Fetal tetralogy of Fallot: Three-dimensional virtual and physical models from ultrasound scan data findings

Three-dimensional reconstructions provide a spatial view of the congenital heart disease with a better understanding of the pathology for parents and allow interactive discussion among the medical team (maternal-fetal medicine specialist, neonatology, pediatric cardiology, and cardiovascular surgeon) and improve both objective knowledge and learner satisfaction for medical students.

Ebstein anomaly: 3D virtual and physical models from obstetrical ultrasound data

3D virtual and physical models from ultrasound scan data allow a 3D spatial view of congenital heart anomalies, interactive discussion among a multidisciplinary team, and improved parental counseling. To the best of our knowledge, this is the first description of 3D physical and virtual models of a fetal Ebstein anomaly.

Is there a role for magnetic resonance imaging in cesarean scar pregnancy after the first trimester?

Magnetic resonance imaging (MRI) can provide additional information in cases of cesarean scar pregnancy beyond the first trimester. MRI and 3D reconstructions can demonstrate the relationships between the uterus, cervix, bladder, and placenta, improving the spatial perspective of the pelvic anatomy in cases requiring surgical management. MRI and 3D reconstructions can also provide more comprehensive images for parental counseling, virtual and face-to-face multidisciplinary team discussion, and medical record storage.

Placenta acrreta spectrum-first trimester, 2D and 3D ultrasound, and magnetic resonance imaging findings

BACKGROUND

The term placenta accreta spectrum (PAS) is commonly used to describe abnormal trophoblastic invasion of the myometrium, serosa, or organs adjacent to the uterus. It is of great obstetric importance because of its high morbidity, risk of hemorrhage, admission to the intensive care unit, risk of hysterectomy, and high risk of iatrogenic pelvic lesions and even death. These risks are minimized when prenatal diagnosis is performed. Prenatal diagnosis of PAS is based on imaging findings suggestive of abnormal and pathologically adherent placentation, including placental lacunae (intraplacental sonolucent spaces), disruption of the bladder-uterine serosa interface, turbulent flow on color Doppler, and bridging vessels.

OBJECTIVE

In this article, we review the major prenatal imaging features of PAS using diagnostic modalities (first trimester, two-dimensional ultrasound, three-dimensional ultrasound, and magnetic resonance imaging) for the diagnosis of PAS.

Prenatal diagnosis of fetal left ventricular diverticulum: 3D virtual and physical reconstruction models

Congenital diverticulum is a very rare congenital heart disease. 3D virtual and physical models from ultrasound scan data provide a spatial visualization and better understanding of congenital heart disease to the parents and support possible surgical procedures.

Vaginal leiomyoma: Advantages of clinical sonovaginography and ultrasound dynamic evaluation of uterine cervix-related lesions

Evaluation of vaginal leiomyoma by dynamic transvaginal ultrasound improves the diagnosis, with the impact on surgical planning, and surgical outcomes. Sonovaginography using three-dimensional ultrasound allows the assessment of spatial relationship between the cervix and the tumor.

Prenatal diagnosis of closed gastroschisis: What to expect in the most severe form of gastroschisis? Case report and literature review

Closed gastroschisis (CG) and vanishing gastroschisis (VG) are the most severe forms of evolution of the malformation. In this case, a fetus presented with gastroschisis at 13 weeks, and the gastroschisis was not visualized at 22 weeks of gestation. Distal ileum, cecum, and ascending colon atresia were diagnosed at surgery, and the child is fully enteral-fed at 5 months of age. In a literature review of 43 cases of prenatal diagnosis of CS-VG, intrauterine death occurred in 4.5% of cases. 79.6% of the cases underwent surgical treatment. Of these cases, 20% of cases died due to complications of treatment, 26% were still under treatment and 54% are alive with enteral feeding. In 77% of the cases, the closure of the umbilical ring occurred after 26 weeks of gestation and the absence of prenatal diagnosis of CG-VG during pregnancy has a risk of 71% of death.

Fetal giant liver hemangioma: Ultrasound, magnetic resonance imaging, three-dimensional reconstruction findings and perinatal outcomes of two cases

In this case report, we present two cases of fetal liver giant hemangioma assessed using ultrasound, magnetic resonance imaging and three-dimensional reconstructions with their respective postnatal outcomes.

Prenatal diagnosis of Pallister-Hall syndrome: ultrasound, magnetic resonance imaging, and three-dimensional reconstructions of phenotypical findings

Pallister - Hall syndrome is a rare malformation that involves the presence of a suprasellar hamartoma and associated malformations. Prenatal diagnosis is also rare, and few cases have been reported using magnetic resonance imaging (MRI). A 35-year-old G5P2A2 woman at the 35th week of gestation was referred to our service. Fetal MRI showed an isointense image in the suprasellar region, pushing the brainstem up and backward, and compressing the vermis and cerebellum on T2-weighted images. On T1-weighted images, the hypointense signal of the tumor was similar to that of the brain parenchyma. Ultrasound images showed a suprasellar mass, which was more echogenic than the normal cerebral parenchyma, posteriorly pushing the brain stem, with involvement of the vermis of the tumor and compression of the posterior fossa. Three-dimensional reconstruction using MRI scan data showed a space view of the tumor and its relationships with the other brain tissues allowing better understanding by parents and multidisciplinary team.

Prenatal and Postnatal Zika Intrauterine Infection: Diagnostic Imaging Techniques and Placental Pathology

Introduction: Zika virus (ZIKV) is an arbovirus (arthropod-borne virus) in the genus Flavivirus and Flaviviridae family. In November 2015, several cases of microcephaly in Northeastern of Brazil suggested ZIKV involvement. Case Report: A 33-year-old primigravida developed fever and cutaneous rash at 7th week of gestation (WGA). The ultrasound and MRI examination showed head circumference < 5th centile and enlargement of lateral ventricles. The infant was delivered at 39th WGA with microcephaly. Microscopy of the placenta showed chronic villitis and intervillitis, nodular stromal fibrosis in the stem villi, and vascular thickening. Postnatal CT showed collapsed cranium due to growth impairment of the suprathalamic brain, multiple cerebral calcifications, parenchymal atrophy, and ventricular dilatation. Now, at 6 years old, the child suffers from severe neurologic symptoms, including seizures. Conclusion: This case gathers images of prenatal and postnatal period, and placental histopathology. The long-term follow-up highlights the dramatic neurological sequelae induced by ZIKV.

Virtual segmentation of three-dimensional ultrasound images of morphological structures of an ex vivo ectopic pregnancy inside a fallopian tube

Ex vivo ultrasound (US) of human tissues has been used for decades on the study of the acoustic physical aspects of the US, to the study of the morphology of the organs. Using three-dimensional (3D) US, we demonstrate the possibilities to study surgical specimens from gynecological conditions. 3D images of the surgical specimen were collected and virtually segmented according to the contrast of its images, providing a 3D image of the ectopic pregnancy and its effects on the fallopian tube.

Placenta accreta: Virtual reality from 3D images of magnetic resonance imaging

Image from a fragment of the video of virtual reality model evaluating a case of placenta accreta spectrum and placental invasion. In this image, the placenta (purple) goes through the uterus and reaches the bladder muscle and mucosa (pink).

Pre and postnatal diagnosis of a third branchial cleft cyst by sonography and magnetic resonance imaging with three-dimensional virtual reconstruction

Branchial cleft cysts (BCCs) are common causes of cervical tumors in children and adulthood; however, prenatal diagnosis of BCC is rare. In neonates, these cysts can suddenly increase in size, causing airway obstruction and becoming a life-threatening condition. In this case report, we describe the prenatal diagnosis of a third BCC at the 25th week of pregnancy using ultrasound, magnetic resonance imaging, and three-dimensional virtual models, as well as the perinatal outcomes of this rare condition.

Choledochal cyst theories going pear-shaped? Evolution of choledochal cyst during intrauterine life in a case evaluated using magnetic resonance imaging and postnatal outcomes

A choledochal cyst is a rare abdominal malformation and was first reported almost three centuries before. There are few theories describing the evolution of the cyst through the lifespan of affected patients until diagnosis and prompt treatment; however, there is no image documentation of the evolution of the malformation. In this report, we demonstrate the evolution of a type I choledochal cyst in a fetus from the 24th to the 37th week of gestation using magnetic resonance imaging and perinatal outcomes with correlation with pathophysiological mechanisms.

Venolymphatic malformations: prenatal diagnosis using magnetic resonance imaging, perinatal outcomes and long-term follow-up

BACKGROUND

Venolymphatic malformations are benign. Fetal MRI can more precisely demonstrate an infiltrative pattern of malformations than US.

OBJECTIVE

To evaluate perinatal outcomes and long-term follow-up of fetal venolymphatic malformations treated in different medical facilities using fetal MRI.

MATERIALS AND METHODS

This retrospective cohort study evaluated 20 pregnant women between 22 weeks and 37 weeks of gestation who were referred from different institutions. They presented with fetuses with various diagnoses of cystic masses on routine US. The cases were studied using MRI. We analyzed prenatal data, perinatal outcomes and long-term follow-up.

RESULTS

We reviewed the MRI scans of 20 patients with venolymphatic malformation. Referral diagnosis was changed in 40% (8/20) of cases, with postnatal concordance of 100% (20/20). Moreover, 65% (13/20) presented with venolymphatic malformation in more than one body segment. The neck was affected in 70% (14/20) of fetuses, while the head and thorax were affected in 30% (6/20) and 45% (9/20), respectively. There were intrathoracic lesions in 35% (7/20), lesions in the abdomen in 30% (6/20), and lesions in the perineum and extremities in 10% (2/20) each. Tracheal displacement, neck deflection and anatomical displacement caused by tumoral compression were present in 15% (3/20) of cases. Moreover, 25% (5/20) of newborns required neonatal intensive care unit admission, and all presented with cervical or thoracic venolymphatic malformation. Furthermore, 50% (10/20) of cases presented with complete resolution after medical therapy. The intrathoracic and cervical residuals (35%, 7/20) were monitored and treated.

CONCLUSION

MRI showed good correlation with postnatal examination of venolymphatic malformation, was useful in the differential diagnosis of fetal cysts on US, and presented a significant postnatal correlation with thoracic infiltration. The outcomes of prenatally diagnosed venolymphatic malformations are good despite the varying protocols among medical facilities.

Proportional vascularization along the fallopian tubes and ovarian fimbria: assessment by confocal microtomography

Objective

To evaluate and reconstruct three-dimensional images of vascularization along the fallopian tube (FT), as well as to determine its relationship with the ovary and ovarian fimbria, and to quantify the blood vessels along the FT according to its anatomical segments, using confocal microtomography (micro-CT).

Materials and Methods

Nine specimens (six FTs and three FTs with ovaries) were fixed in a solution of 10% formalin for > 24 h at room temperature. Iodine staining was performed by soaking the specimens in 10% Lugol’s solution for 24 h. All specimens were evaluated using micro-CT. A morphometric analysis was performed on the reconstructed images to quantify the vascular distribution along the FT.

Results

In the FTs evaluated, the density of blood vessels was significantly greater in the fimbrial segments than in the isthmic segments (p < 0.05). The ovarian fimbria was clearly identified, demonstrating the important relationship between these vessels and the FT fimbriae.

Conclusion

We believe that the vascularization in the fimbriae is greater than and disproportional that in the other segments of FT, and that the ovarian fimbria plays an important role in the development of that difference.

Congenital Duodenal Stenosis: Prenatal Evaluation by Three-dimensional Ultrasound HDlive Silhouette Mode, Magnetic Resonance Imaging, and Postnatal Outcomes

The “double bubble” sign is a common sign of congenital duodenal obstruction (CDO), which has been detected during prenatal diagnosis for over 40 years. CDO is strongly associated with chromosomal and structural abnormalities and encompasses a wide spectrum of diagnoses. Here, we describe a case of duodenal stenosis, a rare cause of duodenal obstruction, which was suspected using conventional two-dimensional ultrasound and three-dimensional reconstruction with the HDlive silhouette mode at the 28^th prenatal week. The suspicion was further supported by magnetic resonance imaging performed at the 32^nd prenatal week and confirmed by postnatal surgery.

Symmetric and ventrally conjoined twins: prenatal evaluation by ultrasound and magnetic resonance imaging and postnatal outcomes

OBJECTIVE

To review the perinatal and long-term outcomes of symmetric and ventrally conjoined twins evaluated prenatally by ultrasound and fetal magnetic resonance imaging (MRI).

METHODS

From March 2010 to January 2019, cases of symmetric and ventrally conjoined twins, who were prenatally diagnosed and referred to the Clínica Diagnóstico por Imagem (CDPI), Rio de Janeiro, Brazil, for prenatal evaluation by ultrasound and MRI were selected. The postnatal information was collected from hospitals where the twins were born and/or treated and from parents' verbal and written information.

RESULTS

Four cases of symmetrical and ventrally conjoined twins were selected. Of these, two were omphalopagi and two thoracopagi. One pair of thoracomphalopagus died early in utero and the other died 6 days after birth. The outcome of the two omphalopagus pairs were separation in emergency surgeries after birth, with neonatal demise of one of the twins due to congenital malformations. In cases of omphalopagi, fetal MRI presented important information of the twins' anatomy before emergency separation of both pairs.

CONCLUSION

Despite the apparently similar conditions of twins with ventral fusion, ventrally attached twins have very different outcomes, most adverse for thoracomphalopagus and related to the singular anatomy of the pair, associated malformations and the extension of the adhesion, requiring individual evaluation of the cases. Fetal MRI is as an important tool for the postnatal surgery management of twin neonates, providing crucial information in cases where urgent separation is required.

Prenatal diagnosis of cervical masses by magnetic resonance imaging and 3D virtual models: perinatal and long-term follow-up outcomes

Objective: To assess perinatal and long-term follow-up outcomes of fetal cervical masses diagnosed by three-dimensional (3D) magnetic resonance imaging (MRI) and 3D virtual models.Methods: This retrospective cohort study evaluated 15 pregnant women (age, 21-38 years) at 29-40 weeks of singleton gestation, whose fetuses exhibited congenital oral and cervical masses. These women were referred to our facility because of suspected fetal malformations on routine obstetric ultrasound, and the cases were confirmed, excluded, or complemented by MRI. Demographic data and perinatal and long-term follow-up outcomes were assessed.Results: Cervical masses were predominant in females (3:2), and the most frequent diagnosis was lymphatic-venous malformation (71%). The masses were cystic in 53.3% of the cases and solid in 46.7%. The esophagus and trachea were displaced in 46.6% of the cases. Associated malformations were diagnosed in 13.3% of the cases. There was complete agreement between prenatal MRI and postnatal diagnoses. Among the newborns, 40% had complications and 46.6% were admitted to the neonatal intensive care unit. Two infants died from complications due to epignathus. Surgical resection was performed in 33.3% of the cases, including complete resection in 26.6%. Sclerotherapy was administered to 53.3% of the cases, with complete remission achieved in 50% of these cases.Conclusion: Cervical masses diagnosed in the prenatal period had good postnatal outcomes except for cases of epignathus, which were associated with high mortality. MRI demonstrated the relationship between cervical masses and adjacent organs and allowed 3D virtual reconstruction of the airways. There was complete agreement between the prenatal diagnosis of cervical masses on MRI and postnatal diagnosis. Surgical treatment was effective in most cases, and sclerotherapy was satisfactory in cases with intrathoracic components.

Evaluation of the fetal abdomen by magnetic resonance imaging. Part 2: abdominal wall defects and tumors

Although ultrasound is still the gold standard for the assessment of fetal malformations, magnetic resonance imaging (MRI) has gained great prominence in recent years. In situations in which ultrasound has low sensitivity, such as maternal obesity, abdominal scarring, and oligohydramnios, MRI has proven to be a safe and accurate method. Regarding fetal abdominal wall defects, MRI appears to be widely used in the prognostic assessment of gastroschisis with intestinal atresia or of complications of omphalocele, allowing better perinatal management and parental counseling. In addition, MRI allows the assessment of local invasion of fetal abdominal tumors, with significant prognostic value for the postnatal period. In this article, we review the main MRI findings in the evaluation of fetal abdominal wall defects and tumors.

Tuboperitoneal fistula, ectopic pregnancy, and remnants of fallopian tube: a confocal microtomography analysis and 3D reconstruction of human fallopian tube pathologies

Objective: The aim of this study was to provide a three-dimensional (3D) microscopic reconstruction of morphological modifications of the fallopian tube (FT) following surgical sterilization (including tuboperitoneal fistula) and ectopic pregnancy (EP) using confocal microtomography (micro-CT). Methods: Six specimens of FT from elective and emergency surgeries were selected: three remnants of the FT (RFT) from surgical sterilization, including one presenting tuboperitoneal fistula, and three FTs with EP. The specimens were fixed in formalin and stained with Lugol solution. Micro-CT studies were conducted on the specimens using protocols adapted from biological studies. Results: Three RFTs from surgical sterilization and three FTs affected by EPs were successfully scanned using micro-CT. There was good contrast impregnation, allowing tissue segmentation and analysis of different sections of the FTs. Three FT specimens from EP exhibited considerable distortion of the tubal anatomy, mainly from the blood clot in the tubal abortion. Three RFT specimens exhibited some features observed in traditional microscopy, such as tubal distension and loss of normal anatomical characteristics of a normal FT, and indicated the presence of a tuboperitoneal fistula in one of the three specimens. Conclusion: Micro-CT can identify morphological characteristics of FT pathologies previously described in a microscopic scale, with tissue contrast and the possibility of 3D reconstruction. Micro-CT is also useful in guiding traditional sectioning of specimens for histopathological studies.

Evaluation of the fetal abdomen by magnetic resonance imaging. Part 1: malformations of the abdominal cavity

Although ultrasound continues to be the mainstay modality for the evaluation of fetal disorders, fetal magnetic resonance imaging (MRI) has often been used as a valuable adjunct in recent years. The exponential growth of the use of fetal MRI has been facilitated by technological advancements such as ultrafast T2-weighted sequences and diffusion-weighted imaging. Fetal MRI can achieve results that are comparable to or better than those of ultrasound, particularly in cases of maternal obesity, severe oligohydramnios, or abnormal fetal position. Because of its superior soft tissue contrast, wide field of view, and multiplanar imaging, fetal MRI is able to evaluate the large fetal organs, such as the lungs, liver, bowel, and kidneys. In addition, fetal MRI allows large or complex malformations to be examined, facilitating the understanding of the malformation within the context of the body as a whole. Initial fetal MRI studies were focused on the central nervous system. With advances in software and hardware, fetal MRI gained importance in the evaluation of the fetal abdomen. The purpose of this article is to review the recent literature and developments in MRI evaluation of the fetal abdomen, with an emphasis on imaging aspects, protocols, and common clinical indications.

Dilatação fluxo-mediada da artéria braquial em mulheres com artrite reumatóide

OBJETIVO: Avaliar a função endotelial em pacientes com artrite reumatóide, pela dilatação fluxo-mediada da artéria braquial. MATERIAIS E MÉTODOS: Sessenta e oito pacientes, sendo 32 com artrite reumatóide e 36 do grupo controle, foram avaliadas pela dilatação fluxo-mediada da artéria braquial (método ultra-sonográfico, no modo B, de avaliação de risco cardiovascular). Em um segundo tempo, foi avaliada a correlação entre a dilatação fluxo-mediada da artéria braquial, a proteína C reativa e o tempo de doença em pacientes com artrite reumatóide. RESULTADOS: A dilatação fluxo-mediada da artéria braquial na artrite reumatóide foi igual a 5,6 ± 9,69% e no grupo controle foi igual a 23,24 ± 5,65%, diferença estatisticamente significante (p < 0,00001). A proteína C-reativa teve resultado de 4,8 ± 9,1 mg/l. A correlação entre a idade, a dilatação fluxo-mediada da artéria braquial e a proteína C reativa nas pacientes com artrite reumatóide não mostrou resultado estatisticamente significante. CONCLUSÃO: Mulheres com artrite reumatóide apresentam importante disfunção endotelial quando comparadas com mulheres normais.