Donald School Journal of Ultrasound in Obstetrics and Gynecology

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2011 | October-December | Volume 5 | Issue 4

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Maja Predojevic, Berivoj Miskovic, Badreldeen Ahmed, Radu Vladareanu, Aida Salihagic Kadic, Afaf Naim Shaddad, Madeeha Al-Noobi, Amira Talic, Daniela Lebit, Salwa Abu-Yaqoub

An Attempt to Standardize Kurjak's Antenatal Neurodevelopmental Test: Osaka Consensus Statement

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:13] [Pages No:317 - 329]

Keywords: Fetal neurobehavior,4D ultrasound,Neurobehavioral screening,Postnatal neurological screening,Cerebral palsy

   DOI: 10.5005/jp-journals-10009-1209  |  Open Access |  How to cite  | 


Analysis of the dynamics of fetal behavior in comparison with morphological studies has led to the conclusion that fetal behavioral patterns are directly reflecting developmental and maturational processes of fetal central nervous system (CNS). Four-dimensional ultrasound (4D US) offers a practical means for assessment of both the brain function and structure. The visualization of fetal activity in utero by 4D US could allow distinction between normal and abnormal behavioral patterns which might make possible the early recognition of fetal brain impairment. That new technology enabled introduction of Kurjak's antenatal neurodevelopmental test (KANET) in low- and high-risk pregnancies. In order to make the test reproducible, the standardization of the test was proposed in Osaka, Japan, during the International Symposium on Fetal Neurology of International Academy of Perinatal Medicine.

The KANET should be performed in the 3rd trimester from 28th to 38th week of gestation. The assessment should last from 15 to 20 minutes, and the fetuses should be examined when awake. If the fetus is sleeping, the assessment should be postponed for 30 minutes or for the next day between 14 and 16 hours. In cases of definitely abnormal or borderline score, the test should be repeated every two weeks till delivery. New modified KANET test should be used with eight instead of 10 parameters: Facial and mouth movements are combined in one category, isolated hand movements and hand to face movements are combined in one category. The score should be the same for abnormal fetuses 0 to 5, borderline score is from 6 to 13 and normal score is 14 or above.

After 4D US assessment of behavioral patterns in the fetuses from high-risk pregnancies, it is very important to continue with follow-up after delivery in infants who were borderline or abnormal as fetuses. Postnatal assessment of neonates includes initial neurological assessment according to Amiel-Tison's methodology (Amiel-Tison Neurological Assessment at Term, ATNAT) in the early neonatal period and every two weeks in preterm infants till discharge and at the postmenstrual age (PMA) between 37 and 40 weeks. If ATNAT is borderline or abnormal, initial assessment of general movements at the age of 36 to 38 weeks of PMA should be performed, than at writhing age (between 46 and 52 weeks), and at the fidgety age after 54 weeks of PMA. If the finding of fidgety movements is mildly abnormal or definitely abnormal, then one more assessment should be done in 2 to 4 weeks till PMA of 58 weeks. Brain ultrasonography should be performed in the first week of life and every 2 weeks afterward till discharge. In severely affected infants with grade 3 and above intraventricular hemorrhage, and those highly suspicious of hypoxic ischemic brain damage, magnetic resonance (MR) should be done if available. Infants should be followed until the age of at least 24 months when diagnosis of disabling or nondisabling cerebral palsy can be ultimately made. Infants with CP should be reassessed at the age of 6 years.



Laila ASE Mousa, Hossam H Kamel, Ahmad G Serour

Ultrasonic Assessment of the Urethra and the Vagina in Normal Continent Women and Women Suffering from Stress in Urinary Incontinence and Vaginal Prolapse

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:9] [Pages No:330 - 338]

Keywords: Three-dimensional ultrasound (3D US),Stress urinary incontinence (SUI),Internal urethral sphincter (IUS),Vaginal prolapse,Collagen,Magnetic resonance imaging (MRI)

   DOI: 10.5005/jp-journals-10009-1210  |  Open Access |  How to cite  | 


Urinary continence depends on two factors the presence of an intact and strong internal urethral sphincter (IUS); and on an acquired behavior, gained by learning and training in early childhood, how to maintain a high alpha-sympathetic tone at the IUS keeping it closed all the time until there is a need.

The IUS is a cylinder that extends from the urinary bladder neck to the urogenital diaphragm. It is composed of a strong collagen sheet with muscle fibers that intermingle with the collagen in the middle of the cylinder's thickness. The strong collagen sheet gives the IUS the high wall tension necessary to create the high urethral closure pressure. The muscle fibers, innervated by alpha-sympathetic nerves (T10-L2) are responsible for closure and opening of the urethra.

Rupture of the IUS causes its weakness and it will not withstand increases of abdominal pressure, and urine will leak. Rupture and split of the collagen sheet are better demonstrated by imaging by 3D US and MRI.

Normal vagina is a cylinder of collageno-elastic-muscular tissues. Its strong collagen sheet is responsible for keeping it in its normal upward and backward position. Labors cause redundancy and weakness of the vaginal walls with subsequent prolapse; and lacerations of the IUS which is intimately overlying the anterior vaginal wall.



Hossam H Kamel, Ahmad G Serour, Laila AS Mousa

Ultrasound Assessment of the Internal Anal Sphincter in Women with Fecal Incontinence and Posterior Vaginal Wall Prolapse (Rectocele)

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:4] [Pages No:339 - 342]

Keywords: Three-dimensional ultrasound (3D US),Fecal incontinence (FI),Internal anal sphincter (IAS),External anal sphincter (EAS),Collagen,Rectocele,Central nervous system (CNS)

   DOI: 10.5005/jp-journals-10009-1211  |  Open Access |  How to cite  | 


Rupture of the internal anal sphincter (IAS) causes its weakness and it will not withstand increases of abdominal pressure, and fecal incontinence (FI) will occur. Recently, we put forward a novel concept on the physiology of defecation. Defecation is divided into two stages: First stage before training and second stage starts at the age of about 2 years, when the mother starts to teach her child how to hold up himself. This is gained by maintaining high alpha-sympathetic tone at the IAS, thus keeping it closed all the time till there is a need to pass stool or flatus, and the time and place are convenient. On defecation, six neuromuscular actions take place under the control of the CNS: (1) The person will relax the external anal sphincter, (2) he will lower the gained high alpha-sympathetic tone at the IAS, thus opening the anal canal, (3) he will relax the pelvic floor muscles bringing the rectum and the anal canal into one axis, (4) the abdominal and diaphragmatic muscles contract to increase the abdominal pressure, (5) the muscles of the distal colon and rectum contract pushing the stool, (6) sequential contractions of the three parts of the external anal sphincter (EAS) that squeeze any residual contents in the anal canal. Thus, the anal canal is closed and empty under normal circumstances. The IAS is a collageno-muscular tissue cylinder that surrounds the anal canal.

The IAS is intimately related to the posterior vaginal wall, and the vagina is over stretched in labor, childbirth trauma affects both the posterior vaginal wall and the IAS. Rupture of the collagen sheet of the IAS which causes its weakness is better demonstrated by imaging by 3D US.

Normal vagina is a cylinder of collageno-elastic-muscular tissues. Its strong collagen sheet is responsible for keeping it in its normal upward position. Labors cause redundancy and weakness of the vaginal walls with subsequent prolapse; and lacerations of the IAS which is closely related to the posterior vaginal wall leading to FI.



Mandakini Parihar, Anand Parihar

Peri- and Postmenopausal Uterine Bleeding Transvaginal Ultrasound with Hysterosonography and Diagnostic Correlation with Hysteroscopy

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:10] [Pages No:343 - 352]

Keywords: Abnormal uterine bleeding,Transvaginal sonography (TVS),Hysterosonography,Hysteroscopy

   DOI: 10.5005/jp-journals-10009-1212  |  Open Access |  How to cite  | 


The recent years have seen medical science and technology expand by leaps and bounds. We have shifted focus from correction of the problem to prevention of the problem. Abnormal uterine bleeding is an important cause of ill health in perimenopausal women. In the perimenopausal years, there is an increase in the incidence of bleeding irregularities. This is because of an increase in the prevalence of benign and malignant uterine lesions. There has also been a significant increase in the number of women presenting with postmenopausal bleeding. At transvaginal ultrasonography (TVS), the finding of a thickened central endometrial complex, with or without cystic changes, is often nonspecific and may be caused by an endometrial polyp, submucosal fibroid, endometrial hyperplasia, carcinoma or cystic atrophy. In addition, because of an increased prevalence of adenomyosis or adenomyosis-like changes in women around this age group, proper transvaginal sonographic assessment of endometrial thickness and abnormalities is of utmost importance but maybe difficult in some women.

When TVS cannot accurately measure the endometrial thickness or when there is a nonspecific thickened central endometrial complex, hysterosonography can provide additional information and can help in the diagnosis and final treatment. Hysterosonography, as an adjunct to TVS, allows identification of intracavitary lesions and focal and diffuse endometrial abnormalities and helps determine the abnormality. Final diagnosis confirmed by hysteroscopy. In this review, we discuss these common abnormalities and the correlation of TVS and hysterosonographic findings with hysteroscopic evaluation.



Badreldeen Ahmed, Oliver Vasilj

Noninvasive Diagnostics of Fetal Anemia

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:3] [Pages No:353 - 355]

Keywords: Fetal anemia,Rh-isoimmunization,Ultrasound,Doppler,Middle cerebral artery peak,Systolic velocity

   DOI: 10.5005/jp-journals-10009-1213  |  Open Access |  How to cite  | 


Even though the use of anti-D immunoglobulin has dramatically decreased the incidence of hemolytic disease of fetus and newborn, it still remains a significant cause of fetal and neonatal morbidity and mortality. The main challenge facing fetal medicine specialists today is not the skill required for invasive therapy, but rather the noninvasive monitoring of the disease so that its progress can be predicted to guide the need and timing of intrauterine transfusions to minimize unnecessary invasive testing. In previous years many different diagnostic tests were proposed but the assessment of middle cerebral artery peak systolic velocity still stands as a gold standard for noninvasive assessment of fetal anemia.



Giovanni Monni, Ulrich Honemeyer

Normal and Abnormal Early Pregnancy

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:29] [Pages No:356 - 384]

Keywords: Sonoembryology,Early pregnancy failure,3- and 4D ultrasound in early pregnancy,First trimester screening,Structural fetal anomalies,Yolk sac,Preeclampsia

   DOI: 10.5005/jp-journals-10009-1214  |  Open Access |  How to cite  | 


The first trimester, mostly defined as the first 100 days of pregnancy, is characterized by many important landmarks heralding the ultimate outcome of pregnancy. Woman becomes aware of her pregnancy after missing her period, being already two weeks postconception at that time. A positive pregnancy test opens Pandora's Box, raising more questions than giving answers. Although a positive pregnancy test most likely suggests an intrauterine pregnancy, production of human chorionic gonadotropin (hCG) occurs as well in tumors (dysgerminoma, choriocarcinoma) or maldeveloped pregnancies, such as ectopic pregnancy, blighted ovum or mola hydatidosa. Other early pregnancy complications and failures, like subchorionic hematoma, missed abortion, incomplete miscarriage, retained products of conception, are likely to be accompanied by clinical symptoms such as lower abdominal pain and/or vaginal bleeding, and suboptimal beta hCG serum levels. Transvaginal ultrasound probes with frequencies of up to 14 MHz have lowered the threshold for US-detection of intrauterine pregnancy to 1200 mIu/ml beta hCG/serum (discriminatory zone), and enable identification of all above-mentioned 1st trimester pregnancy disorders earlier than ever before. Furthermore, the additional interrogation of the region of interest (ROI) with color Doppler (CD) and pulsed-wave Doppler (PW) supplies important information about characteristics of vascularization and flow indices, which assists in further differentiation and prognosis of abnormal early pregnancy findings. With the introduction of transvaginal three-dimensional (3D) sonography, and real-time 3D ultrasound (4D), in vivo studies of the early fetal life became possible. The developmental progress of the embryo and early fetus, its anatomy, and first movement patterns, have been explored by means of ultrasonic 3- and 4D imaging, which can be considered as nonteratogenic as long as investigators adhere to certain safety rules. The new field of sonoembryology has emerged, and researchers are penetrating the mists hiding the beginning of human life. Another area of remarkable expansion has been the 1st trimester scan between 11 and 13/6 weeks of gestation. It includes not only the early diagnose of fetal structural anomalies, like acranius-anencephalus sequence, and the screening for fetal aneuploidies such as trisomia 21,18 and 13, but also offers likelihood ratios for hypertensive pregnancy disorders (pre-eclampsia) and intrauterine growth restriction (IUGR).



Alin Basşgül Yig¢iter

Early Normal and Abnormal Pregnancy

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:20] [Pages No:385 - 404]

Keywords: Early pregnancy,Transvaginal ultrasound,3D-4D ultrasonography

   DOI: 10.5005/jp-journals-10009-1215  |  Open Access |  How to cite  | 


The high resolution, safety and ease of performance make ultrasound the procedure of choice for routine ultrasonography in the first half of pregnancy as a standard of obstetric care. Transvaginal ultrasound has revolutionized the diagnosis and management of early pregnancy. Pregnancies can be detected earlier compared with abdominal ultrasound, patients reassured by showing normal development, accurate gestational age determination, sufficiently early characterization of multiple pregnancy, early diagnosis of lethal anomalies and screening of chromosomal defects can be done with first trimester ultrasonography. Furthermore, recent introduction of three-dimensional and fourdimensional ultrasounds combined with the transvaginal approach has produced more objective and accurate information on embryonal and early fetal development and made it possible to visualize fascinating aspects of embryonic differentiation.



Mandy Abushama, Halima Almuhanadi

The Significance of Early Pregnancy Units in the Practice of a Busy Obstetric Unit

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:4] [Pages No:405 - 408]

Keywords: Miscarriage,Early pregnancy assessment,Obstetric unit

   DOI: 10.5005/jp-journals-10009-1216  |  Open Access |  How to cite  | 


A significant proportion of women experience bleeding in early pregnancy resulting in considerable distress. Early pregnancy unit (EPAU) should promote the sensitive and efficient management of women with early pregnancy problems and we believe this is best achieved by the establishment of a dedicated unit with dedicated staff. This paper outlines the experience of setting up an early pregnancy unit in a busy obstetrical unit.



Francisco Raga, Francisco Bonilla, Fernando Bonilla-Musoles, Juan Carlos Castillo

3D, Vocal and Tomographic Ultrasound Image in Prenatal Diagnosis of Hypospadias

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:2] [Pages No:409 - 410]

Keywords: Hypospadias,3D ultrasound (3D US),Vocal and TUI modes

   DOI: 10.5005/jp-journals-10009-1217  |  Open Access |  How to cite  | 


We report a case of anterior hypospadias, diagnosed at 26th week in a 37 years-old primigravida with normal 46XY kariotype through amniocentesis carried out at 16th week.

Sonographic examination with 2D showed a short and curved penis. The use of three orthogonal planes, Tomographic Ultrasound Image (TUI) and VOCAL allowed an exact prenatal diagnostic, showing the “tulip” sign and defining localization, situation and extension of the urethral orifice.



Miguel A Parra-Saavedra, Libardo A Gómez, Amanda Barrero, Guido Parra, Felipe Vergara, Israel Diaz-Yunez, Martha Gómez, Carlos Bermúdez, Eftichia V Kontopoulos, Rubén A Quintero

Cervical Consistency Index: A New Concept in Uterine Cervix Evaluation

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:5] [Pages No:411 - 415]

Keywords: Cervical consistency index,Preterm labor,Cervical length,Cervix evaluation,Ultrasound

   DOI: 10.5005/jp-journals-10009-1218  |  Open Access |  How to cite  | 



To search an ultrasonographic marker to measure cervix consistency throughout pregnancy quantitatively by transvaginal ultrasonography and compare these values with the current pattern–the cervicometry. In a randomly selected population of pregnant and nonpregnant women using a new cervical consistency index (CCI) and compare these changes with the findings using cervicometry.


The cervical consistency index (CCI) and cervicometry were measured using transvaginal ultrasonography in a reference population of randomly selected women who were mature enough for reproduction, and women in their first, second and third trimester of pregnancy. Patients with history of cervical conization, two or more dilations and miscarriages, Müllerian abnormalities and history of cervix incompetence were excluded from this study. Furthermore, patients with multiple pregnancies and cervical cerclage were not allowed to participate in this study.


A total of 162 patients were evaluated for cervicometry and CCI. Eighty of these women were not pregnant and the remaining 82 were pregnant. The database was analyzed using EPI-INFO version 6.0. Statistical values, such as the average, median and standard deviation between two groups, were analyzed. Statistically significant differences were found between nonpregnant and pregnant women in the first, second and third trimester regarding CCI with p < 0.0001. The cervix of pregnant women loses an average of 1.2% of consistency per week of pregnancy. Cervicometry did not show statistically significant difference among the groups (p = 0.4459).


CCI can quantitatively assess cervix consistency in pregnant and nonpregnant women, also found statistically significant differences between these groups and between the different trimesters of gestation, CCI also shows a remarkably circumscribed linear regression trend from early pregnancy. This ultrasound marker may serve in future for the early identification of patients at risk for preterm delivery. On cervicometry, there was no statistically significant differences between groups mentioned above.



Vaneesha Vallabh-Patel, Robert Vera, Gustavo Martell

Spontaneous Unilateral Tubal Twin Ectopic Pregnancy: A Case-Based Discussion and Assessment

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:5] [Pages No:416 - 420]

Keywords: Tubal ectopic pregnancy,Transvaginal ultrasound,Color Doppler ultrasound,Three-dimensional ultrasound,Serum beta-hCG

   DOI: 10.5005/jp-journals-10009-1219  |  Open Access |  How to cite  | 



Two percent of all 1st trimester pregnancies in the United States are ectopic. Transvaginal ultrasound is considered the mainstay in diagnosis. Color Doppler ultrasound can prove to be an added helpful modality in identifying ectopic pregnancies.

Case report

An 18-year-old nulliparous female presented with vaginal bleeding and lower abdominal pain. Pelvic exam revealed tenderness in the right adnexal region with elevated quantitative serum beta-hCG. A transvaginal ultrasound showed an echogenic ring adjacent to the right ovary and M-mode and color Doppler revealed two fetal heart tones. Color Doppler enabled visualization of randomly dispersed tubal arteries and heart activity of both embryos. A right salpingectomy was performed without complications and beta hCG levels returned to undetectable levels.


B mode ultrasound is a vital diagnostic tool in the detection of ectopic pregnancy. Color Doppler provides both morphologic and functional information essential for determining the optimal therapeutic strategy. Three-dimensional ultrasound with color and/or power Doppler has proven useful in both the initial diagnosis and follow-up of ectopic pregnancies especially in patients following assisted reproduction treatment.



José M Carrera, Vicenc Cararach, Manuel R Carrapato, Francesc Castella

Program Life for Africa

[Year:2011] [Month:October-December] [Volume:5] [Number:4] [Pages:6] [Pages No:421 - 426]

Keywords: International cooperation,Maternal and infant health,Training of health professionals

   DOI: 10.5005/jp-journals-10009-1220  |  Open Access |  How to cite  | 


Life for Africa is an international cooperation program that was developed by Matres Mundi International. It aims to improve the critical situation of maternal and infant health in Africa by improving the number and training of health professionals, particularly in the area of the maternal and infant health. The program, which is sponsored by the majority of the international societies of perinatal medicine (the International Academy of Perinatal Medicine, the World Association of Perinatal Medicine, etc.), consists of the creation of an International School of Perinatal Medicine for Africa and a Reference Hospital for Mothers and Children in Addis Abeba, capital of the African Union. This paper will discuss the reasons in favor of this project and will describe the details and the current situation. It will also provide information about the ‘exploratory mission’ that several members of Matres Mundi and the international societies made to Addis Abeba.


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