Showing papers in "Ultrasound in Obstetrics & Gynecology in 2012"

Neurodevelopmental delay in small babies at term: a systematic review

Abstract: Objective Being small for gestational age (SGA) or having fetal growth restriction (FGR) may be associated with poorer neurodevelopmental outcomes compared to being appropriate for gestational age (AGA). The aim of this paper was to evaluate the existence and magnitude of decrease in neurodevelopmental scores in SGA and FGR infants born at term from a systematic review of the existing literature. Methods Studies of neurodevelopment in SGA/FGR babies were identified from a search of the internet scientific databases. Studies that included preterm births and those that did not define absolute indices of standardized cognitive outcome were excluded. SGA was defined as birth weight below the 10 th centile for gestation and FGR as the same birth-weight standard with abnormal umbilical artery Doppler ultrasound or evidence of abnormal placentation on pathology specimen studies. Effect size was calculated as the standardized mean difference between neurodevelopment scores of controls and SGA/FGR children. Results There were 28 studies of SGA, with a total of 7861 SGA and 91 619 control AGA babies, and three studies of FGR, with a total of 119 FGR and 49 control AGA babies. Data synthesis showed that standardized neurodevelopmental scores in SGA babies were 0.32 SD (95% CI, 0.25–0.38) below those for normal controls, though with heterogeneity between studies (I 2 = 68.3%). Insufficient data were available for FGR babies. Conclusion The findings of the study demonstrate that among babies born at term, being SGA is associated with lower scores on neurodevelopmental outcomes compared to AGA controls. A trial designed to evaluate the effects of intervention in small fetuses born at term in order to improve the neurodevelopmental outcome is urgently needed. Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.

A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia.

Abstract: Objective Severe pulmonary hypoplasia and pulmonary arterial hypertension are associated with reduced survival in congenital diaphragmatic hernia (CDH). We aimed to determine whether fetal endoscopic tracheal occlusion (FETO) improves survival in cases of severe isolated CDH.

Intra- and interobserver variability in fetal ultrasound measurements.

Abstract: Objective To assess intra- and interobserver variability of fetal biometry measurements throughout pregnancy. Methods A total of 175 scans (of 140 fetuses) were prospectively performed at 14‐41 weeks of gestation ensuring an even distribution throughout gestation. From among three experienced sonographers, a pair of observers independently acquired a duplicate set of seven standard measurements for each fetus. Differences between and within observers were expressed in measurement units (mm), as a percentage of fetal dimensions and as gestational agespecific Z-scores. For all comparisons, Bland‐Altman plots were used to quantify limits of agreement. Results When using measurement units (mm) to express differences, both intra- and interobserver variability increased with gestational age. However, when measurement of variability took into account the increasing fetal size and was expressed as a percentage or Z-score, it remained constant throughout gestation. When expressed as a percentage or Z-score, the 95% limits of agreement for intraobserver difference for head circumference (HC) were ±3.0% or 0.67; they were ±5.3% or 0.90 and ±6.6% or 0.94 for abdominal circumference (AC) and femur length (FL), respectively. The corresponding values for interobserver differences were ±4.9% or 0.99 for HC, ±8.8% or 1.35 for AC and ±11.1% or 1.43 for FL. Conclusions Although intra- and interobserver variability increases with advancing gestation when expressed in millimeters, both are constant as a percentage of the fetal dimensions or when reported as a Z-score. Thus, measurement variability should be considered when interpreting fetal growth rates. Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.

Standardized approach for imaging and measuring Cesarean section scars using ultrasonography

Abstract: Incomplete healing of the scar is a recognized sequel of Cesarean section (CS) and may be associated with complications in later pregnancies. These complications can include scar pregnancy, a morbidly adherent placenta, scar dehiscence or rupture. To date there is uncertainty relating to the factors that lead to poor scar healing and how to recognize it. In recent years, there has been an increase in studies using ultrasound that describe scars as deficient, or poorly, incompletely or inadequately healed with few data to associate the morphology of the scar with the functional integrity of the lower segment of the uterus. There have been multiple attempts to describe CS scars using ultrasonography. Different terminology, methods and results have been reported, yet there is still no consensus regarding the prevalence, clinical significance or most appropriate method to describe the appearances of these scars. Developing a test that can predict the likelihood of women having problems associated with a CS scar is becoming increasingly important. On the other hand, understanding whether the ultrasound appearances of the scar can tell us anything about its integrity is not well supported by the research evidence. In this article we present an overview of ultrasound-based definitions and methods used to describe CS scars. We also present information relating to the performance of alternative techniques used to evaluate CS scars. Having examined the current evidence we suggest a standardized approach to describe CS scars using ultrasound so that future studies can be meaningfully compared.

Quantification of cervical elastography: a reproducibility study

Abstract: Objectives To assess a new method for numerical quantification of cervical elastography during pregnancy and to evaluate the repeatability of the measurements. Methods Cervical elastography was carried out twice by a single operator in 112 singleton pregnancies at a median of 21 (range, 12–40) weeks' gestation. In 50 of the cases a second operator performed another elastography measurement. The intraobserver and interobserver repeatability of measurements in different parts of the cervix were assessed using intraclass correlation coefficients with 95% CI and by Bland–Altman analysis. Results There were no statistically significant differences in the elastography measurements made by the same and by two different observers in each area measured, except in the area that receives the force of the transducer directly. The distribution of elastographic measurements obtained in different regions of the cervix demonstrated that the external and superior parts were significantly softer than the internal and inferior parts. Conclusion It is possible to provide an objective quantification of elastographic colors in the cervix. The measurements obtained by elastography may be a mere reflection of the force being applied by the transducer to different parts of the cervix. It is too premature to suggest that the measurements of rate-of-change in tissue displacement reflect histological changes that could provide a measure of cervical ripening. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Estimated weight centile as a predictor of perinatal outcome in small-for-gestational-age pregnancies with normal fetal and maternal Doppler indices.

Abstract: Objective To evaluate the risk of adverse perinatal outcome according to estimated fetal weight (EFW) in a cohort of term small-for-gestational-age (SGA) pregnancies with normal umbilical, fetal middle cerebral and maternal uterine artery Doppler indices. Methods A cohort of 132 term SGA fetuses with normal umbilical artery pulsatility index (PI), mean uterine artery PI and cerebroplacental ratio was compared to a control group of 132 appropriate-for-gestational-age babies, matched by gestational age at delivery. The capacity of the EFW percentile to predict Cesarean delivery, Cesarean delivery for non-reassuring fetal status (NRFS), neonatal acidosis and days of neonatal hospitalization was analyzed. Results As a whole, SGA fetuses with normal Doppler findings did not show a statistically significant difference for intrapartum Cesarean delivery (22.0 vs. 15.9%; P = 0.21) and neonatal acidosis (3.3 vs. 1.5%; P = 0.30), but had significantly higher risk for Cesarean delivery for NRFS (15.9 vs. 5.3%; P < 0.01) and longer neonatal hospitalization (1.39 vs. 0.87 days; P < 0.05) than did controls. SGA fetuses with EFW < 3rd centile had a significantly higher incidence of intrapartum Cesarean delivery (30.0 vs. 15.3%; P = 0.04), Cesarean delivery for NRFS (25.0 vs. 8.3%; P < 0.01) and longer neonatal hospitalization (2.0 vs. 0.9 days; P < 0.01) than those with EFW ≥ 3rd centile. SGA cases with EFW ≥ 3rd centile had perinatal outcomes similar to those of controls with normal EFW. Conclusion Among SGA fetuses with normal placental and cerebral Doppler ultrasound findings, EFW < 3rd centile discriminates between those with a higher risk for adverse perinatal outcome and those with outcomes similar to those of normally grown fetuses. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Obstetric levator ani muscle injuries: current status

Abstract: Levator ani muscle (LAM) injuries occur in 13-36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three-dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long-term follow-up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above-mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high-risk groups be identified and preventive strategies implemented in obstetric practice.

Barriers to prenatal detection of congenital heart disease: a population-based study.

Abstract: Objective To evaluate the extent and determinants of missed prenatal detection of congenital heart disease (CHD) in a population-based setting. Methods This was a retrospective cohort study of cases with CHD, excluding minor defects, identified between 1997 and 2007 by a statewide surveillance program. We examined a comprehensive list of potential risk factors for which data were available in the surveillance database from abstracted medical charts. We analyzed the association of fetal, maternal and encounter factors with 1) whether a prenatal ultrasound was performed and 2) prenatal detection of CHD. Results CHD was detected prenatally in only 39% of 1474 cases, with no improvement in detection rate over the 10-year period. Among the 97% (n = 1431) of mothers who underwent one or more ultrasound examinations, 35% were interpreted as abnormal; fetal echocardiography was performed in 27% of the entire cohort. Maternal and encounter factors increasing the adjusted odds of prenatal detection included: family history of CHD (OR, 4.3 (95% CI, 1.9–9.9)), presence of extracardiac defects (OR, 2.7 (95% CI, 1.9–3.9)) and ultrasound location i.e. high risk clinic vs clinic (OR, 2.1 (95% CI, 1.3–3.1)). Defects that would be expected to have an abnormal outflow-tract view were missed more often (64%) than were those that would be expected to have an abnormal four-chamber view (42%). Conclusion The majority of CHD cases over the 10-year study period were missed prenatally and detection rates did not increase materially during that time. The failure to detect CHD prenatally was related to encounter characteristics, specifically involving screening ultrasound examinations, which may be targeted for improvement. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Counseling in fetal medicine: agenesis of the corpus callosum.

Abstract: In this Review, we aim to provide up-to-date and evidence-based answers to common questions regarding the diagnosis and prognosis of prenatally detected agenesis of the corpus callosum (ACC). A systematic literature search was performed to identify all reports of ACC and reference lists of articles were identified. ACC involves partial or complete absence of the main commissural pathway that connects the two cerebral hemispheres, and can be isolated (with no other abnormalities) or complex (coexisting with other abnormalities). It is a rare finding and the prevalence is difficult to estimate because of selection bias in reported series. The corpus callosum (CC) can be assessed on ultrasound by direct visualization, but indirect features, such as ventriculomegaly, absence of the cavum septi pellucidi or widening of interhemispheric fissure, are often the reason for detection in a screening population. Careful imaging in a center with a high level of expertise is required to make a full assessment and to exclude coexisting abnormalities, which occur in about 46% of fetuses. When available, magnetic resonance imaging appears to be an important adjunct as it allows direct visualization. It can reduce false-positive rates on ultrasound and can confirm ACC, it can assess whether this is complete or partial and it can help in detecting coexisting brain abnormalities not seen on ultrasound. The overall rate of chromosomal abnormality in fetuses with ACC is 18%, but this high rate includes both isolated and complex ACC; more recent studies suggest that chromosomal abnormalities are rare in isolated cases. Nevertheless, postnatal follow-up studies suggest that about 15% of cases thought to be isolated prenatally were found to have associated abnormalities after birth. Neurodevelopmental outcome in isolated ACC was recently reported in a systematic review and suggested normal outcome in about 65-75% of cases. Findings need to be considered in light of the several limitations of existing studies, in terms of study design, selection bias, varying definitions and imaging protocols, ascertainment bias and lack of control groups. These uncertainties mean that antenatal counseling is difficult and further large prospective studies are needed.

Prenatal diagnosis and outcome of fetal posterior fossa fluid collections

Abstract: Objective To evaluate the accuracy of fetal imaging in differentiating between diagnoses involving posterior fossa fluid collections and to investigate the postnatal outcome of affected infants. Methods This was a retrospective study of fetuses with posterior fossa fluid collections, carried out between 2001 and 2010 in two referral centers for prenatal diagnosis. All fetuses underwent multiplanar neurosonography. Parents were also offered fetal magnetic resonance imaging (MRI) and karyotyping. Prenatal diagnosis was compared with autopsy or postnatal MRI findings and detailed follow-up was attempted by consultation of medical records and interview with parents and pediatricians. Results During the study period, 105 fetuses were examined, at a mean gestational age of 24 (range, 17‐28) weeks.Sonographicdiagnoses(Blake’spouchcyst, n =32; megacisterna magna, n =27; Dandy‐Walker malformation, n =26; vermian hypoplasia, n =17; cerebellar hypoplasia, n =2; arachnoid cyst, n =1) were accurate in 88% of the 65 cases in which confirmation was possible. MRI proved more informative than ultrasound in only1/51cases.Anatomicanomaliesand/orchromosomal aberrations were found in 43% of cases. Blake’s pouch cysts and megacisterna magna underwent spontaneous resolution in utero in one third of cases and over 90% of survivors without associated anomalies had normal developmental outcome at 1‐5 years. Isolated Dandy‐Walker malformation and vermian hypoplasia were associated with normal developmental outcome in only 50% of cases. Conclusion Prenatal neurosonography and MRI are similarly accurate in the categorization of posterior fossa fluid collections from mid gestation. Blake’s pouch cyst and megacisterna magna are risk factors for associated anomalies but when isolated have an excellent prognosis, with a high probability of intrauterine resolution and normal intellectual development in almost all cases. Conversely, Dandy‐Walker malformation and vermian hypoplasia, even when they appear isolated antenatally, are associated with an abnormal outcome in half of cases. Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.

Radiofrequency ablation vs bipolar umbilical cord coagulation in the management of complicated monochorionic pregnancies

Abstract: Objective The application of radiofrequency ablation (RFA) termination procedures to complicated cases involving monochorionic twins offers the potential of a less invasive option when compared to endoscopic techniques. The purpose of this study was to compare outcomes between these two techniques. Methods A retrospective review was undertaken of all cases of complicated monochorionic twin gestations treated at the Children's Hospital of Philadelphia from July 1996 to December 2010. Cases were identified from the fetal treatment database and data extracted in a uniform fashion from the patients' charts. Results A total of 149 cases were identified with procedures performed on 146. Indications for selective termination of one fetus were twin reversed arterial perfusion sequence in 53, severe twin-to-twin transfusion syndrome in 43, discordance for fetal anomalies in 26 and selective intrauterine growth restriction in 24. Eighty-eight cases were managed with bipolar cord coagulation (BCC) and 58 with RFA. The procedures in all cases were technically successful in achieving selective termination. The mean gestational age at the time of the procedure was 20.9 ± 2.7 weeks in the BCC group vs 20.2 ± 2.2 weeks in the RFA group (P = 0.1). The median gestational age at delivery was 34.7 (interquartile range (IQR), 29.2–38.6) weeks for the BCC group vs 33.0 (IQR, 23.4–38.9) weeks in the RFA group (P = 0.073). Mean birth weight did not differ between the two groups. The procedure-to-delivery time was 87.1 ± 42.1 days for the BCC group vs 73.8 ± 47.2 days for the RFA group (P = 0.1). Overall survival was 85.2% in the BCC group vs 70.7% in the RFA group (P = 0.014). This was attributed primarily to a survival rate of 10.5% in the RFA group compared with 31.6% in the BCC group for cases where delivery occurred before 28 weeks' gestation (P = 0.01). Premature rupture of the membranes occurred in 27.3% in the BCC group vs 13.7% in the RFA group (P = 0.05). Preterm labor was more common in the BCC group than in the RFA group (22.4 vs 7%, respectively; P = 0.009). Conclusion Despite the smaller caliber of the instrument, RFA is not associated with a decrease in the overall complication rate for selective termination procedures. The technique used for selective termination should still be determined by technical considerations but patients should be informed of the survival rate associated with each technique. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Prediction and probability of neonatal outcome in isolated congenital diaphragmatic hernia using multiple ultrasound parameters.

Abstract: Objectives To evaluate the accuracy and probabilities of different fetal ultrasound parameters to predict neonatal outcome in isolated congenital diaphragmatic hernia (CDH).

Prevalence of levator ani muscle injury in Chinese women after first delivery.

Abstract: Objectives To assess the prevalence of levator ani muscle injury in Chinese women after their first delivery and investigate associated factors. Methods A prospective observational study was conducted involving Chinese nulliparous women recruited in the first trimester of pregnancy. Translabial ultrasound was performed at 35–38 weeks' gestation and 8 weeks postpartum and three-dimensional volume datasets were obtained. Offline analysis to detect levator ani muscle injury was performed by investigators blinded to the delivery details. Results 339 women, with a mean age of 30.6 ± 3.9 years, completed the study. Overall, 201 (59.3%) had a spontaneous vaginal delivery, 62 (18.3%) an operative vaginal delivery (48 ventouse extraction and 14 forceps delivery), 14 (4.1%) an elective Cesarean section and 62 (18.3%) an emergency Cesarean section. No levator ani muscle injury was detected in any woman antenatally. After vaginal delivery, 57 (21.7% (95% CI, 16.7–26.7%)) women had levator ani muscle injury. The rates of injury for spontaneous vaginal delivery, ventouse extraction and forceps delivery were 15.4%, 33.3% and 71.4%, respectively. There was no levator ani muscle injury in the Cesarean section groups. Logistic regression analysis showed that only operative vaginal delivery (odds ratio, 3.09) was associated with an independent increase in the likelihood of levator ani muscle injury. Intrapartum epidural analgesics, duration of second stage of labor and infant birth weight were not independently associated with levator ani muscle injury. Conclusions The prevalence of levator ani muscle injury in Chinese women after their first vaginal delivery was 21.7% (95% CI, 16.7–26.7%). Operative vaginal delivery was found to increase the likelihood of women suffering such injury. A longer follow-up of these women and future studies on the effects of episiotomy are proposed. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

First-trimester detection of structural abnormalities and the role of aneuploidy markers

Abstract: Objectives To determine the sensitivity of first-trimester ultrasound for diagnosing different structural anomalies in chromosomally normal pregnancies, and to establish the role of aneuploidy markers in the detection of abnormalities. Methods This was a retrospective study of chromosomally normal singleton pregnancies with an 11–14-week scan performed in our center during 2002–2009. The ultrasound examination included an early fetal anatomy survey and assessment of nuchal translucency, ductus venosus blood flow and nasal bone. Results Among 13 723 scanned first-trimester pregnancies with no genetic anomalies and complete follow-up, 439 fetuses (3.2%) were found to present with structural anomalies (194 with major anomalies and 245 with only minor anomalies). Forty-nine per cent of major structural anomalies were detected during the first-trimester scan, the highest rates corresponding to acrania (17/17), holoprosencephaly (three of three), hypoplastic left heart syndrome (10/10), omphalocele (six of six), megacystis (seven of eight) and hydrops (eight of nine). Higher than expected detection rates were obtained for skeletal (69%) and cardiac (57%) defects, coincidentally showing the highest presence of an increased nuchal translucency or abnormal ductus venosus blood flow (38% and 52%, respectively). The finding of an absent nasal bone did not appear to be associated with structural defects. Conclusion About half of major structural abnormalities can be diagnosed in the first trimester. Increased nuchal translucency or abnormal ductus venosus blood flow appear to be associated with cardiac and skeletal defects and may facilitate early detection. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Pregnancy loss after chorionic villus sampling and genetic amniocentesis in twin pregnancies: a systematic review

Abstract: Objective To review the available evidence regarding pregnancy loss following first-trimester chorionic villus sampling (CVS) and mid-trimester genetic amniocentesis in twins. Methods We searched the MEDLINE database from January 1990 to May 2011 for randomized and cohort studies reporting on the risk of pregnancy loss after first-trimester CVS performed between 9 and 14 weeks and after genetic amniocentesis performed between 14 and 22 weeks. Where appropriate, we calculated pooled proportions and relative risks with 95% CI. Results No randomized studies were found. For CVS, nine studies fulfilled the inclusion criteria. The overall pregnancy-loss rate was 3.84% (95% CI, 2.48–5.47; n = 4). The rate of pregnancy loss before 20 weeks was 2.75% (95% CI, 1.28–4.75; n = 3) and before 28 weeks was 3.44% (95% CI, 1.67–5.81; n = 3). For amniocentesis, the overall pregnancy-loss rate was 3.07% (95% CI, 1.83–4.61; n = 4). The rate of pregnancy loss before 20 weeks was 2.25% (95% CI, 1.23–3.57; n = 2), before 24 weeks was 2.54% (95% CI, 1.43–3.96; n = 9) and before 28 weeks was 1.70% (95% CI, 0.37–3.97; n = 5). Pooled data from four case–control studies showed a higher risk (2.59% vs. 1.53%) of pregnancy loss before 24 weeks following amniocentesis (relative risk = 1.81; 95% CI, 1.02–3.19). There were no statistically significant differences in reported pregnancy loss between transabdominal and transcervical approaches, use of a single-needle system vs. a double-needle system and single uterine entry vs. double uterine entry in the CVS group. Similarly, in the amniocentesis group, there was no statistically significant difference in fetal loss between the single uterine entry vs. the double uterine entry. Conclusion In the absence of randomized studies, it is not possible to estimate accurately the excess risk following invasive procedures in twins. Currently available data show similar overall pregnancy-loss rates for both amniocentesis and CVS with the excess risk of around 1% above the background risk. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Functional assessment of the fetal heart: a review.

Abstract: The purpose of this review is to evaluate the current modalities available for the assessment of fetal cardiac function. The unique anatomy and physiology of the fetal circulation are described, with reference to the difference between in-utero and ex-utero life. M-mode, early/atrial ratio, myocardial performance index, threedimensional and four-dimensional ultrasound, tissue Doppler including strain and strain rate, speckle tracking, magnetic resonance imaging and venous flow assessment are described. The modalities are analyzed from the perspective of the clinician and certain questions are posed. Does the modality assess systolic function, diastolic function or both? Is it applicable to both ventricles? Does it require extensive post-processing or additional hardware, or does it make use of technology already available to the average practitioner? The reproducibility and reliability of the techniques are evaluated, with reference to their utility in clinical decision-making. Finally, directions for future research are proposed. Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.

Acceptance, reliability and confidence of diagnosis of fetal and neonatal virtuopsy compared with conventional autopsy: a prospective study

Abstract: Objectives To compare prospectively maternal acceptance of fetal and neonatal virtuopsy with that of conventional autopsy and to determine the confidence with which magnetic resonance (MR) virtuopsy can be used to diagnose normality/abnormality of various fetal anatomical structures. Methods MR and/or computed tomography virtuopsy and conventional autopsy were offered to 96 women (102 fetuses/neonates) following termination of pregnancy (TOP), intrauterine fetal death (IUFD) or neonatal death. Multivariable logistic regression analysis was used to investigate the effect on maternal acceptance of virtuopsy and/or conventional autopsy of the age of the mother, gestational age at TOP or delivery after IUFD, order of pregnancy, parity, religion, type of caregiver obtaining consent and reason for death. When parents consented to both MR virtuopsy and conventional autopsy of fetuses ≥ 20 weeks of gestation or neonates, the confidence with which MR virtuopsy could be used to diagnose normality/abnormality of various anatomical structures was determined on a scale in which conventional autopsy was considered gold standard. On autopsy we classified fetuses/neonates as having either ‘normal’ or ‘abnormal’ anatomical structures; these groups were analyzed separately. At virtuopsy, we indicated confidence of diagnosis of normality/abnormality of every anatomical structure in each of these two groups defined at autopsy, using a scale from 0 (definitely abnormal) to 100 (definitely normal). Results Of the 96 women, 99% (n = 95) consented to virtuopsy and 61.5% (n = 59) to both conventional autopsy and virtuopsy; i.e. 36 (37.5%) consented to virtuopsy alone. Maternal acceptance of conventional autopsy was independently positively related to singleton pregnancy, non-Moslem mother, earlier gestation at TOP or delivery afer IUFD and a maternal–fetal medicine specialist obtaining consent. Thirty-three fetuses ≥ 20 weeks of gestation had both conventional autopsy and MR virtuopsy, of which 19 had a full autopsy including the brain. In fetuses with normal anatomical structures at conventional autopsy, MR virtuopsy was associated with high diagnostic confidence (scores > 80) for the brain, skeleton, thoracic organs except the heart, abdominal organs except the pancreas, ureters, bladder and genitals. In fetuses with abnormal anatomical structures at autopsy, MR virtuopsy detected the anomalies with high confidence (scores < 20) for these same anatomical structures. However, in three cases, virtuopsy diagnosed brain anomalies additional to those observed at conventional autopsy. Conclusion MR virtuopsy is accepted by nearly all mothers while conventional autopsy is accepted by about two-thirds of mothers, in whom refusal depends mainly on factors over which we have no control. Although conventional autopsy remains the gold standard, the high acceptance of virtuopsy makes it an acceptable alternative when the former is declined. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Comparison between transvaginal sonography, saline contrast sonovaginography and magnetic resonance imaging in the diagnosis of posterior deep infiltrating endometriosis

Abstract: Objective To compare clinical evaluation, transvaginal sonography (TVS), saline contrast sonovaginography (SCSV) and magnetic resonance imaging (MRI) in the diagnosis of posterior deep pelvic endometriosis (DPE). Methods Women suspected of having posterior DPE on the basis of subjective symptoms and clinical evaluation underwent digital vaginal and rectal examination, TVS, SCSV and MRI. Laparoscopy was performed and specimens were sent for histological examination. Sensitivity, specificity, positive and negative predictive value, as well as positive and negative likelihood ratios were analyzed for each diagnostic method. Results Fifty-four out of 102 women suspected of having posterior DPE underwent laparoscopic surgery. Among these, in 46 (85.2%) cases DPE was confirmed at laparoscopic and histological examination. SCSV correctly identified 43 (93.5%) cases, presenting higher accuracy than did the other procedures. SCSV and MRI were more accurate in diagnosing and discriminating between the different locations of endometriotic lesions, with respective sensitivities of 94.7 and 73.1% for vaginal fornix, 88.9 and 66.7% for the uterosacral ligaments and 80.6 and 83.3% for involvement of the rectovaginal septum. The specificity of SCSV and MRI, respectively, was 97.1 and 94.3% for vaginal fornix, 95.6 and 95.6% for uterosacral ligaments and 100 and 77.8% for involvement of the rectovaginal septum. In the diagnosis of rectal endometriosis, we found a sensitivity of 66.7% for both techniques and specificity of 93.8% for SCSV and 95.8% for MRI. Conclusion TVS should be used as the first-line diagnostic technique and SCSV and/or MRI as second-line methods in the diagnosis of posterior DPE. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Maternal hemodynamics at 11-13 weeks' gestation and risk of pre-eclampsia

Abstract: Objective Women who develop pre-eclampsia are at increased risk of cardiovascular disease and stroke in the subsequent decades. Individuals with cardiovascular disorders have increased central aortic systolic blood pressure (SBPAo) and arterial stiffness, as assessed by pulse wave velocity (PWV) and augmentation index (AIx). The aim of this study was to examine the potential value of assessment of SBPAo, PWV and AIx at 11–13 weeks' gestation in identifying women who subsequently develop pre-eclampsia. Methods This was a screening study for pre-eclampsia in singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Maternal history and characteristics were recorded and PWV, AIx (adjusted to a heart rate of 75 beats per min (AIx-75)) and SBPAo measured. We compared these parameters in women who developed pre-eclampsia (n = 181) with those in unaffected controls (n = 6766) and examined their performance in screening for pre-eclampsia. Results In the pre-eclampsia group, compared to unaffected controls, there was an increase in AIx-75 (1.13 vs. 1.00 multiples of the median (MoM); P < 0.0001), PWV (1.06 vs. 1.00 MoM; P < 0.0001) and SBPAo (1.09 vs. 1.00 MoM; P < 0.0001). In screening for pre-eclampsia by a combination of maternal variables and log10AIx-75 MoM, log10PWV MoM and log10SBPAo MoM, the estimated detection rate was 56.9% at a false-positive rate of 10%. Conclusion Compared with women who remain normotensive, women who develop pre-eclampsia have higher SBPAo and arterial stiffness, which is apparent from the first trimester of pregnancy. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Diagnosis of levator avulsion injury: a comparison of three methods.

Abstract: Objective Levator avulsion is common after vaginal delivery and is strongly associated with prolapse and prolapse recurrence. The aim of this study was to compare assessment by digital palpation and two ultrasound methods, one using rendered volumes and the other multislice imaging, for the diagnosis of levator avulsion. Methods We retrospectively analyzed randomly identified datasets of 266 women seen at a tertiary urogynecology unit. Each patient had undergone an interview, vaginal examination and 3D/4D translabial ultrasound examination. Analysis of the retrieved ultrasound volumes was performed offline, with the operator blinded to all clinical data, using two techniques: assessment of rendered volumes and evaluation on multislice imaging. We tested agreement between the three methods and the association of each method's results with symptoms and signs of pelvic organ prolapse. Results Agreement between the findings on palpation and the two ultrasound methods with regard to diagnosis of levator avulsion ranged from 80% to 87% (Cohen's kappa, 0.35−0.56). The findings for all methods were significantly associated with symptoms, signs and ultrasound findings of pelvic organ prolapse (P = 0.007 to < 0.001), with no single method appearing superior to the others. Conclusions Depending on the availability of local expertise and equipment, any of the three methods tested in this study may be used to document avulsion of the puborectalis muscle.

Maximal amniotic fluid index as a prognostic factor in pregnancies complicated by polyhydramnios

Abstract: Objectives Polyhydramnios is present in approximately 2% of pregnancies and has been associated with a variety of adverse pregnancy outcomes. Our aim was to evaluate the association between the maximal amniotic fluid index (AFI) and the frequency of specific adverse outcomes. Methods This was a retrospective chart review of 524 singleton pregnancies diagnosed with polyhydramnios and delivered in a single tertiary referral center between 2003 and 2008. Polyhydramnios was defined as either AFI ≥ 25 cm or a maximum vertical pocket (MVP) ≥ 8 cm even in the presence of AFI < 25 cm. The cohort was stratified into four groups based on the maximal AFI noted during the pregnancy: < 25 cm but with MVP ≥ 8 cm; 25–29.9 cm; 30–34.9 cm; and ≥ 35 cm. Data were collected to determine the frequency of the following adverse pregnancy outcomes: prenatally diagnosed congenital anomalies, fetal aneuploidy, preterm delivery, Cesarean delivery, low birth weight, 5-min Apgar score < 7 and perinatal mortality. Results Higher AFI was associated with a statistically significant increase in the frequency of adverse pregnancy outcomes. The most severe form of polyhydramnios, as based on the maximal AFI (≥ 35 cm; n = 67), was associated with the highest rates of prenatally diagnosed congenital anomalies (79%), preterm delivery (46%), small-for-gestational-age neonate (16%), aneuploidy (13%) and perinatal mortality (27%). No significant association between degree of polyhydramnios and adverse outcome was demonstrated in cases of idiopathic polyhydramnios (n = 253). Conclusions There is an association between the frequencies of a variety of adverse pregnancy outcomes and the severity of polyhydramnios as reflected by the maximal AFI. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Accuracy of transvaginal sonography and contrast-enhanced magnetic resonance-colonography for the presurgical staging of deep infiltrating endometriosis.

Abstract: Objective To investigate the accuracy of transvaginal sonography (TVS) and contrast-enhanced magnetic resonance-colonography (CE-MR-C) for the presurgical assessment of deep infiltrating endometriosis (DIE). Methods Ninety women were enrolled prospectively for suspicion of DIE. All patients underwent TVS and CE-MR-C, with each operator blinded to the results of the other exam, before laparoscopy. The sites of DIE examined by both imaging techniques were: rectovaginal septum, pouch of Douglas, uterosacral ligaments, vesicouterine pouch, bowel, bladder and vagina. The presence of adhesions and the involvement of adnexa and of a previous abdominal scar, when there was clinical suspicion, were also evaluated. TVS and CE-MR-C findings were compared with laparoscopic and histological results. Results Endometriosis was confirmed by laparoscopy in 95.6% (86/90) of cases. In 82.2% (74/90) of patients there was DIE. The global accuracy for TVS in the detection of DIE was 89.2%, sensitivity was 81.1%, specificity was 94.2%, positive predictive value was 89.6%, negative predictive value was 89.0%, the positive likelihood ratio was 13.9 and the negative likelihood ratio was 0.2. For CE-MR-C, these values were 87.2%, 71.1%, 97.1%, 93.7%, 84.6%, 24.4 and 0.3, respectively. CE-MR-C allowed diagnosis of all cases of bowel involvement; the accuracy for infiltration and stenosis was 100%. The accuracy of TVS for rectosigmoid nodules was 91.1% and that for infiltration was 88.9%. Conclusions Both TVS and CE-MR-C showed satisfactory results for the presurgical assessment of DIE. TVS appears to be a powerful, simple, feasible, cost-effective tool for preoperative staging of DIE. CE-MR-C is an ‘X-ray free’ technique, which could be reserved for cases with deep infiltrating rectosigmoid lesions and for the prediction of stenosis and involvement of the upper part of the colon and small intestine.

Polycystic ovaries at ultrasound: normal variant or silent polycystic ovary syndrome?

Abstract: Objective It is not known whether polycystic ovaries (PCO) are an ovarian appearance without pathological meaning or whether they share with polycystic ovary syndrome (PCOS) the same ovarian follicle abnormality. There are few studies including strictly selected women with PCO but without other criteria of PCOS. In order to address these issues, we compared hormonal, metabolic and ultrasound parameters obtained from patients with PCO only, patients with PCOS and controls. Methods This was a comparative analysis including three age-matched groups of 95 patients, who were included consecutively in a database: controls, patients with sonographic PCO but no symptoms (PCO group) and patients with PCOS. A clinical examination, fasting serum sampling and pelvic ultrasound examination were performed between cycle days 2 and 5 and results were compared between groups. Results The median serum anti-Mullerian hormone (AMH) level in the PCO group was intermediate between that in controls and that in the PCOS group (33.6 pmol/L, 19.8 pmol/L and 63.3 pmol/L, respectively), the differences being significant after adjustment for follicle number (P < 0.05), while the mean androgen serum level in the PCO group was similar to that in the control group and significantly lower than that in the PCOS group (P < 0.05) (median serum testosterone levels: 0.90 nmol/L, 0.79 nmol/L and 1.39 nmol/L; median androstenedione levels: 5.25 nmol/L, 4.37 nmol/L and 6.09 nmol/L, respectively). Body mass index, waist circumference and insulin levels had no effect on these differences. Conclusion PCO is an abnormal condition, affected women showing no evidence of hyperandrogenism but having higher AMH serum levels compared with controls, suggesting a granulosa cell abnormality in PCO similar to that observed in PCOS. The absence of hyperandrogenism in PCO does not seem linked to the metabolic status. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Endometriosis of the abdominal wall: ultrasonographic and Doppler characteristics.

Abstract: Objectives To describe the sonographic and clinical features of abdominal wall endometriosis (AWE), a frequently misdiagnosed condition. Methods This was a retrospective study of 21 consecutive women with pathologically proven endometriosis of the abdominal wall. Ultrasonographic and Doppler examinations were performed, before surgery, with a high-frequency linear transducer. The clinical data and the results of the sonographic examinations were reviewed and described. Results At ultrasound, all the nodules appeared as discrete solid masses that were less echogenic than the surrounding hyperechoic fat. The nodules had a median diameter of 20 (range, 5–50) mm and in 18/21 (86%) cases the nodules had a round/oval shape. In eight of 21 (38%) women the AWE was located at the umbilicus, in six of 21 (29%) it was between the transverse suprapubic line and the umbilicus, in five of 21 (24%) it was found along the scar of a previous Cesarean section and in two of 21 (9%) it was in the right inguinal canal. The content was homogeneously hypoechoic in 12/21 (57%) women and inhomogeneous in the other nine (43%). The outer borders were invariably ill defined. Scarce blood vessels were found by power Doppler. Cyclic or continuous spontaneous pain at the level of the AWE was present in 19/21 (91%) cases, and two (9%) patients were asymptomatic. Conclusions Hypoechoic round/oval nodules with ill-defined borders and a hyperechoic rim should raise the suspicion of abdominal wall endometriosis, even in patients with no history of endometriosis or previous laparotomic surgery. Pressing the ultrasound probe against the nodule should reinforce a suspected diagnosis because of the pain it induces. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Total anomalous pulmonary venous connection: impact of prenatal diagnosis

Abstract: Objectives To investigate whether prenatal screening is effective in the detection of total anomalous pulmonary venous connection (TAPVC) and to identify common prenatal features. Methods This was a retrospective collaborative study involving 19 pediatric cardiac centers in the UK, Ireland and Sweden. Cases with TAPVC born between January 1, 1998 and December 31, 2004, and prenatally diagnosed cases whose estimated dates of delivery were within this time frame, were identified. Cases with functionally univentricular circulation or atrial isomerism were excluded. All available data and stored images were reviewed. Results Four-hundred and twenty-four cases with TAPVC were identified prenatally or postnatally, of whom eight (1.9%) had a prenatal diagnosis of TAPVC. Median gestational age at fetal diagnosis was 26 + 6 (range, 22 + 4t o 32+ 0) weeks. Six further fetuses with TAPVC had an abnormality diagnosed on prenatal ultrasound, but not the TAPVC. This included other congenital heart defects (four cases) and isolated pleural effusion (two cases). Seventeen (4.0%) of the 422 liveborn infants had a first-degree relative with congenital heart disease; and six of 17 had a sibling with TAPVC. Two died in utero .O f the liveborn infants diagnosed prenatally with TAPVC, none required urgent intervention for pulmonary venous obstruction and all were alive and well at a median of 2.3 (range, 1.0–7.0) years after surgical repair. Conclusion Prenatal diagnosis of TAPVC is infrequent using current screening methods. Where there is a family history of TAPVC, specialized fetal echocardiography at 20 and 28 weeks’ gestation may be indicated. Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.

Lung-to-head ratio: A need to unify the technique

Abstract: †Fetal Medicine Unit of the University Hospital Brugmann, Brussels, Belgium; ‡Department of Obstetrics and Gynecology, Center for Integral Assistance to Women’s Health, State University of Campinas Medical School, Campinas, Brazil; §Harris Birthright Research Centre of Fetal Medicine, King’s College Hospital, London, UK; ¶Department of Fetal Medicine, University College London NHS Foundation Trust, London, UK *Correspondence: Dr J. Jani, CHU Brugmann, Department of Obstetrics and Gynecology, Place A. Van Gehuchten n◦4, 1020 Bruxelles, Belgium (e-mail: jackjani@hotmail.com)

Capacity of endometrial thickness measurement to diagnose endometrial carcinoma in asymptomatic postmenopausal women: a systematic review and meta-analysis.

Abstract: Objectives Measurement of endometrial thickness is an important tool in the assessment of women with postmenopausal bleeding, but the role of endometrial thickness measurement by ultrasound in asymptomatic women is unclear. The aims of this study were to determine: (1) the normal endometrial thickness measured by ultrasonography, (2) the prevalence of serious endometrial pathology and (3) the sensitivity and specificity of endometrial thickness measurement by transvaginal ultrasonography (TVS) for diagnosing premalignant and malignant endometrial disease in asymptomatic postmenopausal women. Methods A MEDLINE and EMBASE search (from inception to January 2011) was performed. Articles reporting on endometrial thickness measurement in the diagnosis of endometrial carcinoma and atypical hyperplasia in asymptomatic postmenopausal women not using hormone replacement therapy (HRT) were selected. Endometrial thickness and the prevalence of endometrial (pre)malignancies were recorded. If possible, 2 x 2 tables were extracted. Results Thirty-two studies reporting on 11?100 women were included. The estimated mean endometrial thickness was 2.9 mm (95% CI, 2.63.3 mm). The pooled estimated prevalences of endometrial carcinoma and atypical endometrial hyperplasia were 0.62% (95% CI, 0.420.82%) and 0.59% (95% CI, 0.220.96%), respectively. Summary estimates for sensitivity and specificity of TVS endometrial thickness measurement in the prediction of endometrial carcinoma were 0.83 (95% CI, 0.191.00) and 0.72 (95% CI, 0.230.95) for a 5-mm cut-off and 0.33 (95% CI, 0.040.85) and 0.94 (95% CI, 0.920.96) for a 6-mm cut-off. Conclusions The results from this systematic review do not justify the use of endometrial thickness as a screening test for endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women not using HRT. Copyright (C) 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS).

Abstract: Objective. To estimate the risk of primary epithelial ovarian cancer (EOC) and slow growing borderline or Type I and aggressive Type II EOC in postmenopausal women with adnexal abnormalities on ultrasound. Methods. This was a prospective cohort study in the ultrasound group of the UK Collaborative Trial of Ovarian Cancer Screening of postmenopausal women with ultrasound-detected abnormal adnexal (unilocular, multilocular, unilocular solid and multilocular solid, solid) morphology on their first scan. Women were followed up through the national cancer registries and by postal questionnaires. Absolute risks of EOC and borderline, Type I and Type II EOC within 3 years of initial scan were calculated. Results. Of 48 053 women who underwent ultrasound examination and had complete scan data, 4367 (9.1% (95% CI, 8.8–9.3%)) had abnormal adnexal morphology. Median follow-up was 7.09 (25th–75th centiles, 6.03–7.92) years. Forty-seven (32 borderline or Type I, 15 Type II) were diagnosed with EOC. The overall absolute risk of EOC associated with abnormal adnexal morphology was 1.08% (95% CI, 0.79–1.43%); for borderline and Type I it was 0.73% (95% CI, 0.5–1.03%); and for Type II it was 0.34% (95% CI, 0.33–0.79%). In the subgroup (n = 741) with solid elements (unilocular solid, multilocular solid and solid) overall absolute risk was 4.45% (95% CI, 3.08–6.20%), for borderline and Type I it was 3.1% (95% CI, 1.9–4.6%) and for Type II it was 1.3% (95% CI, 0.6–2.4%). 11 982 women had both ovaries visualized and normal annual scans throughout the 3-year follow-up period. In this group, no borderline or Type I and eight Type II cancers were diagnosed. Conclusion. Asymptomatic postmenopausal women with ultrasound-detected adnexal abnormalities with solid elements have a 1 in 22 risk for EOC. Despite the higher prevalence of Type II EOC, the risk of borderline or Type I cancer in women with ultrasound abnormalities seems to be higher than does the risk of Type II cancer. This has important immediate implications for patients with incidental adnexal findings as well as for any future ultrasound-based screening.

Performance of third-trimester ultrasound for prediction of small-for-gestational-age neonates and evaluation of contingency screening policies

Abstract: Objectives To assess the performance of third-trimester fetal biometry and fetal Doppler studies for the prediction of small-for-gestational-age (SGA) neonates, and to explore contingency strategies using a first-trimester prediction model based on maternal and fetal parameters and third-trimester ultrasound. Methods This was an observational cross-sectional study of uncomplicated singleton pregnancies. Risk assessment for chromosomal abnormality was carried out in 4702 pregnancies using a combination of ultrasound markers (fetal nuchal translucency thickness (NT) and nasal bone assessment) and biochemistry (free beta-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A)) at 11 to 13 + 6 weeks. Maternal demographic characteristics and method of conception were recorded. Third-trimester (30–34 weeks) fetal biometry (biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL)) and umbilical artery (UA) and middle cerebral artery Doppler studies were performed routinely in a subgroup (n = 2310). Reference ranges for birth weight were constructed using the cohort of 4702 women, and neonates were classified as small (SGA, ≤ 5th centile) or appropriate (AGA) for gestational age. First-trimester, third-trimester and integrated first- and third-trimester prediction models for SGA were constructed using regression analysis and three different contingency strategies of rescanning in the third trimester were investigated. Results According to the areas under the receiver–operating characteristics curves (AUCs), AC (AUC = 0.85) and ultrasound-estimated fetal weight (EFW, AUC = 0.87) were equally good predictors of SGA. The model was marginally improved by the addition of UA Doppler, smoking status and first-trimester indices (free β-hCG and PAPP-A multiples of the median) (combined model, AUC = 0.88), but the difference was not statistically significant. A contingency strategy of rescanning 50% of the population in the third trimester according to the risk estimated by a first-trimester prediction model yielded a detection rate of 79% for a 25% screen-positive rate. Conclusion Third-trimester ultrasound is effective in screening for SGA in uncomplicated pregnancies. The use of a contingency screening policy can reduce the need for unnecessary examinations. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Clinically oriented three‐step strategy for assessment of adnexal pathology

Abstract: Objective To determine the diagnostic performance of ultrasound-based simple rules, risk of malignancy index (RMI), two logistic regression models (LR1 and LR2) and real-time subjective assessment by experienced ultrasound examiners following the exclusion of masses likely to be judged as easy and 'instant' to diagnose by an ultrasound examiner, and to develop a new strategy for the assessment of adnexal pathology based on this. Methods 3511 patients with at least one persistent adnexal mass preoperatively underwent transvaginal ultrasonography to assess tumor morphology and vascularity. They were included in two consecutive prospective studies by the International Ovarian Tumor Analysis (IOTA) group: Phase 1 (1999-2005), development of the simple rules and logistic regression models LR1 and LR2, and Phase 2, a validation study (2005-2007). Results Almost half of the cases (43%) were identified as 'instant' to diagnose on the basis of descriptors applied to the database. To assess diagnostic performance in the more difficult 'non-instant' masses, we used only Phase 2 data (n = 1036). The sensitivity of LR2 was 88%, of RMI it was 41% and of subjective assessment it was 87%. The specificity of LR2 was 67%, of RMI it was 90% and of subjective assessment it was 86%. The simple rules yielded a conclusive result in almost 2/3 of the masses, where they resulted in sensitivity and specificity similar to those of real-time subjective assessment by experienced ultrasound examiners: sensitivity 89 vs 89% (P = 0.76), specificity 91 vs 91% (P = 0.65). When a three-step strategy was appliedwith easy 'instant' diagnoses as Step 1, simple rules where conclusive as Step 2 and subjective assessment by an experienced ultrasound examiner in the remaining masses as Step 3, we obtained a sensitivity of 92% and specificity of 92% compared with sensitivity 90% (P = 0.03) and specificity 93% (P = 0.44) when using real-time subjective assessment by experts in all tumors. Conclusion A diagnostic strategy using simple descriptors and ultrasound rules when applied to the variables contained in the IOTA database obtains results that are at least as good as those obtained by subjective assessment of a mass by an expert. Copyright. (C) 2012 ISUOG. Published by John Wiley & Sons, Ltd.