Prenatal identification of esophageal atresia: the role of ultrasonography for evaluation of functional anatomy

OBJECTIVE

To suggest a new ultrasonographic approach for prenatal diagnosis of esophageal atresia (EA).

METHODS

Since 1995, whenever EA is suspected, we perform a systematic multiplanar ultrasonographic scanning of the fetal upper body in order to demonstrate an esophageal pouch. This includes three image plans of the neck and upper chest: coronal, sagittal and axial views in the cephalic direction. The scan time is 20-30 min.

RESULTS

Twenty-five pregnant patients were referred during the period under study for prenatal examinations due to polyhydramnios and/or absent or small stomach. In six fetuses an esophageal pouch was demonstrated at ultrasonography in utero, thus a definitive diagnosis of EA was obtained. All six were confirmed with EA postpartum. In 19 fetuses an esophageal pouch was not demonstrated and all delivered normal neonates. During the same period two additional newborns, who were not included in the referred patients because amniotic fluid volume and stomach size were normal, were diagnosed postpartum with EA. The earliest gestational age of pouch visualization was at 23 weeks. The sagittal view was the best for visualizing a low-level pouch, and the coronal view was optimal for revealing a high pouch.

CONCLUSIONS

Our three-sectional view of the neck and upper chest is useful for in utero detection of esophageal pouch that may enhance the prenatal diagnosis of EA. The positive predictive value for prenatal ultrasound for detecting EA is 100% with a sensitivity of 80%.

Shortened fetal long bones: a possible in utero manifestation of placental function

Shortened fetal long bones (SFLB) are usually indicative of a skeletal dysplasia. Our aim in this observational retrospective study was to describe a new association between SFLB, small for gestational age (SGA) fetuses and placental abnormalities, and to suggest an aetiologic explanation. During the last decade we have evaluated nine cases in which SFLB (more than 2SD below the mean) was associated with SGA, abnormal maternal serum placental hormones and abnormal placental sonography. Six cases had significantly increased second trimester maternal serum beta hCG and four developed toxaemia of pregnancy or had chronic hypertension. On histology, mature placentas with vascular abnormalities, including chorangiosis, large infarcts and slightly increased syncytial knots were noted. The combination of SFLB, SGA fetuses and placental abnormalities (sonographic, as well as histological) suggested a possible common pathway in the aetiology of this association.

Role of color Doppler imaging in diagnosing and managing pregnancies complicated by placental chorioangioma

PURPOSE

The purpose of this study was to evaluate the role of color Doppler imaging in the diagnosis and management of placental chorioangioma.

METHODS

The medical records, sonographic reports, and sonograms of all pregnant women who had placental masses diagnosed in our sonography unit during the years 1992 through 2000 and had been evaluated using both gray-scale and color Doppler sonography were included in this study. Subjective evaluation of the amount and distribution of intralesional vascularity by color Doppler imaging was made in all cases. Cases of chorioangioma of the placenta were compared with cases of placental hemorrhage or subchorionic hematoma. The outcomes of the pregnancies were also recorded.

RESULTS

Fifteen cases of placental masses were evaluated; 8 of them were identified as placental hemorrhage or subchorionic hematoma on the basis of the sonographic findings. The other 7 cases were identified prenatally as placental chorioangioma, at a mean menstrual age of 23 weeks and a mean maternal age of 29 years. The mean size of the tumor was 6.5 cm (range, 4-13 cm). All cases of chorioangioma showed either substantial internal vascularity or a large feeding vessel within the tumor. Three infants were delivered at term with favorable outcome; 2 of them demonstrated reduction of the intratumoral blood flow during follow-up. The other 4 cases were delivered at or before 32 weeks' menstrual age (1 intrauterine fetal death, 2 terminated pregnancies, and 1 normal infant). No case of placental hematoma demonstrated blood flow within the lesion or was associated with complications of the pregnancy.

CONCLUSIONS

Color Doppler imaging helps differentiate placental chorioangioma from other placental lesions and may be useful in the prenatal follow-up of chorioangioma.

Color Doppler imaging in the sonohysterographic diagnosis of residual trophoblastic tissue

PURPOSE

The purpose of this study was to evaluate the role of color Doppler imaging during sonohysterography in the diagnosis of residual trophoblastic tissue.

METHODS

This prospective cohort study involved 25 consecutive women with clinical and sonographic signs of an echogenic intrauterine mass who were referred to the sonography unit of our institution for evaluation. All women underwent saline infusion sonohysterography with color Doppler sonographic evaluation. An operative hysteroscopy with histologic examination was performed in 17 cases.

RESULTS

Thirteen women (group A) had sonohysterographic features suggestive of residual trophoblastic tissue (ie, an echogenic intrauterine lesion not detached from the uterine wall after introduction of saline). The initial diagnosis was confirmed by histologic analysis in all cases. Blood flow was detected within the intrauterine mass in 6 (46%) of these 13 women; the resistance indices were low in all 6 cases (mean +/- standard error, 0.38 +/- 0.01). Twelve women (group B) had sonohysterographic findings negative for retained tissue, and no blood flow was detected within any of the intrauterine masses in this group (p < 0.05).

CONCLUSIONS

Our results confirm the potential role of color Doppler sonography in the initial diagnosis of residual trophoblastic tissue. The detection of color Doppler signals, especially with low-resistance flow, within an intrauterine lesion should increase the confidence of the sonologist in the diagnosis of residual trophoblastic tissue.

The development of the fetal vermis: an in-utero sonographic evaluation

OBJECTIVE

To establish a nomogram for fetal vermis measurements during gestation.

METHODS

A prospective cross-sectional study of normal singleton pregnancies. Measurements of the fetal vermis width (in the axial plane) and height (in the sagittal plane) were performed by high-resolution transabdominal ultrasonography between 18 and 38 weeks of gestation in 256 fetuses.

RESULTS

Adequate vermis measurements were obtained in 256 fetuses. Vermian width and height as a function of gestational age and biparietal diameter were expressed by regression equations and the correlation coefficients were found to be highly statistically significant (P < 0.0001). The normal mean (+/- SD) for each gestational week was defined.

CONCLUSIONS

The present data offer the normal range of the vermian measurements throughout gestation. These values may allow intrauterine assessment of the development of the cerebellar vermis, as well as the posterior fossa.

The development of the fetal thymus: an in utero sonographic evaluation

OBJECTIVES

To establish a nomogram for fetal thymus size during gestation.

METHODS

The study is a prospective, cross sectional evaluation of 403 male and female fetuses between 14 and 38 weeks of normal singleton pregnancies. Measurements of fetal thymus size were performed by high resolution transvaginal ultrasonography between 14 and 17 weeks' gestation, and by transabdominal ultrasonography after 18 weeks' gestation.

RESULTS

Adequate thymus size measurements were obtained in all 403 fetuses. Thymus size as a function of gestational age was expressed by the regression equation: (square root) thymus size (mm)= -39.39+4.41 x gestational age (weeks). The correlation coefficient, r=0.965, was found to be highly statistically significant (p<0.0001). The normal mean and the 90% prediction limits were defined.

CONCLUSION

The present data offer the normal range of fetal thymus size from early stages of gestation that may allow intrauterine assessment of its development. It may be helpful in the prenatal diagnosis of thymic pathologies.

Cervical Shirodkar cerclage may be the treatment modality of choice for cervical pregnancy

BACKGROUND

Our objective was to evaluate the use of cervical suture in cervical pregnancy.

METHODS AND RESULTS

All cases of cervical pregnancy diagnosed and treated in the gynaecological department at the Sheba Medical Center between 1994-2000 were included in the study. Eight such cases were diagnosed. The first four cases were treated medically. The last four cases (the study group) of cervical pregnancy, including one case of heterotopic pregnancy, were treated successfully with placement of Shirodkar cerclage.

CONCLUSION

Cervical cerclage may be considered as the treatment of choice in cases of cervical pregnancies. It may be the only therapy in cases of heterotopic pregnancies (intrauterine and cervical pregnancy).

Sonohysterography for the diagnosis of residual trophoblastic tissue

OBJECTIVE

To assess the efficacy, safety, and associated complications of sonohysterography for the diagnosis of residual trophoblastic tissue.

METHODS

We conducted a prospective study of 23 consecutive patients admitted to our ultrasonography unit with clinical and ultrasonographic signs of retained intrauterine tissue.

RESULTS

Twelve patients had hydrosonographic features suggestive of residual trophoblastic tissue (i.e., an intrauterine lesion not detachable from the uterine wall after instillation of saline), whereas in 11 cases the hydrosonographic findings were negative for retained tissue. Blood flow was detected within abnormal intrauterine masses in 4 of 12 patients with trophoblastic tissue, whereas it was not detected in any patient without retained tissue (P = .093). No complications were encountered during the procedure or the postprocedure period. None of the patients had anesthetic complications, perforation of the uterus, fluid overload, or any other surgical complication. All 12 patients underwent hysteroscopic removal of the suspected residual trophoblastic tissue, and histologic confirmation of residual trophoblastic tissue was obtained in all cases.

CONCLUSIONS

Sonohysterography for detection and diagnosis of residual trophoblastic tissue is an accurate and safe procedure. Further studies comparing the efficacy of sonohysterography with that of diagnostic hysteroscopy are warranted.

A comparative study of multifetal pregnancy reduction from triplets to twins in the first versus early second trimesters after detailed fetal screening

OBJECTIVES

To compare the outcome of multifetal pregnancy reduction from triplets to twins performed either early (at 11-12 weeks' gestation) or late (at 13-14 weeks).

METHODS

Ninety-five high-order pregnancies following assisted conception were studied. Transabdominal sonographically guided multifetal pregnancy reduction was performed early in 46 women, while 49 women first underwent a sonographic fetal anomaly scan before undergoing selective reduction.

RESULTS

Sonographic screening led to selective termination of a specific fetus in nine cases due to increased nuchal translucency and relative intrauterine growth restriction in three cases each, and meningomyelocele, abdominal cyst and cystic hygroma in one case each. In the early reduction group a diagnosis of hypoplastic left heart in the two remaining twins was subsequently made, and one pair of twins suffers from cerebral palsy. The rate of pregnancy loss was not statistically different between the early (4.3%; 2/46) and late (4.0%; 2/49) termination groups. The birth weight and gestational age at birth were not statistically different between the early ( n = 85) and late ( n = 94) groups (2110 +/- 580 vs. 2140 +/- 490 g, and 35.8 +/- 3.0 vs. 35.7 +/- 3.5 weeks). Similarly there was no statistically significant difference between early and late groups in the incidence of very premature (24-32 weeks; 9.3 vs. 8.3%) and premature (33-36 weeks; 46.5 vs. 47.9%) births.

CONCLUSIONS

Early second-trimester multifetal pregnancy reduction from triplets to twins may allow more selective termination of abnormal fetuses without an adverse effect on the outcome of pregnancy. However, further studies are needed in order to confirm our observations in a larger series.

Management of a triplet pregnancy with two anencephalic fetuses and polyhydramnios

The occurrence of a triplet pregnancy discordant for anencephaly is rare and its management presents a clinical dilemma. We report what appears to be the first case of a triplet pregnancy with two anencephalic fetuses complicated by premature contractions and severe polyhydramnios. Its management, which results a healthy newborn weighing 1385 g is discussed.

Hysteroscopy may be the method of choice for management of residual trophoblastic tissue

STUDY OBJECTIVE

To assess the efficacy of and reproductive outcome after selective curettage of residual trophoblastic tissue directed by hysteroscopy compared with conventional, nonselective, blind curettage.

DESIGN

Retrospective analysis (Canadian Task Force classification II-1).

SETTING

Tertiary care medical center.

PATIENTS

Seventy patients after curettage or delivery, with clinical and ultrasonographic signs of suspected residual trophoblastic tissue.

MEASUREMENTS AND MAIN RESULTS

Twenty-four women underwent traditional curettage and 46 underwent hysteroscopic selective curettage. Five (20.8%) patients who underwent traditional curettage later required operative hysteroscopy due to persistent residual tissue. None of those who underwent hysteroscopic selective curettage needed a second operation. No patient in either group experienced anesthetic complications, perforation of the uterus, fluid overload, or other surgical complication. Reproductive outcome was similar in both groups, with tendency to conceive earlier in the hysteroscopy group, but no difference in overall pregnancy rates.

CONCLUSION

Operative hysteroscopy for selective curettage of residual trophoblastic tissue should be considered an alternative to nonselective, blind curettage.

The development of the fetal penis--an in utero sonographic evaluation

OBJECTIVE

To establish a nomogram for fetal penile length during gestation.

DESIGN

A prospective, cross-sectional study of normal singleton pregnancies.

SUBJECTS

Four hundred and nineteen male fetuses between 14 and 38 weeks were studied.

METHODS

Measurements of fetal penis length were performed by high resolution transvaginal ultrasonography between 14 and 17 weeks of gestation, and by transabdominal ultrasonography beyond 18 weeks of gestation.

RESULTS

Adequate penile length measurements were obtained in all 419 fetuses. Penile length as a function of gestational age was expressed by the regression equation: (square root) penile length (mm) = 0.277 + 0.121 x gestational age (weeks). The correlation coefficient, r = 0.967 was found to be highly statistically significant (P < 0.0001). The normal mean and the 90% prediction limits were defined. During the study period, we identified three fetuses with abnormalities involving penile development. Using the above reference data range, it has been shown that their penile length was below the lower limit.

CONCLUSIONS

The present data provide a normal range of fetal penile length from early stages of gestation that may allow intrauterine assessment of the development of the male external genitalia.

Sonographic and clinical characteristics of struma ovarii

Our objective was to evaluate the preoperative clinical, laboratory, and sonographic characteristics of struma ovarii in comparison to ovarian dermoid cysts. A retrospective review of gynecologic patients operated on for mature cystic teratoma over a 10 year period identified 12 cases of struma ovarii. These cases, combined with 4 additional cases from an earlier report, were the subject of this study. Results were compared to 32 cases of ovarian dermoid cysts. Ovarian struma ovarii occurred in 12 (4.8%) of 251 cases of ovarian dermoid cysts. Most patients were premenopausal, and the mean lesion diameter was 57.3 mm (range, 30-95 mm). Struma ovarii occurred more frequently (68.8%) in the right adnexa and was seen with a normal CA-125 level. Blood flow, assessed by Doppler ultrasonography, was located in the center of the lesion in all cases of struma ovarii. Rare cases were seen with elevated tumor markers and low resistance blood flow. With regard to dermoid cysts, blood flow had a higher resistive index. In addition, no blood flow could be detected from the center of the echoic lesion in dermoid cysts (P < 0.0001). In summary, it is difficult to distinguish between struma ovarii and dermoid cysts on the basis of their sonographic appearance. Nevertheless, Doppler flow may aid in the preoperative diagnosis of struma ovarii. Blood flow signals, detected from the center of the echoic lesion, and low resistance to flow may be more common in struma ovarii.

Urorectal septum malformation sequence: prenatal sonographic diagnosis in two sets of discordant twins

Urorectal septum malformation sequence (URSMS) is a rare congenital malformation, which includes ambiguous genitalia, a phallus-like structure, imperforate anus, bladder, vaginal and rectal fistulas and Müllerian duct defects. We report two cases of prenatally diagnosed URSMS, both occurring in two sets of discordant twins. To the best of our knowledge, this is the first antenatal description of such an anomaly. The first fetus, one of a set of monochorionic, monoamniotic twins was detected sonographically at 21 weeks of gestation due to an enlarged phallus-like formation. The second fetus, one of dichorionic, diamniotic twins, was suspected of having an abnormally enlarged rectum at 13 weeks of gestation. The diagnosis of URSMS was established at 29 weeks of gestation by showing abnormal female external genitalia, with a dilated bowel that contained echogenic foci due to enterolithiasis. The diagnosis of both cases was confirmed postnatally. Sonographic findings and differential diagnosis are presented.

Varix of the fetal intra-abdominal umbilical vein: prenatal sonographic diagnosis and suggested in utero management

Varix of the fetal intra-abdominal umbilical vein (FIUV) is a rare entity. We describe an ultrasound diagnosis of this condition together with a review of the literature relating to its prognosis and management. Our conclusion is that close fetal monitoring should be performed, and delivery should be induced when lung maturity has been accomplished or any fetal distress is apparent.

CA 125 measurement and ultrasonography in borderline tumors of the ovary

OBJECTIVES

Our goal was to perform an analysis of ultrasonographic characteristics and CA 125 levels in ovarian tumors of borderline malignancy.

STUDY DESIGN

We performed a retrospective analysis of CA 125 levels and ultrasonographic parameters in 91 patients with borderline tumors.

RESULTS

Serous tumors of borderline malignancy were associated with elevated CA 125 levels in 75% of patients before surgery (mean, 156 IU/mL) compared with 30% of mucinous tumors (mean, 28 IU/mL; P =.004). CA 125 was elevated in 35% of stage IA serous tumors (mean, 67 IU/mL) compared with 89% of tumors with spread beyond the ovary (mean, 259 IU/mL; P =.001). Mucinous tumors tended to be bigger (13.1 +/- 7 cm) on ultrasonography than serous tumors (9.3 +/- 6.2 cm, P =.016). Mucinous tumors were multilocular in half the patients and contained papillations in 40% of the patients. Serous tumors were multilocular in 30% of the patients but presented with solid or papillary patterns in 78% of the patients (P =.001). A resistance index of <0.4 was found in 36% of mucinous tumors and half the cases of serous tumors. In 13% of patients, ultrasonographic characteristics were compatible with a simple cyst only, including 1 patient with microinvasion and 1 patient with stage IIIB disease. Sensitivity of gray-scale ultrasonography was 87%, that of CA 125 measurement was 62%, and that of flow was 55%. At least 1 diagnostic test result was abnormal in 93% of patients, 2 were abnormal in 69% of patients, and all 3 were abnormal in 21% of patients.

CONCLUSIONS

A high proportion of borderline tumors of the ovary, particularly of the serous type, were associated with elevated CA 125 levels and abnormal ultrasonographic characteristics, although some tumors presented as simple cysts.

Contribution of color Doppler flow to the ultrasonographic diagnosis of tubal abnormalities

Our objective was to characterize tubal abnormalities with color Doppler ultrasonography. We evaluated 25 women with adnexal masses suggestive of tubal masses using gray scale sonography. Color Doppler flow was added to further characterize the adnexal lesion. Of 18 women diagnosed as having hydrosalpinx, in 6 cases the diagnosis was tuboovarian abscess and in 1 case the diagnosis was tubal torsion. In the periphery of the hydrosalpinx, color Doppler flow revealed a mean resistive index of 0.752 +/- 0.04. In the periphery of the tuboovarian abscess, an abundant flow with reduced resistance to flow (mean resistive index = 0.448 +/- 0.04) was seen. The difference was statistically significant (P < 0.0001). In the case of adnexal torsion, no blood flow was detected in the lesion. All cases but one were confirmed in either laparoscopy or laparotomy or during colpotomy and drainage of the abscess. For adnexal masses suggestive of tubal lesions, color Doppler flow can further characterize the masses by detecting a significantly richer and low resistant blood flow in cases of tuboovarian abscess in comparison to hydrosalpinx.

Fetal aortic arch measurements between 14 and 38 weeks' gestation: in-utero ultrasonographic study

OBJECTIVE

To establish in-utero reference ranges for fetal transverse aortic arch diameter (TAD) and distal aortic isthmus diameter (DAID) using high-resolution ultrasound techniques.

DESIGN

A prospective, cross-sectional study was performed on 125 normal singleton pregnancies between 14 and 38 weeks' gestation. Transverse and diameter and DAID were measured by transvaginal ultrasonography until 17 weeks' gestation, and by abdominal ultrasound between 18 and 38 weeks' gestation.

RESULTS

Transverse arch diameter as a function of gestational age was expressed by the regression equation TAD = -1.17 + 0.169 X GA, and DAID = -1.39 + 0.189 X GA; TAD and DAID are transverse aortic and distal aortic isthmus diameters expressed in millimeters and GA is gestational age in weeks. The correlation r = 0.924 and 0.938 was found to be highly statistically significant (P < 0.001) for TAD and DAID. The normal mean of TAD and DAID per week and the 95% prediction limits were also defined.

CONCLUSIONS

The normative data established by us may be helpful in the prenatal diagnosis of congenital heart defects, including abnormal growth of the aortic arch.

[Sonographic demonstration of a levonorgestrel-releasing IUD (Mirena)]

Mirena, a new intra-uterine device (IUD) introduced in Israel during the past year, releases 20 mcg/day of levonorgestrel for 5 years. It has the advantages of reduced pregnancy rates and diminished menstrual blood loss, together with a low risk of pelvic inflammatory disease compared with current IUD's. It has a typical sonographic appearance, differing from that of regular IUD's, which was demonstrated in all 15 women examined in this study. Its sonographic appearance includes both proximal and distal ends of the vertical arm of the device, which extend into the internal cervical os and fundal region, respectively. Acoustic shadowing between both ends defines the location of the device, which should help avoid consultations due to "lost IUD's."

The development of the fetal sternum: a cross-sectional sonographic study

OBJECTIVE

To assess the relationship between gestational age and sonographic appearance of the various sternal components and establish growth during human gestation.

DESIGN

A prospective cross-sectional study.

METHODS

The study was performed on 252 consecutive normal singleton pregnancies from 19 weeks of gestation until term, using transabdominal high-resolution ultrasound techniques. The sternal length, as well as the number of ossification centers at each gestational age, were recorded.

RESULTS

The first occasion at which a fetal human sternum could be visualized with two to three ossification centers was at 19 weeks' gestational age. The fifth ossification center was first visualized at 29 weeks' gestation. The mean +/- SE of sternal length varied from 15 +/- 0.98 mm (95% confidence interval (CI) 12.79-17.21) at 19-20 weeks, to 36.50 +/- 0.29 mm (95% CI 35.58-37.42) at 37-38 weeks' gestation. Sternal length as a function of gestational age was expressed by the regression equation: sternal length (mm) = -11.06 + 1.39 x gestational age (weeks). The correlation coefficient, r = 0.924 for sternal length, was found to be highly statistically significant (p < 0.0001).

CONCLUSIONS

The presented data offer normative measurements of the fetal sternum which may be helpful in the prenatal diagnosis of congenital syndromes that include, among other manifestations, abnormalities of sternal development.

Ovarian stimulation and in vitro fertilization in women with mature cystic teratomas

OBJECTIVE

To report the results of ovulation induction and in vitro fertilization-embryo transfer (IVF-ET) in patients with ovarian cystic teratomas.

METHODS

Six women with ultrasonographically diagnosed ovarian cystic teratomas (mean diameter 2.4 cm) who presented with infertility underwent IVF-ET (n = 4) or ovulation induction (n = 2). Serial ultrasound examinations were used to determine the size of the cystic teratomas during therapy and throughout pregnancy.

RESULTS

Ovarian stimulation was successful, as evidenced by the serum estradiol concentration on the day of hCG administration (mean in IVF-ET patients, 3558+/-1319 pg/mL) and the number of oocytes retrieved (10+/-4.24). Three patients having IVF-ET and both patients having ovulation induction conceived, and six healthy infants were born. Cyst sizes remained unchanged throughout treatment and pregnancy. There were no cyst-related complications during ovulation induction or IVF-ET, or during the entire course of pregnancy, labor, and delivery.

CONCLUSION

The presence of ovarian cystic teratoma should not be considered a contraindication for therapy in women undergoing ovulation induction and IVF-ET.

Outcome of fetuses with isolated borderline unilateral ventriculomegaly diagnosed at mid-gestation

OBJECTIVE

To evaluate the outcome of fetuses with isolated borderline, unilateral ventriculomegaly.

DESIGN

A retrospective survey was conducted at four perinatal centers in Israel.

SUBJECTS AND METHODS

Only fetuses with one ventricular width of > or = 11 mm and the other < 10 mm were included in the study. In all cases, the difference of the ventricular width between the two ventricles was > 2.4 mm (two standard deviations). Fetuses with other malformations, chromosomal abnormalities, or those with evidence of in utero infection, were not included in the study.

RESULTS

Unilateral ventriculomegaly was found in 27 subjects (after excluding one case with unilateral ventriculomegaly and Down's syndrome). The mean width of the enlarged ventricle was 11.7 +/- 0.9 mm, while the other normal ventricle was 7.2 +/- 0.9 mm. The mean gestational age at diagnosis of the unilateral ventriculomegaly was 23.6 +/- 2.7 weeks. In one case, pregnancy was terminated, and pathological examination of the fetal brain failed to detect any structural abnormality. Twenty-five patients delivered at term and only one at 34 weeks' gestation. The neurological development in all 25 fetuses was normal, and one fetus had petit mal seizures.

CONCLUSION

Fetuses with isolated, borderline unilateral ventriculomegaly, but without other abnormalities, have a good neurological outcome.