Sonographic appearance of appendiceal mucocele

We present a case of the diagnosis of an appendiceal mucocele in a 23-year-old woman. The unusual preoperative sonographic appearance of the lesion is described and its clinical significance and differential diagnosis are discussed.

Early second-trimester low umbilical coiling index predicts small-for-gestational-age fetuses

OBJECTIVE

To evaluate the role of the early second-trimester Doppler velocimetric studies of the umbilical coiling index and umbilical cord cross-sectional area as tests for the prediction of small-for-gestational age infants.

METHODS

Doppler blood flow studies in 147 singleton pregnancies at risk for delivery of a small-for-gestational-age neonate were performed at 15 +/- 1 (SD) weeks' gestation from the uterine artery, umbilical artery, middle cerebral artery, inferior vena cava, and ductus venosus. Pulsatility index values were calculated for the arteries, and preload index values and systolic-atrial contraction ratios were calculated for the veins. The sonographic cross-sectional area of the umbilical cord was measured in a plane adjacent to the insertion into the fetal abdomen. The umbilical coiling index was calculated by using sonographic longitudinal views of cord vessels from several segments antenatally and by dividing the total number of helices by cord length (centimeters) postnatally. Small-for-gestational-age neonates were identified when the birth weight was below the 10th percentile for gestational age.

RESULTS

Among 147 pregnancies studied, 124 fulfilled the study criteria. Thirty-nine of the neonates were small for gestational age at birth (31.5%). The mean +/- SD gestational age at delivery of the appropriate-for-gestational-age neonates was 39.7 +/- 1.28 weeks, and that of the small-for-gestational-age neonates was 36.4 +/- 2.9 weeks (range, 28-40 weeks). The best single predictor of a small-for-gestational-age infant was the coiling index, with sensitivity of 79%, specificity of 86%, a positive predictive value of 72%, and a negative predictive value of 90%.

CONCLUSIONS

The umbilical coiling index measured in the second trimester is useful in predicting the birth of a small-for-gestational-age infant and may serve as a marker for subsequent growth restriction.

Cardiac function in fetuses with intracardiac echogenic foci

OBJECTIVE

To evaluate cardiac dimensions and function in euploid fetuses with intracardiac echogenic foci.

STUDY DESIGN

Forty-eight fetuses with a single cardiac echogenic focus situated in the left ventricle had echocardiography performed at 22-24 weeks of gestation. Fifty normal fetuses at 22-24 weeks' gestation served as controls. Two-dimensional and M-mode directed fetal echocardiography were used to exclude cardiac anomalies and measure right and left ventricular free walls and interventricular septal thickness and ventricular systolic and diastolic dimensions. Cardiac size was expressed as a ratio of ventricular wall thickness/biparietal diameter, and cardiac function was expressed as ventricular shortening fraction. Doppler fetal echocardiography measurements included pulmonary and aortic maximum systolic velocities and time to peak velocities as indices of ventricular systolic function, and the ratio between early ventricular filling (E-wave) and active atrial filling (A-wave) peak velocities at the level of the atrioventricular valves as an index of ventricular diastolic function.

RESULTS

Early ventricular filling/active atrial filling peak velocity ratios were significantly lower in fetuses with intracardiac echogenic foci than in control fetuses. In the mitral valve the ratio was 0.37 +/- 0.14 (0.039) (mean +/- SD (95% confidence interval for difference between the means)) vs. 0.59 +/- 0.19 (0.052) and in the tricuspid valve it was 0.42 +/- 0.16 (0.045) vs. 0.62 +/- 0.21 (0.058). No significant differences were found in cardiac dimensions, ventricular shortening fraction and Doppler systolic indices.

CONCLUSION

Euploid fetuses with intracardiac echogenic foci show low E/A ratio values in midtrimester echocardiography. This finding might indicate cardiac diastolic dysfunction.

Endometrium-to-myometrium relative echogenicity coefficient. A new sonographic approach for the quantitative assessment of endometrial echogenicity

A computer program was developed to assess the endometrial echogenicity relative to the myometrial one, based on the gray-level processing of the midsagittal uterine image. The endometrial region of interest was specified within the upper part of the uterine cavity. The adjacent area of the myometrium was used to determine the reference brightness. The endometrial region of interest was analyzed along the anteroposterior uterine axis, as a set of thin strips directed parallelly to the midcavitary line. The endometrial/myometrial relative echogenicity coefficient (E/M REC) was computed for each strip and displayed graphically as a function of the distance from the midcavitary line. The area under the E/M REC curve within the limits of the total endometrial width was defined as total area (TA) and was used as a measure of the endometrial echogenicity. This parameter was assessed in 9 patients during their normal ovulatory cycles and in 29 IVF-treated patients with mechanical infertility. TA has a significant linear increase during the days of the ovulatory cycles. TA was found in high correlation with log(estradiol). TA can be used reliably for sonographic endometrial dating in ovulatory cycles.

Evaluation of ureterocele with Doppler sonography

Ureterocele is a common disorder characterized by cystic dilatation of the terminal submucosal portion of 1 or both ureters. Conventional imaging modalities for the diagnosis of ureterocele include intravenous urography and voiding cystourethrography; gray-scale sonography, augmented by color Doppler and spectral analysis studies, can be useful in diagnosing and managing this condition as well. We describe the diagnosis of ureterocele using transvaginal gray-scale and color Doppler sonography with spectral analysis in 2 women. Color Doppler sonography demonstrated urine flow into the bladder, and spectral analysis was used to measure the flow velocity. Together, these modalities can provide additional information about urinary flow dynamics, aid in implementing treatment for patients with ureterocele, and eliminate the need for invasive diagnostic procedures.

Assessment of endometrial receptivity for gestation in patients undergoing in vitro fertilization, using endometrial thickness and the endometrium-myometrium relative echogenicity coefficient

OBJECTIVE

To evaluate the outcome of in vitro fertilization (IVF) treatment in relation to the sonographic parameters of the endometrium.

DESIGN AND METHODS

Seventy-five patients with no uterine pathology (age 31.1 +/- 5.4 years) treated in our IVF clinic for various indications were assessed during 75 cycles in which good-quality (grades 1 and 2) embryos were transferred. Controlled ovarian stimulation was achieved by the long protocol (gonadotropin releasing hormone agonist and gonadotropins). The bilayered endometrial thickness (BET), estradiol, luteinizing hormone and progesterone serum levels were measured in 272 tests. A special computer program was used to measure endometrial echogenicity relative to myometrial echogenicity. The gray-level data were analyzed on the basis of the midsagittal sonographic uterine image. Endometrium-myometrium relative echogenicity coefficient (E/M REC) values were computed and displayed graphically along the anteroposterior axis of the endometrial layers in the upper part of the uterine cavity. The area under the E/M REC curve within the BET limits was defined as the relative echogenicity area (REA) and was used as a measure of endometrial echogenicity. Each cycle was sampled in six time segments representing desensitization, follicular and luteal phases. Assigning the day of ovum pick-up as day 0, the time segments of each cycle were: first, day -20 to day -11; second, day -10 to day -6; third, day -5 to day -2; fourth, day 0; fifth, day +7 to day +14; sixth, day +15 to day +21.

RESULTS

A total of 276 embryos were transferred (3.68 +/- 1.01 per cycle), of which 223 were of good quality (2.97 +/- 1.51 per cycle). An intrauterine pregnancy was diagnosed in 29 patients. All patients in this study had a BET of > 5 mm in the third and the fourth time segments. There was no significant difference in BET and REA between pregnant and non-pregnant patients tested in the first to the fifth time segments of the IVF cycles. Both BET and REA measured in the sixth time segment were significantly higher in pregnant compared to non-pregnant patients.

CONCLUSIONS

Our results suggest that the proposed sonographic assessment of the endometrium shows no benefit in characterization of uterine receptivity in IVF patients with a reactive endometrium. High BET and REA values can indicate pregnancy during the sixth time segment, when the decidualization of the endometrium is well established.

Fetal cardiac measurements derived by transvaginal and transabdominal cross-sectional echocardiography from 14 weeks of gestation to term

OBJECTIVE

Most of the routine ultrasound screening in our institution consists of early transvaginal examinations at 14-17 weeks. Complete fetal echocardiography is performed in every case. However, normal values for most fetal cardiac structures at this stage of gestation are not available. Our aim was to construct normal ranges for fetal cardiac structures, derived from cross-sectional echocardiography, at 14-40 weeks of gestation.

DESIGN

A prospective study was performed. The study group consisted of 637 pregnant women referred for a routine sonographic examination. Women with abnormal prenatal or postnatal outcome were not included in the study. Transvaginal examinations were used for 14-17 weeks of gestation. More advanced pregnancies were examined transabdominally.

RESULTS

We constructed normal ranges for the left and right end-diastolic transverse ventricular diameters (n = 637), left/right ventricular ratio (n = 637), aortic root diameter (n = 637), pulmonary artery diameter (n = 637), aortic/pulmonary ratio (n = 490), left and right transverse atrial diameters (n = 201) and left/right atrial ratio (n = 201).

CONCLUSIONS

The results provide the examiner with normal ranges for fetal cardiac structures for the early transvaginal examination. The continuity of all curves from 14 to 40 weeks of gestation allows follow-up of any specific fetus to term.

Myometrial thickness in pregnancy: longitudinal sonographic study

The purpose of this study was to evaluate in vivo the changes in myometrial thickness throughout pregnancy. Myometrial thickness was measured in 25 singleton uncomplicated pregnancies. Ultrasonographic sagittal and transverse sections were used to measure uterine wall thickness from the low anterior wall (lower segment) and the anterior, posterior, right, and left walls of the upper segment and from the fundus. In each case four measurements were made in the second and third trimesters. Myometrial thickness of the upper uterine segment remains fairly constant in the first and second trimesters of pregnancy, whereas a significant linear trend was found between a decreasing thickness of the lower uterine segment and advancing gestational age. Myometrial thickness is significantly increased behind the placental insertion site as compared to other portions of the uterine wall. These data may serve as baseline reference values for further studies in the antepartum fetal surveillance of high-risk pregnancies.

The instantaneous measurement of multiple Doppler spectra in the investigation of ovarian masses

The use of Doppler indices of tumor vascularity as markers for malignancy has been a subject of debate, with inconsistencies in specificity and sensitivity as well as in the diagnostic cut-off values. Part of the discrepancy might be explained by the limited number of vessels selected within the tumor for Doppler evaluation. A typical sample of three or four vessels may not be sufficiently large for correct representation of the vasculature of the tumor, which may contain many vessels. The existing conventional Doppler (color and spectral) techniques clearly have limitations. We present here a novel Doppler modality, namely two-dimensional spectral Doppler imaging (SDI), which allows the acquisition of many Doppler spectra within a few seconds. The operator selects a region of interest within a color Doppler image. The Doppler sequence is initiated and the entire selected region is automatically scanned for about 20 s until all spectral Doppler data have been acquired and processed. The system computer generates a color-coded map of the desired Doppler indices overlaid on the gray-scale image. The system also displays a cumulative histogram or a table of the requested Doppler index from all the sections in the tissue. The whole process is automatically performed by the system computer, without any need for operator intervention. The system provides the examiner with a 'fishing net' for Doppler indices, instead of the 'fishing hook' used in current techniques.

Fetal pyelectasis in consecutive pregnancies: a possible genetic predisposition

Mild fetal pyelectasis is a relatively common finding. The objective of this study was to assess its recurrence rate in subsequent pregnancies. The study comprised 420 women with two consecutive normal uncomplicated pregnancies screened at 15-24 weeks' gestation by ultrasound. Pyelectasis was defined as a fetal pelvis of 4 mm or more in its anterior-posterior dimensions. Of 64 fetuses with pyelectasis, 43 (67%) had a recurrence of this finding in their subsequent pregnancy. Compared with normal fetuses, those with pyelectasis had a relative risk of 6.1 to have a recurrence of this finding in their next pregnancy (95% confidence interval, 4.3-7.5, p < 0.001). These results suggest a predisposition for pyelectusis that may be influenced by genetic and/or environmental factors. More data are needed before an accurate adjustment based on previous results can be made.

Re-emergence of Cholera Vaccine

Although epidemic cholera was first described in 1817, the disease probably has been common in the Indian subcontinent since ancient times.1 Until recently, a single bacterial type (Vibrio cholerae 01) has been responsible for each of the seven recorded cholera pandemics. The current epidemic began in Celebes (Sulawesi), Indonesia, in 1961, and is currently raging through all continents.2 During the 1990s, over 1 million cholera cases have been reported from Latin America, 2000 from Ukraine and the Russian Republic during 1994 alone (GIDEON computer software, C.Y. Informatics, Ramat Hasharon, Israel). Of the 208,755 cases of cholera (5034 fatal) officially reported to the World Health Organization in 1995,3 41.1% were from Latin America, 34.0% from Africa, 24.4% from Asia, and 0.5% from Europe and Oceania. Interest in our own country of Israel stems from the popularity of tourism (over 1 million travelers exit Israel yearly) and the presence of disease in neighboring areas. Following an epidemic of 397 cases in Jerusalem during 1970, periodic outbreaks have occurred in Gaza, Judea and Samaria.4 Three tourists returned with the infection to Israel during the 1980s, all from Egypt (which officially claims to have no cholera).5 Despite universal interest in this ancient disease, medical science has long been frustrated in its search for an effective vaccine. The most important 'vaccine' against cholera is common sense, and consists of intelligent eating and drinking while in endemic areas. For example, local raw fish (ceviche) is a common source of the disease in Latin America, while shellfish (particularly oysters) are often implicated along the American Gulf Coast. Virtually all forms of water purification are effective against Vibrio cholerae. Although antibiotic prophylaxis might be considered in some circumstances (doxycycline; or a quinolone in areas of tetracycline resistance), it is not routinely advocated.

Expectant management of twin pregnancies discordant for anencephaly

OBJECTIVE

To study the clinical course and perinatal outcome of twin pregnancies discordant for anencephaly, without selective termination.

METHODS

We conducted a descriptive retrospective study of 14 cases of dichorionic twin pregnancies discordant for anencephaly, which were managed expectantly in five Israeli perinatal centers.

RESULTS

None of the patients miscarried. The mean gestational age at delivery was 35.9 +/- 2.8 weeks (range 29-39). Only three patients (21%) delivered before 35 weeks' gestation. Polyhydramnios occurred in six of the anencephalic amniotic sacs. Nevertheless, most occurrences were mild and none necessitated therapeutic amniocentesis. The mean birth weight of the normal fetus was 2610 +/- 690 g (range 1100-3200). One apparently normal twin had a cardiac anomaly and died shortly after birth, and one was electively delivered at 33 weeks because of severe intrauterine growth retardation and subsequently developed cerebral palsy. The rest had normal short- and long-term outcomes.

CONCLUSION

Expectant management of a twin gestation discordant for anencephaly diagnosed at the second trimester is associated with a favorable outcome for the unaffected fetus.

In utero sonographic appearance of intestinal duplication cysts

The antenatal appearance of gastrointestinal duplication cysts is described. Two cases are presented: a duplication cyst of the pylorus and a cyst of the terminal ileum. The embryogenesis and the clinical utility of prenatal diagnosis of these malformations of the alimentary tract are discussed. Antenatal detection of these cystic masses allowed close neonatal surveillance and timely surgical intervention prior to neonatal complications.

Fluorescent in-situ hybridization (FISH) as an aid to marker chromosome identification in prenatal diagnosis

Five cases of supernumerary marker chromosomes were identified in prenatal diagnosis as derived from chromosomes 18, X, and Y. One unexpected finding was in a case where the PCR was positive for the SRY gene while fluorescence in situ hybridization was positive for two X centromeres. In another case with an X derived supernumerary marker the newborn was phenotypically normal. Two women with fetal mar(18) and mar(Xp) decided to terminate the pregnancy. The fifth pregnancy had a karyotype of 46,XX,-15,+der(15)t(Y:15)(q11,23;p13). A phenotypically normal girl was born at term.

New heritable fragile site with spontaneous expression at 1q41

The report presents a family ascertained through recurrent spontaneous abortions in which a new heritable fragile site located at 1q41 is segregating. The fragile site is present in the mother and her son. It is expressed spontaneously in 100% of the metaphases from lymphocyte culture using standard conditions. The use of folate deficient medium and the addition of FUdR to the medium did not affect the appearance nor the level of expression of the fragile site.

Effect of bioactive glass templates on osteoblast proliferation and in vitro synthesis of bone-like tissue

Using in vitro synthesized bone tissue with cells aspirated from the patient's marrow is an appealing idea to avoid the profound limitations of biological and synthetic grafts. Procedures to synthesize bone tissue in vitro primarily relied on seeding various substrates with cells that have osteogenic capacity in culture. It should be noted that in an in vitro system, osteoprogenitor cells, as well as bone cells themselves can rapidly change their phenotype, hence the substrate needs to promote the expression of the bone cell phenotype. Furthermore, it needs to provide a template for bone deposition while gradually resorbing once bone tissue has been laid down. This paper presents initial evidence that bioactive glass, a synthetic material with documented extensive bone bioactivity properties, represents a material that optimally combines the requirements of the ideal template for in vitro synthesis of bone tissue. When made in porous form, and conditioned to develop a bone-like surface prior to being seeded with pluripotential cells capable of expressing the osteoblastic phenotype, these templates lead to expeditious and abundant in vitro synthesis of extracellular matrix with most important characteristics of bone tissue.

Doppler studies of fetal cerebral blood flow

Doppler flow velocity waveforms from fetal cerebral vessels can be reliably obtained by a transabdominal or transvaginal scanning route. Changes in pulsatility imply alterations in cerebral impedance and reflect the physiological regulatory mechanisms underlying pathological processes during pregnancy. In fetuses severely distressed due to failure of placental function, the ratios reflecting the redistribution of fetal circulation (e.g. the 'brain-sparing effect') help to identify fetuses at risk for fetal hypoxia. Apart from providing an increase in medical knowledge, this non-invasive technique is proving to be clinically useful.

Maternal plasma glucose levels and Doppler flow velocity waveforms in cerebral arteries of growth-retarded fetuses

Doppler flow studies of the intracranial internal carotid artery and middle cerebral artery performed in 17 women at 30-36 weeks of gestation, referred for evaluation of small for gestational age fetuses, resulted in abnormally low pulsatility index values (below 2 SD). These patients were investigated when fasting and 1 h after a 100-gram glucose load. Increase of 20 ml/dl or more was followed by elevation of the mean pulsatility index in the internal carotid artery from 1.03 +/- 0.09 to 1.44 +/- 0.22 (p < 0.001), and in the middle cerebral artery from 1.12 +/- 0.16 to 1.83 +/- 0.24 (p < 0.001). Pulsatility index values returned to normal (within 2 SD for gestational age) in 15 of the subjects investigated after glucose load. These findings suggest the importance of standard fasting state or determination of maternal plasma glucose levels in patients undergoing Doppler flow evaluation of growth-retarded fetuses.

Neu-Laxova syndrome: prenatal ultrasonographic diagnosis, clinical and pathological studies, and new manifestations

A diagnosis of the Neu-Laxova syndrome (NLS) was made by ultrasonography at 32 wks of gestation. Ultrasonographic examination showed intrauterine growth retardation (IUGR), Dandy-Walker anomaly, choroid plexus cysts, receding forehead and microcephaly, bilateral cataract without prominent eyes, scalp edema with no generalized edema, retrognathia, curved penis, and flexion deformities of limbs. The findings in this case are consistent with NLS; however, they did not fit any of Curry's [1982] groups. Massive swelling of hands and feet were among the main manifestations in classic NLS cases. In the case presented herein, edema was noted only in the scalp. This might shed further light on the question of variability vs. heterogeneity in the NLS. This case shows the existing possibility of an early diagnosis of NLS and adds Dandy-Walker anomaly and choroid plexus cysts as new findings to this syndrome.

Sonographic indications for karyotyping procedures. An international questionnaire

An international survey was conducted to investigate attitudes to karyotyping procedures in cases of fetal anomalies detected by ultrasound. A questionnaire was sent to 111 current members of the International Society of Ultrasound in Obstetrics and Gynecology. The overall response rate was 48%. Analysis of the replies reflects a wide variation in the criteria for the definition of a sonographic abnormality, the indication for a diagnostic procedure, and the timing for intervention. The results emphasize the need for additional data on several sonographic findings (e.g. choroid plexus cysts, renal pyelectasis, short limbs) and for improved selection of patients for chromosomal investigation.

[Fetal echocardiography]

Fetal echocardiography is an ultrasonic technique for the diagnosis of cardiac defects and fetal arrhythmias. During 1981-1990 we examined 1800 women referred for elective examinations from all over the country. Most, at high risk for fetal cardiac anomalies, were examined in the 22nd week of gestation. Others were examined whenever a fetal arrhythmia or a cardiac defect was suspected. In 251 fetuses (13.9%) pathological cardiac conditions were found, and structural heart defects in 51 (2.8%). When a cardiac defect with poor prognosis was diagnosed during the 2nd trimester, termination of pregnancy was suggested. In 35% of these cases termination of pregnancy was accepted. In 12% of the women examined spontaneous intra-uterine fetal death had occurred, while in 52% live babies were born, but half died within 6 months. In 215 fetuses (11.9%) a cardiac arrhythmia was found, which in 73% consisted of supraventricular premature beats. In 15.8% the fetus was endangered by the arrhythmia, mainly supraventricular tachycardia, atrial fibrillation or atrial flutter. Treatment was by drugs administered to the mother. In 1 case of complete A-V block echocardiographic follow-up demonstrated rapid deterioration of heart function. Delivery was induced and a pacemaker was implanted in the newborn.

Delirium: phenomenologic and etiologic subtypes

While all delirious patients have clouding of consciousness (alteration of attention) and cognitive dysfunction, the level of alertness of different patients may range from stuporous to hyperalert. We, therefore, developed an analog scale to rate the alertness of delirious patients, and a separate scale to rate the severity of their clouding of consciousness. Based on these scales, patients were categorized overall as relatively "activated" (relatively alert despite clouding of consciousness), or "somnolent" (relatively stuporous along with clouding of consciousness). Cognitive function was estimated using the Mini-Mental Status Exam. Separate ratings were made of hallucinations, delusions, illusions, and agitated behavior. Activated and somnolent patients had similar ages, overall severity of delirium, and Mini-Mental Status Exam scores. Activated patients, however, were more likely to have hallucinations, delusions, and illusions than somnolent patients, and were more likely to have agitated behavior. Patients with hepatic encephalopathy were more likely to have somnolent delirium, while patients with alcohol withdrawal appeared more likely to have activated delirium. These data indicate that phenomenologic subtypes of delirium can be defined on the basis of level of alertness. These subtypes are validated in part by their differing associations with symptoms unrelated to alertness. These subtypes may have different pathophysiology, and thus, potentially different treatments.