Criteria for the prenatal diagnosis of holoprosencephaly

Holoprosencephaly is a congenital anomaly of the central nervous system whose prenatal sonographic appearance may to similar to that of ventriculomegaly. A clear differential diagnosis is extremely important because the two conditions have different prognoses and therefore require different obstetric management. Eight cases of prenatally recognized holoprosencephaly are analyzed and criteria for a specific diagnosis proposed. The specificity and limitations of ultrasound findings, such as identification of a holoventricle, presence of a dorsal sac, and facial anomalies are discussed.

Antenatal diagnosis and obstetric management of Dandy-Walker syndrome

Real-time ultrasound equipment has the potential for investigating the fetal neural axis and allows the diagnosis of many anomalies arising from this area. Five cases of Dandy-Walker syndrome, one of the major causes of congenital hydrocephalus, were diagnosed antenatally. In all cases ultrasound allowed specific recognition of the defect in the cerebellar vermis. This defect connected the fourth ventricle to a posterior fossa cyst in four cases and to an occipital meningocele in one case. In three cases the diagnosis was made prior to viability, and the parents elected termination of pregnancy. In two cases recognized in the third trimester, neurosurgical care was provided soon after delivery.

Perineal scanning

Although various techniques have been described to aid in the ultrasound diagnosis of placenta previa and incompetent cervix, these maneuvers depend on the precise identification of the internal cervical os, a feat which is notoriously difficult to accomplish consistently. In an attempt to get a closer view of the cervix we tried another approach. This simple technique of perineal scanning has the potential to help considerably with these problems.

Ultrasound cystourethrography by perineal scanning for the assessment of female stress urinary incontinence

Perineal scanning using linear array ultrasound was used as an alternative to radiologic cystourethrography in the investigation of female urinary incontinence. The technique provides similar information to that obtained by fluoroscopy without exposing the patient and the physician to radiation. The bladder neck and urethra as well as the urodynamic catheter are readily visualized. Familiarity with the unusual configuration of the sonogram needs to be attained.

The value of serial human chorionic gonadotropin testing as a diagnostic tool in ectopic pregnancy

This study examines the sensitivity of serial human chorionic gonadotropin determinations in the detection of ectopic pregnancy for patients who present with human chorionic gonadotropin titers less than 6500 mIU/ml. A log human chorionic gonadotropin time curve was used to calculate the slope of change. A slope below 0.11 (85% confidence limit for intrauterine gestations) is used as the cutoff value. Of 50 patients with serial titers at sampling intervals of 2 to 5 days, 26 (49%) had falling values and 22 had subnormal slopes. Only five had initially normal slopes and two of these patients eventually had falling titers. The sensitivity of an abnormal slope (below 0.11) in the detection of ectopic pregnancy was 90%. A 12.5% false positive rate was found in a group of 24 intrauterine pregnancies.

The prenatal diagnosis of Robin anomalad

The Robin anomalad was diagnosed by the sonographic detection of polyhydramnios and fetal micrognathia in a patient at risk because of a previously affected child. Ultrasound in the second trimester failed to demonstrate any facial anomaly, but mandibular hypoplasia was clearly documented in the third trimester. The antenatal diagnosis allowed immediate neonatal assistance to prevent glossoptosis-induced respiratory failure.

Antenatal diagnosis of renal anomalies with ultrasound. IV. Bilateral multicystic kidney disease

Bilateral multicystic kidney disease is a congenital disorder that is fatal in the newborn period. A series of nine cases of bilateral multicystic kidney disease diagnosed prenatally by ultrasound is presented. Ultrasound criteria necessary for the diagnosis are bilateral multicystic kidneys, loss of renal architecture, nonvisualization of the fetal bladder, and absence of amniotic fluid. Seven of the nine cases had autopsy confirmation of the diagnosis. Three cases had other associated congenital anomalies. Precise prenatal diagnosis may allow patients the option of elective abortion or may prevent unnecessary obstetric intervention. We propose that a reliable diagnosis can be made with prenatal ultrasound.

Pathological pregnancies. Results of amniotic fluid studies and fetal outcome

Late amniocenteses (greater than 20 weeks' gestation) were performed in 114 pregnancies with no a priori genetic risk, but referred because of abnormal clinical and/or ultrasound findings suggesting fetal malformations. Reasons for referral included polyhydramnios (51 cases), oligohydramnios (15 cases), fetal growth retardation (FGR) (16 cases) and abnormal fetal ultrasound findings excluding anencephaly (32 cases). In 42 of these cases, referral was motivated by a combination of the above abnormal findings. When polyhydramnios was the sole anomaly (25 cases), 5 fetuses were malformed (20%), abnormal fetal karyotype and/or elevated amniotic fluid alphafetoprotein (AFP) were demonstrated in 2 cases. Oligohydramnios was the sole anomaly in one case; the infant died of prematurity. Fetal growth retardation was the sole anomaly in 14 cases, 11 otherwise normal newborns were small for date, 2 died at birth and 1 was malformed (1/14, 7%). In this group all fetal karyotypes were normal and in 2 cases amniotic fluid AFP were increased. In the 32 pregnancies without abnormal amniotic fluid volume and/or FGR and with fetal malformation(s) suggested by ultrasound, all malformations except one (ovarian cyst possibly ruptured during birth) were confirmed at birth, amniotic fluid AFP was elevated, and/or karyotype was abnormal in 6 cases. In 42 pregnancies where more than one alarm sign was present, abnormal karyotype and/or elevated amniotic fluid AFP level were recorded in 21 of the 39 cases where amniocentesis was performed, 33 fetuses were malformed (79%) and 13 died in the perinatal period (31%). The high incidence of abnormal results of amniocentesis found in this survey of pathological pregnancies, particularly in those with multiple alarm signs, emphasizes the need for amniocentesis in these situations.

The effect of different human chorionic gonadotropin assay sensitivity on screening for ectopic pregnancy

The distribution of human chorionic gonadotropin levels in 184 patients with ectopic pregnancy is examined. The impact of changing the sensitivity of human chorionic gonadotropin testing on the incidence of false negative results is discussed. Pregnancy blood tests with a detection threshold of 200 mIU/ml were associated with an 11.9% incidence of false negative results.

Diagnosis of ectopic pregnancy: value of the discriminatory human chorionic gonadotropin zone

A prospective study was conducted to test the hypothesis that the absence of an intrauterine gestational sac when the serum level of human chorionic gonadotropin (hCG) is above 6500 mIU/mL is indicative of ectopic pregnancy. A total of 383 patients who were clinically suspected to have ectopic pregnancies had pelvic ultrasound examinations with serum hCG determinations on the day of the scan. There were 217 (57%) intrauterine gestations, 104 (27%) ectopic pregnancies, and 62 (16%) spontaneous abortions. Forty-one percent of patients had an hCG level above 6500 mIU/mL. The absence of an intrauterine gestational sac at an hCG concentration above this level had a sensitivity of 100%, a specificity of 96%, a positive predictive value of 86%, a negative predictive value of 100%, and was 98% efficient, based on a 19.4% prevalence of ectopic pregnancies among this group.

Value of culdocentesis in the diagnosis of ectopic pregnancy

The diagnostic value of culdocentesis was examined in all patients admitted with hemoperitoneum during a three-year period. There was a total of 158 women with positive culdocentesis, of whom 132 (83.5%) had tubal ectopic pregnancies and 26 had other diagnoses. Of the 132 patients with ectopic gestations, the majority (62%) had unruptured tubes. A nondiagnostic culdocentesis should not be used either to raise or to lower the clinician's suspicion of ectopic pregnancy as 16% of patients with an ectopic pregnancy had a nondiagnostic culdocentesis, of which one-quarter were ruptured and three-quarters had hemoperitoneum diagnosed at the time of surgery. A positive culdocentesis along with a positive serum human chorionic assay was associated with an ectopic pregnancy in 99.2% of cases. This procedure should not be limited to the evaluation of patients with classic peritoneal signs, as 45% of the authors' patients with a positive culdocentesis did not have such findings.

The interhemispheric fissure: a commonly mislabeled cranial landmark

The bright midline echo observed in fetal cranial sonography has been termed by many authors the "falx cerebri." Anatomic, embryologic, and sonographic evidence presented here suggests that this terminology is incorrect and that use of the term "interhemispheric fissure" is more appropriate.

Sonographically monitored amniocentesis to decrease intraoperative complications

The rates of intraoperative complications (dry and bloody taps) of two amniocentesis techniques were compared in 1300 patients undergoing second trimester procedures for genetic indications. The sonographically guided technique consisted of the selection of a site for needle insertion with ultrasound, removal of the transducer, and immediate amniocentesis. The sonographically monitored technique consisted of the continuous visualization of the needle during the entire procedure. Six hundred twelve amniocenteses were performed with the sonographically guided technique and 688 with the sonographically monitored technique. There was a statistically significant decrease in the incidence of bloody and dry taps of the first needle insertion (relative risk = 38%, P less than .0001) and also in the number of patients that required multiple needle insertions (relative risk = 42%, P less than .0001) with the sonographically monitored technique.

Sonographic monitoring to guide the performance of postabortal uterine curettage

This communication describes a technique of sonographically monitored uterine curettage. This method is of particular value in the management of postabortal endomyometritis associated with retained products of conception or in any situation in which anatomic variation (for instance, retroversion) makes curette insertion difficult.

Antenatal diagnosis of renal anomalies with ultrasound. III. Bilateral renal agenesis

Bilateral renal agenesis is a lethal congenital anomaly. A reliable prenatal diagnosis is extremely important, since it may offer options for pregnancy termination or may change obstetric management in the third trimester. This study examined the accuracy of ultrasound in making an antenatal diagnosis of bilateral renal agenesis in three different populations: (1) patients with a family history of bilateral renal agenesis, (2) patients diagnosed during the course of a routine scan, and (3) patients referred because of a previous suspicious ultrasound examination in a level I ultrasound facility. In group A there were three true positive, 13 true negative, no false negative, and no false positive diagnoses. In group B there were three true positive and no false positive diagnoses. In group C there were 12 true positive, 17 true negative, one false negative, and no false positive diagnoses. The value and potential pitfall of the different diagnostic criteria are discussed. We conclude that ultrasound is a valuable tool in the detection of intrauterine renal failure, although there are limitations to a specific diagnosis of bilateral renal agenesis.

The diagnosis of congenital renal anomalies with ultrasound. II. Infantile polycystic kidney disease

Infantile polycystic kidney disease in an autosomal recessive disorder which in its severe form is characterized by bilateral renal enlargement and renal failure. The present study was undertaken to assess the diagnostic accuracy of antenatal sonography in a population at risk. Nineteen patients with fetuses at risk for infantile polycystic kidney disease were referred for ultrasound examination to the Perinatal Unit at Yale-New Haven Hospital. Ten infants had infantile polycystic kidney disease (53%). A positive antenatal sonographic diagnosis was made by the presence of oligohydramnios, an absent urinary bladder, bilateral renal enlargement as measured by the kidney circumference-to-abdominal circumference ratio, and the typical hyperechogenic appearance of the kidneys in the disease. A correct antenatal diagnosis was made in nine of the 10 affected infants. There were no false positive diagnoses. A false negative diagnosis occurred in an infant with a less severe form of the disease. Ultrasound is a valuable tool in the antenatal diagnosis of infantile polycystic kidney disease.

Fetal cardiac dimensions: a potential tool for the diagnosis of congenital heart defects

This study proposes normal values for fetal heart dimensions. They include the transverse and longitudinal diameters of the heart, as well as an estimate of the cardiac volume. The resulting nomograms were useful in the diagnosis of various congenital anomalies, as is demonstrated in three case reports. Although the nomograms are not intended to compete with more elaborate techniques of investigation of the fetal heart, such as M-mode echocardiography or Doppler studies, they are much easier to use and could be used as a complementary method to identify possible fetal cardiac anomalies.

Fetal pericardial fluid: a normal finding of the second half of gestation

In a series of 104 consecutive pregnancies ranging from 20 to 40 weeks' gestation which were examined with real-time ultrasound, we observed 46 fetuses with pericardial fluid. High resolution makes the detection of normal pericardial fluid now feasible.

The diagnosis of fetal microcephaly

Of 16 fetuses in whom microcephaly was suspected, nine (56.2%) were affected with microcephaly, and seven (43.8%) were unaffected. Subsequently, nomograms with mean and SDs for biparietal diameter, occipitofrontal diameter, head perimeter: bdominal perimeter, biparietal diameter:femur length, and femur length:head perimeter we derived. With the use of the data from 27 sonograms of the 16 fetuses, different thresholds of abnormality were tested. Three standard deviations from the mean for biparietal diameter, occipitofrontal diameter, head perimeter, and femur length:head perimeter were sensitive thresholds for the diagnosis of fetal microcephaly with no false negative diagnoses. Four standard deviations from the mean for occipitofrontal diameter, head perimeter:abdominal perimeter, and femur length:head perimeter were specific tests with no false positive diagnoses. The use of multiple diagnostic tests was necessary to improve accuracy in the diagnosis of fetal microcephaly. Further clinical studies are needed to delineate more clearly optimal tests and thresholds of abnormality.

Pergolide therapy in Parkinson's disease

A total of 26 patients were treated with pergolide mesylate, a semi-synthetic ergot derivative with the property of direct dopamine activity. Of these patients, 18 suffered from late failure of L-dopa, while the remaining 8 had never before been treated with L-dopa. The aim of the trial was to study the activity of pergolide, either by giving it to untreated patients or by reducing as much as possible the L-dopa given in patients with parkinsonism. Adverse effects and failure rate were reduced by slowly increasing the daily dosage, by giving considerable dose flexibility whenever side-effects were manifest, and by the use of relatively low doses (mean of 3.8 mg in the L-dopa-group and 2.9 in the other group). At present, from 26 patients, 13 (50%) still remain in the study for an average treatment period of 16 months (3 weeks to 25 months for the group as a whole). All patients experienced a beneficial effect from pergolide, especially during the first months of treatment, in selfcare, rigidity, gait and automatic movements. Slight or no improvement was seen in tremor, speech and posture. The most frequent side-effects were nausea and vomiting (in the initial phase of the treatment), insomnia and psychotoxic reactions (mostly periods of confusion accompanied by visual hallucinations and paranoid illusions). The study indicated that pergolide mesylate is a useful additive for treatment of parkinsonism, but special attention should be paid to the important psychotoxic adverse effects that may appear, even at a low dose.

A longitudinal study of fetal weight growth

In a longitudinal study of fetal growth, the authors attempted to provide normal values for estimating fetal weights at various gestational ages.

The binocular distance: a new way to estimate fetal age

Fetal ocular biometry has been previously established and reported. The purpose of this communication is to report an equation to predict fetal age from the binocular distance. The error of the estimation is also reported. The potential value of this measurement is illustrated in a case of thanatophoric dysplasia.

Vascular anatomy of the fetus

Real-time ultrasonography is utilized in this study to demonstrate most of the large vessels in fetuses from 22 weeks on. Images of the aorta, the coronary ostium, the vessels of the aortic arch, the carotids, the ductus arteriosus, the superior mesenteric artery, the celiac axis, the common iliac artery, the external iliac artery, and the femoral artery are demonstrated. Additionally, images of the subclavian vein, the superior mesenteric veins, the splenic vein, the portal vein, the hepatic veins, the ductus venosus, the renal veins, the iliac veins, and the inferior vena cava, as well as the pulmonary artery and veins and the azygos vein, are presented.

Estimation of gestational age from measurements of fetal long bones

The general practice of using fetal long bone growth charts to derive gestational age does not yield mathematically valid results. The authors tried to calculate gestational age from the lengths of long bones (femur, humerus, tibia, ulna) from 12 to 40 weeks of gestation. The combined use of the four bones allows a good estimation of gestational age that may be useful should the biparietal diameter measurement be unreliable, unobtainable, or abnormal.