed study of cervical anatomy and biometry than 2D US. Cervical evaluation by 3D multiplanar sections can be added in the screening for preterm labor.

Three-dimensional (3D) imaging combined with power Doppler, theoretically provides the possibility to assess the volume and quantify the power Doppler signal in the whole target organ, whereas, information from 2D US on vascularization and blood flow is restricted to a single subjectively chosen 2D plane. The measurement of cervical indices is reproducible and may be used in clinical practice and research to determine the changes of the cervical morphology and vascularization in pregnancy. Consequently, further studies of 3D ultrasound imaging of the cervix in pregnancy and clinical correlations to obstetrical events are required for better understanding the physiology and functional pathophysiology of the cervix during pregnancy.

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REVIEW ARTICLE

Joachim W Dudenhausen

Management of Multiple Pregnancy

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:6] [Pages No:45 - 50]

Keywords: Multiples,prematurity,IUGR,ultrasound

   DOI: 10.5005/jp-journals-10009-1020  |  Open Access |  How to cite  | 

Abstract

Background

Changing delivery age and successes in reproductive have medicine induced an increase in incidence of the multiples in the industrialized world.

Methods

Selective literature research was performed complemented by the autor's clinical experience and national and international guidelines

Results

The risks of prematurity, IUGR, and antenatal demise are raised. Maternal risks are pre-eclampsia, diabetes, and bleeding during delivery. Prenatal and genetic diagnostics including ultrasonography are the most important methods of supervision during pregnancy. These are significant for diagnosis of twin-to-twin transfusion syndrome and cygosity.

Consequences

Cooperation betweeen prenatal medicine, obstetrics and neonatology is important for the care of mothers with multiples.

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REVIEW ARTICLE

Guillermo Azumendi, Sejfulah Perva, Ingrid Marton, Madeeha Al-Noobi

Study of Fetal Neurodevelopment in Multiple Pregnancies

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:10] [Pages No:51 - 60]

Keywords: Cerebral palsy,assisted reproduction techniques,multiple pregnancies,ultrasound,fetal neurology

   DOI: 10.5005/jp-journals-10009-1021  |  Open Access |  How to cite  | 

Abstract

According to many reports multiple pregnancies compared to singelton have a 5-10 fold increased risk for CP and some of increased risk is due to the risk of preterm delivery, no mater whether, it mono or dizygotic conception. In those cases CP is most probably complication of peripartal periventricular hemorrhage or leukomalacia. Known fact about twins is that the lower is the gestational age at the time of delivery, the probability that they are monozygotic is greater. Monochorionic multiple pregnancies and feto-fetal hemodynamic transfusion instability are leading to cerebral ischemia. For all of mentionable reasons monozygotic multiple pregnancies have a greater risk of cerebral impairment.

CP in an apparently singleton pregnancy could be associated with a “vanishing” twin phenomenon. There are reports that some of the congenital anomalies in apparently singleton pregnancies may be associated with the unrecognized or unrecorded loss of a co-twin.

It has been established that ART conceptions are at a greater risk of CP because of the greater risk of preterm delivery. There have been many attempts to minimize CP prevalence by reduction of number of fetuses in a multifetal ART pregnancy but without affect, most probably because the majority of ART conceptions are dizygotic.

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REVIEW ARTICLE

Ulrich Honemeyer

Primary Care in Obstetrics and Gynecology — A Place for Advanced Ultrasound?

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:14] [Pages No:61 - 74]

Keywords: Adnexal mass,power Doppler,transvaginal ultrasound,saline infusion sonohysterography,obstetric ultrasound screening,primary care

   DOI: 10.5005/jp-journals-10009-1022  |  Open Access |  How to cite  | 

Abstract

The evaluation of adnexal masses based on transvaginal sonography (TVS) and when their size is too big- transabdominal US can be facilitated and refined by using color Doppler (CD), power Doppler (PD), and pulsed Doppler(PW), including three-dimensional ultrasound (3D US). With these modes, we obtain information about vascularity and flow indices, and their distribution within a mass. Considering the fact that neoangiogenesis is a main feature of malignancy, this is essential information. Thus, we are able to assume the benign or malignant character of an adnexal mass, make the right choice of additional imaging or biochemical tests, and then channel the treatment appropriately. This is subsequently demonstrated for simple cyst, hemorrhagic cysts, endometrioma, dermoid, serous papillary cystoma, ectopic pregnancy, and ovarian carcinoma.

Abnormal uterine bleeding (AUB) is a common problem in primary care. Compared to transabdominal approach, TVS improves the detection rate of underlying uterine pathology. In conditions like endometrial hyperplasia, polyps, submucous leiomyoma, and endometrial cancer, CD, PD, PW and contrast enhanced transvaginal ultrasound may optimize sonographic evaluation. Saline infusion sonohysterography (SISH) in out patient department (OPD) is an alternative to invasive diagnostic hysteroscopy in patients with AUB.

Care for maternal and fetal well-being during pregnancy is a main task in OPD. The assessment of fetal pathology is almost entirely based on Ultrasound. Several illustrations of fetal anomalies detected during 1st trimester and 2nd trimester screening, of abnormal findings in feto-maternal Doppler ultrasound, and fetal pathology demonstrated in 3D/4D ultrasound mode, conclude this review of advanced ultrasound in primary care.

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REVIEW ARTICLE

Agnieszka Nocun, Marcin Wiechec, Jill Beithon RT

Early Fetal Echocardiography at the Time of 11+0–13+6 Weeks Scan

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:8] [Pages No:75 - 82]

Keywords: Early fetal echocardiography,early prenatal diagnosis,first trimester,congenital heart defects

   DOI: 10.5005/jp-journals-10009-1023  |  Open Access |  How to cite  | 

Abstract

Early Fetal Echocardiography (EFE) is generally defined as a fetal cardiac scan performed until 16 weeks of gestation. Fetal indications for EFE in the first trimester are in strong connection with ultrasound findings during routine nuchal scan: early diagnosed extracardiac malformations, abnormal ductus venosus (DV) velocimetry, tricuspid valve regurgitation (TR), single umbilical artery and increased NT measurement as a major fetal factor. Essential components of EFE include: abdominal view (AbdV), four chamber view (4CV), three vessel view (3VV), origin and cross-over of the great arteries (GA), aortic arch (AoA), ductal arch (DA), superior and inferior venae cavae and at least 2 pulmonary veins.

EFE has some limitations, which determine delayed diagnosis of some CHDs. Early fetal echocardiography is feasible and reasonable. It gives parents the opportunity to exclude approximately 60% of cardiac abnormalities and to reassure them of normal heart anatomy as early as possible.

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RESEARCH ARTICLE

L Orosz, J Lukács, M Szabó, T Kovács, I Zsupán, G Orosz, Z Tóth, O Török

Long-term Outcome of Pregnancies with Increased Nuchal Translucency and Normal Karyotype

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:8] [Pages No:83 - 90]

Keywords: Congenital heart defects,fetal echocardiography,nuchal translucency,hydrocele,first trimester screening,long-term follow-up

   DOI: 10.5005/jp-journals-10009-1024  |  Open Access |  How to cite  | 

Abstract

Objectives

The aim of this study was to examine the prevalence of major and minor anomalies according to the increase of NT thickness.

Methods

This is a long-term retrospective study in which singleton gestations of euploid fetuses with increased NT were analyzed. NT measurement was performed in the first trimester examination according to the criteria of fetal medicine foundation (FMF) when the fetal crown-rump length (CRL) was 45 to 84 mm. The cases were followed up from 1 to 5 years postpartum to assess the presence of CHD and to point out other anomalies that could be associated with increased NT.

Results

The outcome of 133 cases could be analysed out of 198 pregnancies of which in 55 cases some congenital anomalies (minor or major) were revealed up to the 5 years of life (prevalence of 41.4%). The prevalence of CHDs, including the defects of the great vessels, stood out among the others. In the group with NT between 95th and 99th centiles four cases with minor heart problems were identified (11.1%, 4/36). The rate of major cardiac defects proved to be 13.3% (6/45) in the group with NT between 3.5-4.4 mm, and 17.3% (9/52) in the group with NT > 4.5 mm. Among the 35 healthy children with various minor health problems not related to the presence of increased nuchal translucency there were 7 cases with hydrocele. In 3 of them it was associated with unilateral inguinal hernia but in 3 it was isolated and one was part of a complex malformation (The rate of other organ-specific anomalies did not prove to be significant). In the whole study population only thirteen cases (9.8%) ended up in intrauterine death, or arteficial abortion.

Conclusion

The prevalence of major cardiac defects as well as other major anomalies increases with fetal nuchal thickness. Since the prevalence of CHD is 100 times higher in the population of fetuses with NT above 4.5 mm, specialist fetal echocardiography should be offered in the second trimester together with other follow-up investigations. Among the children without any major abnormalities, a high number of minor anomalies were revealed during the long-term follow-up. These anomalies do not have significant disadvantage to the quality of life, but some of them necessitates short or long-term medical treatment and this should also be leveled with the future parents. Despite the numerous investigations the exact etiology of increased NT remains unknown. The relatively high prevalence of hydrocele in the newborns in our material raises the question wheather it is related to the presence of NT in the fetal period because of abnormal lymphatic development or alterations in the extracellular matrix. Further long-term follow-up studies could probably contribute to find explanation on the etiology of increased NT in the first trimester. These data can be used when counseling parents of euploid fetuses with increased fetal NT.

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RESEARCH ARTICLE

Zoltán Tóth, János Aranyosi, Tamás Deli, Péter Bettembuk, Bence Kozma, Tamás Kovács, Olga Török

Fetal Aortic-cerebral Doppler Resistance Index Ratio: An Indicator of Physiologic Blood Flow Distribution

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:6] [Pages No:91 - 96]

Keywords: Fetal blood flow,descending aorta,middle cerebral artery,Doppler index ratio

   DOI: 10.5005/jp-journals-10009-1025  |  Open Access |  How to cite  | 

Abstract

Objective

To interpret the physiologic fetal arterial blood flow distribution by relating the vascular impedance of the fetal descending aorta (DA) and middle cerebral artery (MCA) and to establish the reference ranges for the aortic-cerebral Doppler resistance index ratio (ACRI).

Study design

Ninety-six patients with uncomplicated pregnancies were recruited for the cross-sectional assessment of the Doppler resistance index (RI) in the fetal DA and MCA between the 38rd and 40th weeks of gestation. The normal ranges of the ACRI were calculated. A cut-off value was designed to facilitate the clinical application of the ACRI.

Results

Between the 38th and 40th weeks of gestation in normal pregnancies the ACRI of healthy fetuses is constant, the overall mean is: 1.062 (+/– 0.087). A single cut-off value of 1.2 is recommended to assist separating normal and pathologic arterial blood flow patterns.

Conclusion

The normal ACRI reflects the identical vascular resistance of the descending aorta and the cerebral vessels, which maintains the physiologic fetal central arterial blood flow. Additional clinical studies are necessary to assess the diagnostic efficacy of the abnormal ACRI (>1.2) as a potentially useful marker of the centralized arterial circulation indicating the early stage of fetal hypoxemic jeopardy.

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CASE REPORT

Juan Mario Troyano-Luque, Margarita Álvarez de la Rosa, Ana Isabel Padilla, Laura Ces, José María Martínez, Bienvenido Puerto, Eduardo Gratacós, Luis Tadeo Mercé

Pre- and Postnatal Features of Hydrometrocolpos in One Fetus of a Dizygotic Twin Pregnancy

[Year:2009] [Month:July-September] [Volume:3] [Number:3] [Pages:5] [Pages No:97 - 101]

Keywords: Prenatal diagnosis,ultrasound,cloaca,hydrocolpos

   DOI: 10.5005/jp-journals-10009-1026  |  Open Access |  How to cite  | 

Abstract

A female fetus of a dizygotic pregnancy presented with a retrovesical cystic mass at 16 weeks. Severe and recurrent fetal ascitis developed at 25 weeks. Pre-eclampsia, probably due to mirror syndrome, precipitated fetal extraction, which led to severe prematurity complications and neonatal death. Necropsy showed: cloacal anomaly, anal atresia, ambiguous genitalia and bicornuate uterus.

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