Malformation of cortical development with abnormal cortex: early ultrasound diagnosis between 14 and 24 weeks of gestation

OBJECTIVE

To describe neurosonographic findings diagnostic or highly suggestive of the presence of malformations of cortical development involving the cortex that may be identified before 24 weeks of gestation.

METHODS

This was a retrospective single-center study of fetuses referred for neurosonography, during 2012-2019, with an abnormal cortical or sulcation pattern diagnosed early in the mid trimester. Stored files were analyzed for demographic data, abnormal brain findings, non-central nervous system abnormalities, final diagnosis and postnatal outcome.

RESULTS

The study cohort included 20 fetuses, with a mean gestational age at diagnosis of 18.7 (range, 14.4-23.6) weeks, in 11 of which the diagnosis was made before 20 weeks of gestation. Reasons for referral were: midline anomaly (n = 7), ventriculomegaly (n = 4), infratentorial findings (n = 3), suspected malformation of cortical development (n = 3), 'abnormal brain' (n = 2) and skeletal dysplasia (n = 1). On neurosonography, both the sulcation pattern and the cortical layer were abnormal in four cases, only the sulcation pattern was considered abnormal in seven and only the cortical layer was abnormal in nine. Nineteen fetuses presented with associated central nervous system anomalies and six also had non-central nervous system malformations. One case was recurrent. Eighteen parents opted for termination of pregnancy, including one selective termination in a twin pregnancy, and two fetuses were liveborn.

CONCLUSIONS

Familiarity with fetal brain anatomy and its early sonographic landmarks allowed early diagnosis of malformations involving cortical development. These patients are likely to represent the most severe cases and all had associated malformations. The presence of an abnormal cortical layer and/or abnormal overdeveloped sulci appear to be early signs of malformation of cortical development. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Thick corpus callosum in the second trimester can be transient and is of uncertain significance

OBJECTIVES

Depiction of a thick corpus callosum (CC) in utero is rare, and is generally associated with severe brain anomalies. Our aim was to describe a group of fetuses diagnosed during second-trimester ultrasound examination as having an apparently isolated thick CC, which normalized subsequently in the cases followed to term.

METHODS

Among 59 fetuses referred to the Ob-Gyn Ultrasound Division of Lis Maternity Hospital with suspected callosal anomalies between January 2013 and June 2014, we identified nine cases with an apparently isolated thick CC for inclusion in this retrospective cohort study. Length and body thickness of the CC were compared with previously published nomograms. Fetuses with a suspected isolated thick CC were identified and followed until delivery or termination of pregnancy (TOP). Evaluation consisted of chromosomal analysis, at least one magnetic resonance imaging (MRI) examination and repeat ultrasound examinations. Postnatal evaluation included brain ultrasound examination, MRI when indicated and neurodevelopmental assessment through validated pediatric questionnaires.

RESULTS

The nine fetuses were diagnosed with an apparently isolated thick CC at a mean gestational age of 23 + 5 (range, 21-29) weeks. Eight exhibited a CC body thickness ≥ 2SD above the mean for gestational age and one exhibited only a thickened genu. Six also exhibited a relatively short CC. Two patients opted for TOP but declined autopsy. In five of the seven remaining fetuses, the CC thickness normalized during follow-up. In the remaining two, the increased CC thickness was a variant of the cingulate sulcus. The CC length remained ≤ 2SD in five of the six fetuses with a short CC. Fetal MRI was performed and confirmed the diagnosis in six fetuses. The karyotype was normal in all fetuses. Short-term neurodevelopmental outcome was reported as normal in all six children with complete follow-up.

CONCLUSIONS

Although the number of fetuses in our study is relatively small, it seems that an apparently isolated thick CC is not necessarily associated with poor prognosis. In such cases, a definitive diagnosis should not be reached based on a single measurement and repeat follow-up examinations during the third trimester are recommended. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Feto-feto-fetal transfusion syndrome in monozygotic monochorionic triamniotic triplets: vascular evaluation by a cast model

A unique cast model of the placenta in a rare case of feto-feto-fetal triplet transfusion syndrome (FFFTTS) allowed the demonstration of why the transfusion syndrome developed in one fetus and not in the other two in that single placenta. The vasculature anatomy of a monochorionic triamniotic triplet placenta with FFFTTS of three healthy infants (one donor, two recipients) born in the 35th week of gestation was cast by means of dental casting materials. After the cast hardened, the tissue was corroded, revealing the cast blood vessels. The diameters and lengths of the chorionic blood and intraplacental vessels of the cast placenta were measured with a digital caliper. The cast revealed two artery-artery (A-A) anastomoses on the chorionic plate between the two recipients and the donor. Seven artery-vein (A-V) deep anastomoses connected only the arteries of the donor and the veins of the two recipients. The blood vessel connections among the fetuses allowed the evaluation of a pathologic case with its own control in a single placenta. From the vascular appearance, we speculate that the A-A anastomoses between the two fetuses protected them from developing blood transfusions, but that the A-V anastomoses contributed to their development.

Prediction of fetal weight by ultrasound: the contribution of additional examiners

OBJECTIVES

To assess the contribution of additional examiners to: the average discrepancy between estimated and actual fetal weights; the correlation between estimated and actual fetal weights; the reduction in major (> 10%) discrepancies between estimated and actual fetal weights.

DESIGN

Three experienced sonographers independently measured fetal biparietal diameter, head circumference, abdominal circumference and femur length in 39 fetuses at term. The estimated fetal weights were calculated for each examiner. Fetal biometric measurements were analyzed to obtain the source of differences in estimations among the examiners. Discrepancy, correlation and number of major (> 10%) discrepancies between the estimated and actual fetal weights were calculated for each examiner, and the contribution of additional examiners was analyzed.

RESULTS

The differences in measurements of the biparietal diameter and femur length were lower than those of the head and abdominal circumferences. For each of the three examiners, the average discrepancy between the estimated and actual fetal weights was 6.1%, 5.9% and 6.3%. When the estimation was based on two examiners, the discrepancy decreased to 4.8-5.6%. The contribution of a third examiner was nil. Major (> 10%) discrepancies between estimated fetal weight and actual birth weight were found in seven, eight and nine estimations of the examiners. Estimation by two examiners decreased the number of major discrepancies, and estimation by all three examiners further decreased by approximately 50% the number of major discrepancies between the estimated and actual fetal weights.

CONCLUSION

Measurements by multiple examiners changes only slightly the average number of discrepancies between estimated and actual fetal weights. However, the reduction in major (> 10%) discrepancies is statistically and clinically significant.

Combined vulvar vestibulitis syndrome with vaginismus: which to treat first?

The common approach to vulvar vestibulitis syndrome (VVS) combined with vaginismus is to treat the VVS before the vaginismus. Our study initially ignored the VVS and instead treated the vaginismus first.

Vascularity index distribution within the testis: a technique for guiding testicular sperm extraction

Azoospermia is defined as the absence of spermatozoa in the ejaculate, although some foci of spermatogenesis may exist in the testes of these men. Currently, there are no clinical, seminal or hormonal parameters for identifying spermatogenesis within the testis sufficient for achieving genetic offspring. As a result, multiple biopsies are performed at several arbitrary sites of both testes in search of spermatozoa. We developed a power Doppler (PD) ultrasound (US) image-based technique that predicts sites with the greatest potential for spermatogenesis. PDUS images of the testes of azoospermic men were acquired at seven cross-sections to reconstruct a 3-D matrix for constructing a spatial map of preferential regions where spermatozoa are most likely to exist. This technique may obviate the need for arbitrary multiple biopsies that inflict some degree of damage upon testicular tissue, and may increase the success rate of identifying viable spermatozoa in testicular biopsies.

Characteristics of uterine peristalsis in spontaneous and induced cycles

OBJECTIVE

To characterize the dynamics of the intrauterine fluid-wall interface (IUFWI) from in vivo transvaginal ultrasound images by new techniques of image processing of sagittal cross-sections of the uterus, in healthy women with normal cycles and patients treated with clomiphen citrate (CC).

DESIGN

Clinical study.

SETTING

An ultrasound unit in a large university-affiliated municipal hospital.

PATIENT(S)

Twenty-five patients with normal spontaneous cycles (group A) and nine patients treated by CC (group B).

INTERVENTION(S)

Transvaginal ultrasound examinations.

MAIN OUTCOME MEASURE(S)

Transvaginal ultrasound images were processed to carry out a computational analysis of the resultant IUFWI.

RESULT(S)

The amplitude and the width of the IUFWI were higher in group B, but the ratio of these measurements was similar in both groups. The frequency of wall motility of group A was lower and its pattern was more symmetrical than that of group B.

CONCLUSION(S)

The differences in the dynamic characteristics of spontaneous and CC-induced cycles may constitute an additional parameter that should be considered in embryo transport.

Outcome of 306 twin deliveries according to first twin presentation and method of delivery

The objective of this manuscript is to examine the effect of presentation of the first twin and mode of delivery on perintal outcome in twin deliveries. We reviewed all records of twin deliveries at a gestational age of 32 weeks and more from January 1, 1989 to December 31, 1995. Study cases were divided according to the first twin presentation (vertex = group A, nonvertex = group B) and then subdivided according to the planned mode of delivery, vaginal trial of labor (VTOL), and cesarean section (CS). The protocol for group A facilitated an attempt at vaginal delivery and for group B, vaginal delivery was considered as for a singleton fetus in breech presentation. Of 306 pairs of twins, 235 were in group A and 71 in group B. In group A, 219 women (93.2%) were eligible for VTOL, and the remaining 16 underwent CS. Thirty-three group B women were eligible for VTOL (46.5%; p<0.001) and 38 had CS. In group A, of the 219 candidates for VTOL, 199 (90.9%) delivered vaginally and 20 underwent a CS. In group B, of the 33 VTOL candidates 18 (54.5%) delivered vaginally and 15 underwent CS. Neonatal outcome did not differ in relation to the presentation of the first twin or the planned/actual mode of delivery. There were no cases of birth trauma, neurological complications, or perinatal mortality. Trial of vaginal labor is safe in twin deliveries with the first twin in vertex presentation. Provided criteria for vaginal breech delivery are adhered to, this also appears to be a reasonable option in twin deliveries with the first twin in nonvertex presentation.

Dynamics of the intrauterine fluid-wall interface

Intrauterine fluid movements, which are responsible for embryo transport to a successful implantation site at the fundus, may be induced by myometrial contractions. Myometrial contractions in nonpregnant uteri were studied from in vivo measurements of intrauterine pressures with fluid-filled catheters and by visual observations of high-speed replaying of ultrasound images of the uterus. Transvaginal ultrasound (TVUS) images of sagittal cross sections of the nonpregnant uterus were scanned with an intravaginal ultrasound probe. Images at consecutive times (2 s apart) were digitized and processed by employing modern techniques of image processing. The sets of images were compared to evaluate time variation of the fluid-wall interface with respect to amplitude, frequencies, and wavelength of myometrial contractions. Analysis of TVUS images from 11 volunteers during the proliferative phase revealed that myometrial contractions are fairly symmetric and are propagated from the cervix towards the fundus at a frequency of about 0.01-0.09 Hz. The wavelength, amplitude, and velocity of the fluid-wall interface during a typical contractile wave were found to be 10-30 mm, 0.05-0.2 mm, and 0.5-1.9 mm/s, respectively. Additional data acquisition from a large number of normal subjects is needed to build a data base to predict normal characteristics of myometrial contractions in a nonpregnant uterus, in order to better understand their role in the preimplantation process.

Antenatal sonographic diagnosis of epignathus at 15 weeks of pregnancy

Epignathus is a rare, benign, congenital teratoma of the hard palate. Most of these teratomas are unidirectional and protrude through the mouth. Hence, the prognosis depends on the size of the tumor and the degree of face distortion and airway obstruction that it causes. However, some epignathi protrude bidirectionally, involving and destroying the brain tissue, resulting in a poor prognosis. This report presents a case of ultrasonographic detection of a bidirectional epignathus at 15 weeks of pregnancy.

Doppler velocimetry of the umbilical artery as a predictor of outcome in pregnancies characterized by elevated beta-subunit human chorionic gonadotropin

OBJECTIVE

Women with unexplained elevated maternal serum beta-subunit human chorionic gonadotropin (beta-HCG) are at an increased risk for adverse pregnancy outcome, most likely due to placental abnormalities. Such abnormalities may also result in disturbed blood flow through placental vessels. The purpose of this study was to assess whether Doppler velocimetry of the umbilical artery has a predictive value for pregnancy outcome in patients with unexplained elevated maternal serum beta-HCG.

STUDY DESIGN

The study group included 63 patients, in whom the only finding was elevated maternal serum beta-HCG. Systolic/diastolic (S/D) ratios were calculated using a continuous wave Doppler measurement of the umbilical artery, performed beginning at 22 weeks of gestation and followed at 6- to 8-week intervals. Serial results for each individual were incorporated into a single 'velocimetry score', calculated as the rate of abnormal velocimetry measurements.

RESULTS

beta-HCG was found to be associated with poor pregnancy outcome: including intrauterine growth restriction (IUGR) (19%), pregnancy-induced hypertension (PIH) (14%), and preterm labor (PTL) (19%). Patients were then divided into 2 groups according to their velocimetry score: group A, VS < or = 80 (n = 47), and group B, VS > 80 (n = 16). A low velocimetry score was associated with a higher rate of IUGR, PIH, and a significantly higher rate of PTL.

CONCLUSIONS

Umbilical artery Doppler velocimetry may serve as a predictor of pregnancy outcome in the high-risk group characterized by unexplained elevated beta-HCG.

Doppler velocimetry of the umbilical artery as a predictor of pregnancy outcome in pregnancies characterized by elevated maternal serum alpha-fetoprotein and normal amniotic fluid alpha-fetoprotein

OBJECTIVE

Women with elevated maternal serum alpha-fetoprotein (MSAFP) and normal amniotic fluid alpha-fetoprotein (AFAFP) are at an increased risk of an adverse pregnancy outcome. Such MSAFP elevations are probably the consequence of transplacental leakage caused by placental abnormalities. These may result in disturbed bloodflow through placental vessels. The purpose of this study was to assess whether measurement of such disturbances by Doppler velocimetry of the umbilical artery has a predictive value for pregnancy outcome.

STUDY DESIGN

The study group consisted of 85 patients, in whom the only finding was elevated maternal serum alpha-fetoprotein. Systolic/diastolic (S/D) ratios were calculated using a continuous wave Doppler measurement of the umbilical artery, performed at 6 to 8-week intervals. Serial results for each individual were incorporated into a single 'Velocimetry Score'.

RESULTS

In group B (14 patients) with an abnormally elevated umbilical S/D ratio, a higher incidence of intrauterine growth retardation (42.9%), preterm deliveries (78.6%), and fetal loss (42.9%) was noted, as compared with group A (71 patients) with a normal S/D ratio.

CONCLUSIONS

Umbilical artery Doppler velocimetry may serve as a predictor of pregnancy outcome in the high-risk group characterized by elevated MSAFP.

Flow velocity waveforms of the uterine artery in pregnancy: transvaginal versus transabdominal approach

Our objective was to compare recordings of flow velocity waveforms from the uterine artery via the transvaginal and transabdominal approach in normal human pregnancies. In a cross-sectional study from 16 to 40 weeks' gestation, 88 healthy pregnant women underwent a continuous-wave Doppler examination of their uterine arteries by both the transvaginal and the transabdominal approach. Measurements were recorded for both uterine arteries and averaged. Values recorded transabdominally were significantly lower than those obtained transvaginally in all patients < or = 27 weeks' gestation. From 28 weeks to term, transabdominal values remained lower, but the difference was smaller and insignificant, and noted only as a trend. Transvaginal velocimetry of the uterine artery produces significantly higher systolic:diastolic ratios than that of transabdominal recordings until 27 weeks' gestation. Thereafter, trophoblastic invasion of the uteroplacental circulation is maximal, and the difference between the values are minimal and insignificant. However, a pattern of lower resistance in the transabdominal approach remains consistent until term.

Continuous wave Doppler velocimetry of the main-stem uterine arteries: the transvaginal approach

The purpose of the study was (1) to establish the efficacy of the transvaginal approach for continuous wave Doppler velocimetry of the main-stem uterine arteries in normal pregnancy and (2) to provide reference values for the flow velocity waveform indices of the main-stem uterine arteries in normal pregnancy. In a cross-sectional study from 16 to 40 weeks of pregnancy, 201 healthy normal women were examined by transvaginal continuous wave Doppler, and flow velocity waveforms were obtained from the main branch of the uterine artery on both sides. Nomograms were compiled for the systolic: diastolic ratio, pulsatility index and resistance index. Values for all variables declined during the course of pregnancy until 22 weeks' gestation, and then remained stable to term. Intra- and interobserver variations were 5% and 8%, respectively, and the examination time was < 5 min. Flow velocity waveform indices declined during pregnancy, indicating a decrease of resistance in the uteroplacental circulation. Our results are comparable to those obtained transvaginally by pulsed wave Doppler, previously reported in the literature. The transvaginal approach for continuous wave Doppler velocimetry of the main-stem uterine arteries is a simple, quick, accurate, safe, cheap and highly reproducible method, and is therefore suitable for evaluating the uteroplacental circulation.

Pregnancy during long-term gonadotropin-releasing hormone agonist therapy associated with clinical pseudomenopause

A case of pregnancy occurring with escape of suppression from GnRH-a therapy is described. Clinical pseudomenopause had been established, and the pregnancy was exposed to depot GnRH-a for 8 weeks. Normal pregnancy outcome demonstrated that successful implantation may occur in the first escaped ovulatory cycle.