Reproducibility of the fetal cerebral vessels assessment in full and late term pregnancies

Objective: Data concerning feasibility of the fetal cerebral Doppler examination in full term and late term pregnancy is lacking. Our purpose was to perform an evaluation of these arteries with power Doppler ultrasound, calculating the percentage of identification and measurement and the intraobserver reproducibility.Methods: This was a cross sectional study evaluating a population of 578 normally grown fetuses divided according to the week of examination. The first group included fetuses examined at week 40 (N = 323) and the second fetuses examined at week 41 (N = 255). The three major branches of the internal carotid artery (anterior, middle and posterior cerebral arteries, ACA, middle cerebral artery (MCA), posterior cerebral arteries (PCA)) and their anastomosis (A1, A2, P1, P2) were examined with power Doppler ultrasonography by three independent ultrasonographers. The proportion of vessel identified and measured was calculated and the reproducibility among the three operators was investigated.Results: The major arteries at the circle of Willis were fully identified/measured in 65/56 and 62/48% of fetuses at 40 and 41 weeks. The MCA obtained the higher percentage of identification and measurement at both periods (> 80 and >70%). The entire set of anastomosis were less frequently identified/measured at both periods (50/< 50% of cases), especially in the A2 segment. The best agreement was obtained in the MCA and the worst in the PCA-P1 segment.Conclusions: At 40 and 41 weeks, the fetal cerebral vessels, especially the MCA, are suitable for power Doppler evaluation, providing an interesting tool to evaluate fetal hemodynamics in full and late term pregnancy.

[Ultrasonographic and clinical methods in the management of prolonged pregnancy]

AIM

The aim of this study was to evaluate the role of Bishop score, sonographic measurements of uterine cervical length and maternal characteristics, as predictors of spontaneous onset of labor within 24 hours, as well as response to induction in prolonged pregnancies.

METHODS

Pregnancies with gestational age over 280 days were followed as outpatient. Patients were included in the study if spontaneous delivery occurred between 286 and 295 days of gestation, or in pregnancies with gestational age of 291-293 days who required labor induction. Data about Bishop score, ultrasonographic cervical characteristics (length, funneling, volume) and maternal features (parity, body mass index and age) registered at the last control immediately before the delivery were retrieved from clinical charts.

RESULTS

Data from 195 patients were available. Bishop score and, in particular, ultrasonographic cervical length can predict the spontaneous onset of labor with a positive predictive value (PPV) of 22% and 44%, respectively in 24 hours. On the other hands, in patients requiring labor induction, parity and ultrasonographic cervical length remained the only predictive parameters with a PPV of 39% and 42%, respectively. In term of predictive performance, the value of 30 mm was identified as the best cut-off value for the ultrasonographic cervical length (specificity 59% and sensitivity 69%).

CONCLUSION

In prolonged pregnancies, Bishop score and ultrasonographic cervical length were shown to be relevant in the prediction of spontaneous onset of labor, while in patients who required labor induction, ultrasonographic cervical length represented the only clinic parameter predicting the onset of labor.

[Usefulness of ultrasound in the delivery room]

The use of diagnostic ultrasound and the diffusion of the technique improved the obstetric treatment and the usefulness of ultrasound increases in the delivery room for maternal and fetal care and as method of diagnosis of some obstetric complications. The knowledge of intrapartum ultrasound imaging can be considered useful for the obstetric team, since there is evidence that ultrasound can improve the obstetric management. The mean indications are described: fetal biometry and estimated fetal weight, amniotic fluid volume, fetal situation and presentation, placental localization and anatomy, assessment of size and location of uterine leiomyomas, fetal cardiac activity, evaluation of umbilical cord and fetal cardinal movements intrapartum. Besides, the use of ultrasound is reported in obstetric and postpartum complications. Actually ultrasonography, as a non-invasive, safety and low-cost technique, offers a diagnostic method in particular conditions during labour, delivery and postpartum.

[Postpartum hemorrhage]

Postpartum hemorrhage, frequently due to uterine atony, is an important cause of maternal death and morbidity. The knowledge of causes, of antenatal and intrapartum risk factors and of physiopathological changes in hemodynamics and coagulation during pregnancy are essential for the management of the condition. At the present time, many efforts are made to organize a multidisciplinary approach to this complication of delivery involving clinical and laboratory staffs, since the rapid correction of hypovolemia, the diagnosis and treatment of defective coagulation, the surgical and pharmacological control of bleeding are mandatory. Several medical options have been developed and the surgical management includes traditional and newer conservative procedures with variable success rates. The developments in the treatment of postpartum hemorrhage may reduce hysterectomy that is to be considered the last resort to resolve the hemorrhage in some cases. In the modern management of postpartum hemorrhage protocols and guidelines should be available in every delivery room.

[Therapy and prevention of obstetric hemorrhage by tamponade using a balloon catheter]

The aim of this study was to verify the possibility to use a balloon catheter as hemostatic method in pregnancies at high risk for hemorrhage as an alternative to less conservative surgical procedures. In 4 pregnancies at risk for hemorrhage, a compressive endouterine or endocervical method, consisting of a balloon catheter filled of warm saline solution, was used in order to stop or to prevent otherwise uncontrollable bleeding. In the cases treated the use of the balloon catheter was safe and effective both in the treatment of hemorrhage due to abnormal placentation and in the prevention of hemorrhagic complications due to abnormal implantation of pregnancy. Among novel medical and surgical approaches developed to control obstetric hemorrhage, tamponade using a balloon catheter could be considered a valid option. Moreover, this procedure, by avoiding radical surgical treatments, such as hysterectomy, which are frequently performed in unstable patients, could offer the advantage of preserving fertility.

Intra- and interobserver repeatability of femur length measurement in early pregnancy

OBJECTIVE

To assess the intra- and interobserver reproducibility of songographic measurement of fetal femur length between 10 and 16 weeks of gestation.

METHODS

Femur length was measured three times by the same trained observer in each fetus of 136 pregnant women. A second trained observer then repeated the measurements. The coefficient of variation, intraclass correlation coefficient and repeatability coefficient with 95% CIs were calculated for each observer and between the two observers.

RESULTS

The inter- and intraobserver repeatabilities of femur length were good. For interobserver correlation, the coefficient of variation was 4.6% (95% CI, 3.0-6.2), the intraclass correlation coefficient was 0.82 (95% CI, 0.69-0.95) and the repeatability coefficient was 2.1 (95% CI, 1.8-2.7). For intraobserver correlation, the coefficient of variation was 4.2% (95% CI, 3.2-5.6), the intraclass correlation coefficient was 0.91 (95% CI, 0.75-0.97) and the repeatability coefficient was 3.23 (95% CI, 2.33-3.86) for Observer 2. Similar results were obtained for the other observer.

CONCLUSION

Transvaginal femur length measurement is technically feasible and easy to perform between 10 and 16 weeks of gestation. The high degree of intra- and interobserver repeatability indicates it to be a reproducible method.

[Early transvaginal sonographic measurement of cephalic index]

BACKGROUND

The aim of this study is to obtain normal values of cephalic index by transvaginal scan early in pregnancy.

METHODS

In this prospective cross-sectional study, transvaginal high-resolution sonography was performed between 57 and 112 days' gestation in 1087 euploid fetuses. Measurements of cephalic index with standard deviations, calculated as the ratio biparietal diameter/occipito-frontal diameter, were obtained in the single gestational periods considered.

RESULTS

Cephalic index was found to show fairly constant values throughout the period evaluated with smaller values of standard deviation. The best correlation with gestational age was described by a linear correlation.

CONCLUSIONS

The data obtained by transvaginal scan can be used as parameters of normal values in early pregnancy.

[Early transvaginal measurement of cephalic index for the detection of fetuses at risk for Down syndrome]

BACKGROUND

The aim of this study was to evaluate the utility of cephalic index screening in early pregnancy for the identification of fetuses at risk for trisomy 21.

METHODS

Measurements of cephalic index, calculated as the ratio between biparietal diameter/occipito-frontal diameter, were obtained in 36 Down syndrome fetuses and the values were compared with normal data in the same gestational periods considered.

RESULTS

Cephalic index was found to show fairly constant values throughout the period evaluated. The measurements obtained in Down syndrome fetuses were similar to those obtained in euploid fetuses.

CONCLUSIONS

The data obtained show that in early pregnancy cephalic index cannot be considered a useful tool in the detection of fetuses at risk for Down syndrome.

A new mathematical formula for predicting long bone length in early pregnancy

OBJECTIVE

To propose new mathematical formulae to estimate fetal long bone biometry in early pregnancy and to establish their efficacy in comparison to previously constructed mathematical formulae.

METHODS

A study population of 1960 singleton euploid fetuses was referred for transvaginal ultrasound examinations between 71 and 112 days of gestation prior to genetic amniocentesis. To determine the relationship between the biparietal diameter and long bone length, a sample group of 400 randomly chosen normal fetuses was evaluated. Regression equations were derived, then tested in the remaining 1560 control fetuses and compared with previously reported mathematical formulae by other authors. Mean absolute error, mean absolute percentage error and mean systematic error with their standard deviations were calculated.

RESULTS

The relationships between femur or humerus length vs. biparietal diameter (BPD) and gestational age (GA) were, respectively: expected femur length = -16.92108 + 0.4569402 x BPD + 0.171617 x GA (P < 0.001) and expected humerus length = -16.28531 + 0.4283019 x BPD + 0.1696017 x GA (P < 0.001). The confidence intervals of the predicted values for different values of biparietal diameter and gestational age and confidence intervals for the regression coefficients, such as the distribution of the residuals, are given. All previous formulae obtained by transabdominal ultrasound demonstrated an overestimation of expected long bones measurements; this was reduced using different formulae obtained in early pregnancy. Using our mathematical formulae, the mean absolute percentage error and the mean systematic error in estimating femur and humerus length were very low (11.15% and -2.02%; 10.59% and -1.74%, respectively).

CONCLUSIONS

The new ultrasonographic morphometric models derived from transvaginal measurements in early pregnancy show a good reliability in estimating fetal long bone length.

Endovaginal sonographic diagnosis of the fetal urinary tract anomalies in early pregnancy

Transvaginal sonography has enhanced the ability to follow fetal development and detect pathologies in early gestation. Examination of the fetal urinary tract is an integral part of routine sonographic examinations in the second trimester of pregnancy and one of the major benefits of prenatal sonography is to allow early diagnosis of relatively common urinary tract malformations. Detailed evaluation of the fetal urinary tract and identification of anomalies were considered to be difficult before the 18th week of gestation prior to the use of transvaginal sonography. Using the transvaginal route, a detailed evaluation of the kidneys is possible around 12 weeks and structural anomalies of the urinary tract are being detected at an ever-increasing rate. Transvaginal sonography, owing to its proximity to the maternal pelvic organs, allows an earlier determination of the normal fetal urinary system and more accurate diagnosis and identification of fetal urinary anomalies as compared with transabdominal ultrasound.

Acceptability of early transvaginal or abdominal sonography in the first half of pregnancy

OBJECTIVE

To evaluate the acceptability of early transvaginal sonography by pregnant patients.

METHODS

A questionnaire was completed by 246 patients and the resulting data were analysed.

RESULTS

The incidence of discomfort was higher for the transabdominal than for the transvaginal route. Moreover, the transvaginal approach in early pregnancy, when compared with other transvaginal sonographic examinations was described as more satisfactory in 95% of cases.

CONCLUSIONS

Transvaginal sonography in early pregnancy is better tolerated than transabdominal sonography.

Transvaginal sonographic detection of embryonic-fetal abnormalities in early pregnancy

OBJECTIVE

To estimate the detection rate of abnormalities by transvaginal ultrasound in early pregnancy.

METHODS

We prospectively analyzed records of 3592 sequential pregnant women at 10-16 weeks' (singleton) gestation (mean 13 weeks and 2 days). After exclusion of 114 women, there were 3478 women in the study. Each woman underwent a transvaginal sonographic survey for fetal anomalies as well as biometric measurements. Fetuses diagnosed with malformations were followed to delivery, and those without underwent transabdominal sonography at 18-24 weeks' gestation.

RESULTS

The anomaly detection rate by transvaginal ultrasound was 51.6% (33 of 64; 95% confidence interval [CI] 38.7, 64.2) in early pregnancy, and the detection rate by transvaginal ultrasound combined with second-trimester transabdominal ultrasound was 84.4% (54 of 64; 95% CI 73.1, 92.2). Cystic hygroma and fetal hydrops were the anomalies detected most frequently by transvaginal ultrasound. Low detection rates for abnormalities of the face and of the cardiac, skeletal, and urinary systems were found even when both methods were used.

CONCLUSION

Transvaginal sonography appears to be an effective way to identify many congenital fetal anomalies in early pregnancy. There is a good probability of diagnosing cystic hygroma and fetal hydrops, although other abnormalities, particularly heart defects, are associated with lower detection rates.

Prognostic value of ultrasound findings of fetal cystic hygroma detected in early pregnancy by transvaginal sonography

OBJECTIVE

To assess the prognostic value of first and early second trimester transvaginal ultrasound findings of fetal cystic hygroma such as volume, presence of septa and associated fetal anomalies or malformations.

DESIGN

A prospective study of fetal cystic hygroma volume detected at 10-15 weeks of gestation by transvaginal scan.

SUBJECTS

The study comprised a series of 33 cystic hygromas detected throughout the period March 1994 to March 1998 in 1918 pregnant women.

METHODS

The volume of the hygroma and the presence of septa and other associated fetal anomalies or malformations were evaluated and correlated with fetal karyotype, persistence of the hygroma and pregnancy outcome.

RESULTS

A volume equal to or greater than 75 mm3 revealed a sensitivity of 66.7% [eight of 12 cases; 95% confidence interval (CI), 34.9-90.1%] for the identification of abnormal fetal karyotype, 72.7% (eight of 11 cases; 95% CI, 39.0-90.4%) for the identification of persistence of the hygroma and 90% (nine of 10 cases; 95% CI, 55.5-99.7%) for identification of an unfavorable outcome of pregnancy. Furthermore, the prognostic value of ultrasound in determining pregnancy and fetal outcome were improved by combining data on the volume of the hygroma and the presence of associated anomalies or malformations.

CONCLUSIONS

Measuring the volume of a cystic hygroma proves to be a useful ultrasound prognostic indicator in determining the risk of an associated karyotypic abnormality and adverse fetal and pregnancy outcome. However, due to limited sample size, caution is required in interpretation of the data and further studies are needed.

Clinical significance of placenta previa detected at early routine transvaginal scan

Transvaginal ultrasonography in early pregnancy was used to determine the prevalence of placenta previa and the rate of persistence until delivery. The location of the placenta was registered systematically in 2342 pregnant women who underwent transvaginal ultrasonography at 10 to 16 weeks' gestation as a primary examination. The outcome of pregnancy as well as the presence or absence of placenta previa at delivery was noted in a total of 2158 cases. A receiver operating characteristic curve was generated for the different measurements from the edge of the placenta to the internal cervical os versus placenta previa at delivery. In 105 of the 2158 women screened in the early stages of pregnancy (4.9%) the placenta extended to or over the internal cervical os, and in 34 of 2158 patients (1.6%) the distance to the placental edge beyond the internal cervical os was equal to or greater than 14 mm. Of the eight cases of placenta previa at delivery, six (75%) were identified in our study, and two cases were missed. When a cutoff value of greater than 14 mm is used for the receiver operating characteristic curve the likelihood is 17.6% (95% confidence interval = 6.8 to 34.5) for placenta previa at delivery. Although a high percentage of false-positive results occur owing to the low prevalence at delivery, this screening procedure can identify high-risk patients who should be rescanned later in pregnancy.

[Estimate of fetal long bone length in early pregnancy: comparison between mathematical formulae]

BACKGROUND

The aim of this study was to determine the efficacy of different mathematical formulae described in the literature and to propose new mathematical formulae to estimate fetal long bones biometry in early pregnancy.

METHODS

In 1481 singleton euploid fetuses a transvaginal ultrasound examination was performed between 9 and 16 week's gestation. To determine the relationship between the biparietal diameter and long bone lengths, a sample group of 100 randomly chosen normal fetuses was evaluated by regression equations. The equations derived were then tested in the remaining 1381 control fetuses and the mean absolute percentage error and the mean systematic error with their standard deviations were compared with previously reported mathematical formulae by other authors.

RESULTS

All previous formulae described in literature when applied to our population revealed an overestimation of expected long bones measurements. Using our mathematical formulae, the mean absolute percentage error and the mean systematic error were 11.5% and 1% in estimating femur and 10.9% and 0.8% in estimating humerus length, respectively.

CONCLUSIONS

These newly derived ultrasound morphometric formulae could be proposed as reliable models in estimating fetal long bone lengths in early pregnancy.

Transvaginal assessment of fetal anatomy at 11 to 16 weeks of gestation in relation to fetal position

OBJECTIVE

To investigate the ability of the high-frequency transvaginal scanning technique to assess embryo-fetal anatomy in early pregnancy in relation to fetal position and in comparison with transabdominal scan.

METHODS

A study population of 1,402 pregnant women were examined by transvaginal ultrasonography performed at 10(+1) to 16(+0) weeks of pregnancy. At 14(+1) to 16(+0) weeks of gestation, an ultrasonographic examination was performed in 247 pregnant women by transvaginal and transabdominal route. The criteria necessary for an adequate visualization of fetal organs and structures were met.

RESULTS

The visualization rate of complete fetal anatomy increased with increase in menstrual age and fetal position affected this possibility. A detailed brain anatomy was more easily viewed with the fetus in the cephalic or transverse position than in the breech position, whereas the thoracic and abdominal anatomy were viewed more easily with the transverse position compared to the cephalic or breech position. Complete surveys of fetal anatomy were possible in 50% and 62% of women with transabdominal scan and in 85% and 85% with transvaginal one at 15 and 16 weeks' gestation, respectively (p < 0.001).

CONCLUSION

A detailed assessment of fetal structures was possible in most cases at 13 weeks of gestation. Fetal position can influence this capability. At 14(+1) to 15(+0) weeks' gestation more anatomical surveys were completed with a transvaginal scan compared to a transabdominal one and this was influenced by fetal position.

Cerebellar hypoplasia: could it be a sonographic finding of abnormal fetal karyotype in early pregnancy?

OBJECTIVE

To evaluate the screening utility of early transvaginal measurement of transverse cerebellar diameter for the identification of fetuses with abnormal karyotype.

METHODS

We retrospectively analyzed the transverse cerebellar diameters of 56 fetuses with abnormal karyotypes (study group) and 1,892 euploid fetuses (control group) at 11-16 weeks of gestation. A nomogram with confidence intervals (10th and 90th percentile) was established for transverse cerebellar diameters versus gestational age in the control fetuses and individual values for chromosomally abnormal fetuses were plotted. A regression equation of expected transverse cerebellar diameter for each gestational age was calculated from 100 euploid fetuses chosen randomly and applied to the remaining control fetuses and to the study group fetuses. The ratio of observed to expected cerebellar diameters was calculated in the control group and compared with those obtained in single chromosome anomalies.

RESULTS

The measurements obtained in aneuploid fetuses are within the normal range for gestational age. Only in 2 of the 37 Down syndrome fetuses and in 2 of the 4 fetuses with trisomy 13 was the observed to expected measurement ratio below the 5th percentile for gestational age.

CONCLUSION

In our experience, the measurement of transverse cerebellar diameter cannot be considered as a useful tool in the detection of aneuploidy in early pregnancy. The data concerning trisomy 13 are too small, so that caution should be exercised when supposing an association between cerebellar hypoplasia detectable by early transvaginal scan and risk of this aneuploidy.

Prevalence and significance of isolated fetal choroid plexus cysts detected in early pregnancy by transvaginal sonography in women of advanced maternal age

This study examines the prevalence of isolated fetal choroid plexus cysts (CPCs) detected in early pregnancy by transvaginal sonography in an increased genetic risk population and their association with abnormal fetal karyotype. A prospective study was performed on 1692 pregnant women (>37 years) who underwent transvaginal scan at 11-16 weeks' gestation before genetic amniocentesis. The prevalence of isolated CPCs in our population was 1.48 per cent. An abnormal fetal karyotype was found in one case (4 per cent). It was concluded that if fetal CPCs are apparently isolated, genetic amniocentesis is not mandatory and additional risk factors such as advanced maternal age should be the main indication for fetal karyotyping.

Early transvaginal measurement of cephalic index for the detection of down syndrome fetuses

OBJECTIVE

The aim of this study was to produce normal cephalic index values by transvaginal scan early in pregnancy and to evaluate the screening utility of this measurement for the identification of fetuses at risk for Down syndrome.

METHOD

In this prospective cross-sectional study, transvaginal high-resolution sonography was performed between 9 and 16 weeks of gestation in 1,087 euploid fetuses and 36 Down syndrome fetuses. Measurements of the cephalic index, calculated as the ratio biparietal diameter/occipito-frontal diameter, were plotted against gestational age.

RESULTS

The cephalic index was found to show fairly constant values throughout the period evaluated. The best correlation with gestational age was described by a linear correlation. All the measurements obtained in Down syndrome fetuses were within the normal ranges.

CONCLUSION

Our data show that in early pregnancy the cephalic index cannot be considered a useful tool in the detection of fetuses at risk for Down syndrome.

Ultrasound-guided fine needle aspiration of ovarian cysts during pregnancy

OBJECTIVE

To evaluate the safety and efficacy of ultrasound-guided fine needle aspiration in the treatment of ovarian cysts during pregnancy.

STUDY DESIGN

Nine out of twenty-nine patients between the 6th and the 16th week of gestation with unilateral ovarian cysts ranging between 65 and 540 cm3 in volume were selected for sonographically-guided fine needle aspiration.

RESULTS

No complications were observed at either short or long-term follow-up; all patients delivered healthy infants at term. Clinical and sonographic post-partum follow-up was uneventful in all cases. In three cases it was necessary to repeat the procedure once and in one case twice during pregnancy. In one case a recurrent serous cyst was excised at operative laparoscopy performed 3 months after delivery.

CONCLUSIONS

Ultrasound-guided fine needle aspiration was safely performed in nine patients as an alternative treatment to surgery when persistent monolateral and unilocular ovarian cysts with regular borders and completely anechoic structure are detected during pregnancy.

Isolated mild fetal pyelectasis detected by transvaginal sonography in advanced maternal age

OBJECTIVE

To evaluate the importance and evolution of isolated, mild fetal pyelectasis, detected in early pregnancy by high-resolution transvaginal sonography, and to determine its association with abnormal fetal karyotypes.

METHODS

Transvaginal scan at 11-16 weeks' gestation and transabdominal ultrasound examinations at the time of amniocentesis (16-18 weeks) were performed in 1093 pregnant women undergoing genetic amniocentesis because of advanced maternal age. In 795 cases, transabdominal scans were repeated at 22-24 weeks. Women were excluded if they had a spontaneous abortion, chose to terminate their pregnancy, or declined amniocentesis. Each patient was screened for fetal pyelectasis, defined as an increase in anteroposterior renal pelvic diameter, using cutoff values related to various stages of pregnancy.

RESULTS

Isolated fetal pyelectasis was detected at the first ultrasound examination in 56 women (5.1%) in early pregnancy, in 32 (2.9%) at the time of amniocentesis, and in 23 (2.9%) at 22-24 weeks' gestation. Two fetuses with diagnoses of mild pyelectasis at the first transvaginal ultrasound demonstrated abnormal karyotypes at amniocentesis. In one case, the pyelectasis disappeared at 22-24 weeks' gestation.

CONCLUSION

This retrospective study shows that pyelectasis is more frequently detectable by high-resolution transvaginal sonography in the first half of pregnancy than in the second half. When detected in early pregnancy, the finding is frequently transient and not associated with an increased risk of abnormal fetal karyotypes.

Early transvaginal measurement of transcerebellar diameter in Down syndrome

OBJECTIVE

To evaluate the screening utility of early transvaginal measurement of the transverse cerebellar diameter for identification of Down syndrome fetuses.

METHOD

Measurements of the transverse cerebellar diameter were obtained by transvaginal sonography between 11 and 16 weeks of gestation in 544 fetuses with a normal karyotype and in 37 Down syndrome fetuses.

RESULTS

The transverse cerebellar diameter was found to show a fairly constant increment of values throughout the period evaluated with a linear relationship to the gestational age. The measurements obtained in Down syndrome fetuses are within the normal range for gestational age.

CONCLUSION

The transverse cerebellar diameter cannot be considered a useful tool in the detection of Down syndrome in early pregnancy.

Transvaginal sonographic fetal biparietal diameter/kidney length ratio in early pregnancy as a screening tool for renal malformations

OBJECTIVE

The aim of the study was to produce by 7.0 MHz high resolution transvaginal scan early in pregnancy normal values of biparietal diameter/kidney length ratio that can be used as reference ranges.

METHODS

In this prospective cross-sectional study, a transvaginal high-resolution sonography was performed between 11 and 16 weeks' gestation in 807 pregnant women with a history of regular cycles, singleton pregnancies and absence of fetal malformations. Measurements of kidney length and biparietal diameter were obtained in all cases and biparietal diameter/kidney length ratio was plotted against gestational age.

RESULTS

The values of biparietal diameter/kidney length ratio were found to be fairly constant throughout the period evaluated.

CONCLUSION

Our results indicate that this new age-independent ratio can be useful in the early detection of some fetal kidney malformations affecting normal growth.

[Early prognostic ultrasonographic indices in pregnancy with fetal cystic hygroma]

OBJECTIVE

Aim of this study was the correlation of same early ultrasonographic signs with fetal karyotype, prognosis of pregnancy and neonatal outcome.

EXPERIMENTAL DESIGN

Volume of cystic hygroma and presence of septations are correlated with fetal karyotype and an ultrasonographic follow-up was carried out during pregnancy. Details concerning neonatal outcome were recorded at delivery.

PATIENTS

Diagnosis was performed in 13 patients between 8.3 to 16.5 weeks' gestation referred to our center for prenatal diagnosis or for obstetric reasons.

METHOD

Ultrasonographic examinations were performed using 5.0 and 6.0 MHz endovaginal convex probes.

SURVEYS

Hygroma was diagnosed as a cystic dilatation in the nuchal region larger than 3 mm in diameter in the anterolateral aspects. The volume was calculated considering the lesion as spherical and using the standard formula for an ellipsoid volume; the presence of septations was considered.

RESULTS

A volume greater than 70 cc3 and the presence of septations demonstrated a strictly correlation with fetal karyotype, evolution of the features, pregnancy and neonatal outcome.

CONCLUSIONS

Prognosis varies depending on fetal karyotype, volume, presence of septations and other associated malformations. The volume of the hygroma and the presence of septa are associated with higher incidence of chromosomal diseases and a poorer fetal prognosis.

[Echographic markers of fetal chromosomopathies. Diagnostic possibilities with transvaginal ultrasonography and our experience]

OBJECTIVE

Aim of this study was to evaluate, during early pregnancy, the correlation of some anomalies and malformations with fetal chromosomopathies.

EXPERIMENTAL DESIGN

Morphostructural and biometric anomalies in chromosomopathic fetuses were evaluated.

PATIENTS

1331 pregnancies at high risk for genetic disease and malformations referred to our center for prenatal diagnosis.

METHOD

Scans were performed using endovaginal convex probes (5.0 to 7.0 MHz).

SURVEYS

Urinary, cardiac and cerebral malformations as well as alterations of bone growth were evaluated.

RESULTS

With respect to the other malformations, cystic hygroma is more frequently associated with an abnormal fetal karyotype.

CONCLUSIONS

The majority of morphostructural abnormalities diagnosed during first trimester by transvaginal sonography cannot, in according to personal experience, be used as markers of chromosomopathies.

Transvaginal fetal biometry in early pregnancy

OBJECTIVE

To produce reference charts for fetal size with transvaginal sonography that are potentially helpful in evaluating normal and abnormal early pregnancies.

DESIGN

A prospective cross-sectional study.

SUBJECTS

1081 normal singleton pregnancies with a normal fetal karyotype or normal healthy baby at delivery, at 9-16 weeks' gestation. Measurements included crown rump length, biparietal diameter, transverse cerebellar diameter, head and abdominal circumference, mean abdominal diameter, thoracic circumference, femur length, humerus length and foot length.

RESULTS

The best description of the relationship between single ultrasonographic parameters and gestational age was achieved by polynomial regression analysis. All fetal biometric parameters correlated closely with gestational age. Biparietal diameter maintained the closest correlation with gestational age (r2 = 97.15, p < 0.001; y = -0.545 - 0.06x + 0.15x2); transverse cerebellar diameter showed the poorest correlation with gestational age (r2 = 88.17, p < 0.001). Reference ranges (5 degrees and 95 degrees percentile intervals) were constructed for all biometric parameters in relation to gestational age. Mean residuals are similar for all parameters with a very low range.

CONCLUSIONS

These data provide normograms for first and early second trimester fetal measurements which may be of aid in the dating of pregnancies and can be useful in the early detection of genetic disorders affecting the growth of fetal structures.

[Embryo-fetal development in the early stages of pregnancy]

The introduction of high resolution transvaginal US in obstetrical clinical practice permits earlier and more detailed visualization of embryo-fetal structures in early pregnancy. A transvaginal US examination with a high-resolution probe (5.0-6.0 MHz) was performed in 1246 pregnant patients between 9 and 16 weeks of gestation and known gestational age. Ten embryo-fetal biometric parameters were measured (crown-rump length, biparietal diameter, head circumference, transverse cerebellar diameter, thoracic circumference, mean abdominal diameter, abdominal circumference, femur length, humerus length and foot length). Reference ranges with 5 degrees and 95 degrees percentile intervals were constructed for all biometric parameters in relation to gestational age. Only one scan per patient was considered for this study. All the parameters evaluated demonstrated a high correlation with gestational age at polynomial regression analysis. The mean coefficient of determination (r2) ranged from 97.15 for biparietal diameter to 88.17 for transverse cerebellar diameter. The data are useful as reference range for the assessment of normal embryofetal development by transvaginal US in the early stages of pregnancy.

Transvaginal ultrasound detection of septated and non-septated cystic hygroma in early pregnancy

OBJECTIVE

To evaluate the correlation of sonographic transvaginal signs of cystic hygroma and fetal outcome.

METHOD

Diagnosis was made in 11 cases at 9.1-13.4 weeks of gestation. Fetal karyotype, presence of septations and other associated malformations were considered. The volume of septated and non-septated cystic hygromas was compared by a t test with a statistical significance of p < 0.01.

RESULTS

Septation of the hygroma was found in 4 cases and fetal death occurred in 3 of these with an abnormal karyotype. Five fetuses demonstrated regression of the hygroma within the 19th week. The volume of septated and non-septated cystic hygromas are statistically different (p < 0.01).

CONCLUSIONS

Diagnosis of cystic hygromas is possible in early pregnancy by transvaginal scan. Prognosis varies depending on fetal karyotype, volume, presence of septations and other associated malformations. The volume of the hygroma and the presence of septa are associated with a higher incidence of chromosomopathies and a poorer fetal prognosis.

Fetal biometric ratios by transvaginal sonography as a marker for aneuploidies in early pregnancy

The aim of this study was to obtain by transvaginal sonography in early pregnancy normal biometric charts of some fetal ratios and to evaluate the utility of these ultrasonographic indices as biometric markers for the identification of fetal chromosome abnormalities. The study population included 1054 normal euploid fetuses and 30 fetuses with an abnormal karyotype. We obtained six standard ultrasound measurements by transvaginal sonography at 11-16 weeks' gestation before genetic amniocentesis in patients at risk for genetic disorders. Seven biometric ratios (biparietal diameter/femur length, biparietal diameter/humerus length, head circumference/abdominal circumference, abdominal circumference/femur length, abdominal circumference/humerus length, femur length/foot length, and humerus length/foot length) were calculated and reference curves were plotted. The ratios from aneuploid fetuses showed no differences from reference ranges. Only in trisomy 13 fetuses were abnormal values of head circumference/abdominal circumference, biparietal diameter/humerus length, and biparietal diameter/femur length ratios detected, probably due to the high incidence of microcephaly and central nervous system malformations in these fetuses. The normal values of sonographic ratios obtained by transvaginal sonography in the first and early second trimester of pregnancy cannot generally be considered a useful tool for the detection of chromosomal abnormalities. Only ratios involving cephalic measurements can be used in early pregnancy as screening markers in the detection of trisomy 13 fetuses.

[Early diagnosis of embryo-fetal malformations by transvaginal echography in a high-risk population]

BACKGROUND

High resolution transvaginal sonography permits, in respect of traditional transabdominal scan, an earlier diagnosis of some fetal anomalies and malformations.

METHODS

In our prospective study, between 11th to 16th weeks gestation, 820 pregnant patients at high risk for chromosomopathies and for fetal malformations were scanned in order to obtain a detailed survey of embryofetal structures and organs and an earlier diagnosis of fetal malformations.

RESULTS

Thirty-two fetal anomalies and malformations (3.9%) were detected, and in 4 cases (0.49%) the diagnosis was obtained later in pregnancy. Fetuses with structural malformations were scanned during pregnancy and, if possible, postnatally. We reconsidered the pitfalls in relation to the time of transvaginal scan and the fetal pathology.

CONCLUSIONS

En early prenatal diagnosis of fetal anomalies by transvaginal sonography is related to the knowledge of normal embryofetal development and the pathogenesis of malformations.

[Embryo-fetal ultrasonographic diagnosis in the early pregnancy using transvaginal echography]

The diagnostic capability of high resolution transvaginal sonography in early pregnancy is described. Transvaginal sonography allows for the visualisation of some fetal organs and structures one to four weeks earlier than transabdominal ultrasound thus permitting evaluation of several embryofetal parameters early in pregnancy. This technique permits formulation of fetal measurement charts and detection of embryo-fetal malformations during the initial stages of pregnancy. Knowledge of the transvaginal sonographic appearance of embryonal and fetal biometric and structural anatomy enables us to determine the appearance of the normal fetus. Transvaginal scan may be employed as a screening tool for the identification of fetal anomalies in early stages of pregnancy. An increasing number of case reports and documented records of cases of malformations and anomalies diagnosed during the first trimester of pregnancy using this technique have been reported in the literature. The most frequent embryo-fetal malformations and anomalies detected at transvaginal scan and the earliest gestational age of diagnosis are described. At present a limited number of anomalies can be diagnosed because only a part of the potentially recognizable anomalies have been described using this technique. The importance of this new imaging technique as well as the necessity of a through knowledge of embryology are evident. Transvaginal sonography allows for biometric evaluation, for a clearer visualization of embryo-fetal morphology and for detection of several malformations and anomalies during early pregnancy.

[Visualization of the fetus in early pregnancy with transvaginal sonography]

The aim of this prospective study is to define in early pregnancy the time and percentage of visualization of embryo-fetal structures and organs. 820 patients at high risk for fetal genetic anomalies and/or malformations were scanned by high resolution transvaginal probe between 10 and 16 weeks' gestational age. Criteria for exclusion were: fetal malformations, multiple pregnancies and loss of pregnancy. We determined percentage of visualization in the different weeks of: orbits, face, cerebellum, cisterna magna, cardiac chambers, abdomen, diaphragm, stomach, kidneys and bladder. The percentage of visualization of fetal organs and structures investigated increased with gestational age and at 13 weeks ranged from 80% to 100%. With the introduction of high-frequency transvaginal probes in early pregnancy embryo-fetal structures and organs can be imaged and studied in great detail and more accurately identified than with traditional abdominal ultrasound, up to 4 weeks earlier. Another important advantage is the fact that some fetal malformations can be detected earlier.

Transvaginal sonographic measurement of cisterna magna in fetuses with abnormal karyotype

The fetal cisterna magna was measured by transvaginal sonography in early pregnancy in 525 pregnant women at increased genetic risk in order to test whether the measurements thus obtained afforded a sonographic marker for abnormal fetal karyotype. The measurements of the cisterna magna increased as pregnancy progressed and showed a good linear correlation with gestational age (r = 0.616; p < 0.001). Chromosome abnormalities were found in 23 fetuses. In all these cases, the cisterna magna measurements were normal, and no differences were observed between fetuses with normal and abnormal karyotype in the different periods tested. While transvaginal sonographic measurement of the cisterna magna is easy to perform in early pregnancy, it is a poor screening test for the detection of abnormal fetal karyotypes.

Transvaginal sonographic assessment of the fetal urinary tract in early pregnancy

Fetal renal size in the first trimester and the early second trimester of pregnancy was evaluated by high-frequency transvaginal sonography in 537 singleton fetuses at risk for cytogenetic abnormality but not at risk for congenital kidney disease. The percentage of visualization of both kidneys and bladder at different menstrual ages (11-16 weeks) is presented, and centile reference charts for evaluating kidney growth have been compiled. All kidney measurements were found to increase as pregnancy progressed. At 13 weeks, fetal kidneys and fetal urinary bladder were visualized in 92% of the cases screened. The incidence of pyelectasis was high in our population (4.5%), and this pathology was studied by other sonographic scans during pregnancy and postnatally. All fetuses had normal karyotypes. The results presented provide a reference for the assessment of normal renal morphology and growth in early pregnancy.

Preoperative ultrasound assessment of omental spread in ovarian cancer

The accuracy of high-resolution ultrasound in the detection of macroscopic omental metastases was evaluated in 50 consecutive patients undergoing surgery for ovarian cancer. Ultrasound provided an overall diagnostic accuracy of 83.7%, with a sensitivity of 76.6% and a specificity of 100%. The sensitivity in the diagnosis of diffuse omental involvement was 93.3%. Moreover, the overall diagnostic accuracy, sensitivity and positive predictive value of the method increased as the study progressed. In the last 25 cases examined, in fact, these values were 94.7, 90, and 90%, respectively.

A novel inositol mono-phosphatase inhibitor from Memnoniella echinata. Producing organism, fermentation, isolation, physicochemical and in vitro biological properties

A novel inositol mono-phosphatase inhibitor, L-671,776 (1), was discovered from a culture of the hyphomycete, Memnoniella echinata (ATCC 20928). 1 has a molecular weight of 388 and a molecular formula of C23H32O5. The mode of inhibition is non-competitive, with a Ki of 450 microM. It shows no inhibition of myo-inositol 1,4-bisphosphate 1-phosphatase or myo-inositol 1,4,5-triphosphate 5-phosphatase, although it weakly inhibits myo-inositol 1,4,5-triphosphate 3-kinase (IC50 = 3 mM). It elevates inositol monophosphates in rat parotid slices (EC50 approximately 3 mM), but abolishes agonist effects. It also produces short-lived contraction of guinea pig trachea at 300 microM.

Ovarian fibrothecoma: sonographic and histologic findings

The sonographic and histologic findings observed in 11 cases of ovarian fibrothecoma were compared, and an attempt was made to find a correlation between each histologic type of the tumor (pure thecoma, predominantly fibrous fibrothecoma, mixed fibrothecoma) and its sonographic appearance. The presence of a homogeneous echogenic pattern, with marked posterior acoustic shadowing, in the absence of any calcification, was highly suggestive of a predominantly fibrous ovarian fibrothecoma; the presence of a diffusely hypoechoic ovarian mass, with no posterior echo enhancement, was strikingly correlated with pure thecomas; mixed fibrothecomas were characterized by the presence of an echogenic pattern with no posterior acoustic shadowing. Sonographic findings, even though nonspecific, can provide the clinician with useful information which permits to detect these rare neoplasms preoperatively.

Pelvic lymphocele following radical para-aortic and pelvic lymphadenectomy for cervical carcinoma: incidence rate and percutaneous management

Thirty-six women, treated with radical hysterectomy (Piver types III-IV) plus systematic para-aortic and pelvic lymphadenectomy for cervical carcinoma, underwent serial postoperative ultrasound examinations to determine the incidence of lymphocele and the therapeutic efficacy of percutaneous catheter drainage. Pelvic lymphoceles, ranging in volume from 46-300 mL, occurred in eight patients (22.2%) between the 12-24th postoperative day. Percutaneous catheter drainage, inserted under local anesthesia, was used for a mean time of 14.5 days (range 4-32), resulting in a mean daily drainage of 92.2 mL and a mean total volume of 1727.5 mL per patient. Catheter drainage allowed complete clinical and sonographic remission in all cases, and only one asymptomatic recurrence was observed at 3-month and 6-month follow-up. Ultrasound-guided percutaneous catheter drainage has proved to be a well-tolerated, safe, and effective technique in the management of lymphocele that obviates the need for more invasive surgical procedures.

Transvaginal ultrasound evaluation of myometrial invasion in endometrial carcinoma

In 20 cases of histologically proved endometrial cancer the depth of myometrial invasion was ascertained by means of transvaginal ultrasound, using a high-frequency endocavitary probe. The sonographic findings were confirmed by histologic examination in 18 of the 20 patients evaluated (90.0%). Transvaginal ultrasound provides a fuller preoperative clinical picture and supplies additional diagnostic information which is invaluable in the choice of therapeutic approach.

Effects of intra-amniotic isoxsuprine on amino acid placental transfer in rats

Direct administration of isoxsuprine to the rat fetus increases placental transfer of 35S-methionine and this increase is statistically significant on day 17 as compared with intraperitoneal administration and controls (p less than 0.01; p less than 0.05). In contrast, no statistically significant differences were found between the groups on day 16.