Brita K. Boyd

Sonohysterography: Do 3D Reconstructed Images Provide Additional Value?

OBJECTIVE The purpose of this study was to retrospectively determine the value of adding 3D multiplanar sonography to 2D sonohysterography. MATERIALS AND METHODS Between September 2003 and April 2005, 80 women (mean age, 43.5 years; range, 26-78 years) underwent sonohysterography with both conventional 2D sonohysterography and 3D multiplanar imaging (volume of data acquired and reconstructed in the transverse, sagittal, and coronal planes). Three blinded readers interpreted the 2D scans alone and then the 2D and 3D images together. Visualization of endometrial abnormality (polyps, fibroids, or septations) and definition of fundal contour were scored by each reader on a three-point scale (1, visualized; 2, unsure; 3, not visualized). Wilcoxons signed rank test was used to assess mean differences between findings. Reader agreement was determined with the kappa statistic. Pathologic correlation was performed when the findings were available. RESULTS Average (mean +/- SD) reader scores for identification of endometrial abnormality were not significantly different: 1.70 +/- 0.91 for 2D alone versus 1.69 +/- 0.92 for 2D and 3D combined (p = 0.38). There also was no significant difference when polyps (2.14 +/- 0.90 vs 2.12 +/- 0.93), fibroids (2.57 +/- 0.79 vs 2.53 +/- 0.82), and septations (2.88 +/- 0.39 vs 2.87 +/- 0.42) were evaluated separately. Average scores for definition of fundal contour were significantly (p < 0.0001) different (2.93 +/- 0.34 for 2D alone versus 1.45 +/- 0.80 for 2D and 3D combined). Agreement between readers was found with average kappa values of 0.72 for 2D alone and 0.78 for 2D and 3D. For the 42 subjects for whom pathologic findings were available, readers identified 92% of the abnormalities. CONCLUSION Three-dimensional reformations improve visualization of the uterine fundus and aid in identification or exclusion of a fundal contour abnormality but do not add value in the detection of endometrial abnormalities.

MR imaging findings in fetal goiter caused by maternal Graves disease

Antenatal diagnosis of fetal goiter should be appropriately managed to avoid perinatal complications. Here, we present the MR imaging features of a fetal goiter caused by maternal Graves disease. Diffusely enlarged fetal thyroid gland was seen showing homogeneously elevated signal on T1-weighted images and intermediate signal on T2-weighted images. To our knowledge, this is the first MR imaging documentation of fetal goiter.

Prenatal diagnosis of tetrasomy 9p

Dhandha et al. [2002] report three cases of tetrasomy 9p andprovide a useful and interesting case review from the literature. Tetrasomy 9p is a rare clinical syndrome with only 32 cases reported to date, with reports of both mosaic and non-mosaic cases. The phenotypic differences of tetrasomy 9p seem to be the result of the degree of mosaicism. We recently identified a patient with tetrasomy 9p diagnosed prenatally and report our findings here. The mother was a 22-year-old gravida 1 para 0 white woman.During the pregnancy,multiple fetal anomalies were identified by repeated ultrasounds, as early as 22 weeks of gestation. These fetal anomalies included a strawberry shaped skull, mildly enlarged fetal ventricles, bilateral cleft lip and palate, a small-sized stomach, a possible horseshoe kidney, and rockerbottom deformityof the footand/or clubfeet.Alsonotedwaspersistent abnormal posturing of the fetal fists with overlapping of the fetal digits. Amniocentesis was performed at 24weeks of gestation,which showed47,XX,þi(9)(p10) in 20 cells. The isochromosome was confirmed as chromosome 9 by FISH. The patient was born by induced labor at 3557-week gestation due to premature rupture of membranes. The infant was a female weighing 1,730 g, 41 cm long, with occipital frontal circumference (OFC) of 28.5 cmat birth. Apgar scores were 1 and 6 at 1 and 5 min, respectively. Physical examination at birth revealed strawberryshaped head, downslanting palpebral fissures, large anterior fontanel, hypertelorism, bilateral small low-set ears, micrognathia, beaked nose, bilateral cleft lip and cleft palate, brachydactyly with hypoplastic thumb, and bilateral foot deformities with eversion. The patient was also found to have patent foramen ovale, bicuspid aortic valve, and patent ductus arteriosus. At 33 days of age, the patient died of aspiration pneumonitis with respiratory distress. Ultrasound and MRI of the head were performed postnatally, and diagnoses of hydrocephalus, ventriculomegaly with left ventricle being larger in size than the right one, agenesis of the corpus callosum, and Dandy– Walker variantweremade. The above physical findings, along with ventriculomegaly, Dandy–Walker variant, and horseshoe kidney detected by ultrasound, are consistent with the emerging phenotype for tetrasomy 9p, summarized by Dhandha et al. [2002]. Karyotyping from amniocentesis confirmed our case as tetrasomy 9p. Chromosomal analysis was also performed on peripheral blood lymphocytes and cord fibroblasts of the infant at birth.All but one of the 20 cells from lymphocytes, and all but three of the 20 cells from fibroblasts, showed identicalkaryotypeasheramniocytes, 47,XX,þi(9)(p10). The one cell from lymphocytes and three cells from fibroblasts analyzed showed anormal female karyotype, suggesting low level of mosaicism. In our patient, we were able to analyze three different tissues, and found low level of mosaicism in two of the three cell types. No early deaths are reported for mosaic cases of tetrasomy 9p. The level of mosaicism seen in our case at birth was very low. Considering that all of her amniocytes analyzed had an abnormal karyotype, this could represent a non-mosaic case of tetrasomy 9p in the fetus, and thus account for the early death in our patient.

Trisomy 8 mosaicism: Selective growth advantage of normal cells vs. growth disadvantage of trisomy 8 cells

A fetus with trisomy 8 mosaicism was identified prenatally due to an abnormal maternal serum triple screen. Tissue samples were taken at birth to determine the level of trisomy 8 mosaicism found within embryonic and extra‐embryonic tissues, rates of cell division for the two cell lines, and the effect of mosaicism on the phenotype. The level of trisomy 8 cells in blood and fibroblasts was higher than in placental tissue. Cell cycle kinetics, by incorporation of bromodeoxyuridine for 48 hr, was not significantly different between the trisomy 8 and normal cells for blood or amnion. Fluorescent in situ hybridization (FISH) using centromeric probe for chromosome 8 showed significantly more trisomy 8 in interphase vs. metaphase in lymphoblasts, umbilical cord fibroblasts, and chorion. The loss of trisomy 8 cells is not due to anaphase lag, as determined by micronuclei analysis. The similarity of cell cycle kinetics between trisomy 8 cells and normal diploid cells suggests some trisomy 8 cells are exiting the cell cycle prematurely. This growth disadvantage of trisomy 8 cells results in the appearance of growth advantage for diploid cells.

Ultrasound Examination of the Fetal Heart.

Congenital heart disease (CHD) occurs in 4-13 per 1000 births in the United States. While many risk factors for CHD have been identified, more than 90% of cases occur in low-risk patients. Guidelines for fetal cardiac screening during the second trimester anatomy ultrasound have been developed by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) in order to improve antenatal detection rates and to standardize the fetal cardiac screening examination. Patients found to be at increased risk of CHD because of risk factors or an abnormal screening examination should be referred for second trimester fetal echocardiography. Recently, 3D and 4D ultrasound techniques are being utilized to enhance detection rates and to better characterize cardiac lesions, and several first trimester ultrasound screening markers have been proposed to identify patients at increased risk of CHD. However, detection rates have not improved significantly due to limitations such as cost, access, and training that are associated with new technologies and screening methods. The most cost effective way to improve detection rates of CHD may be to standardize screening protocols across practices according to established guidelines and to have a low threshold for referral for fetal echocardiography.

Dichorionic, diamnionic twin pregnancy discordant for anencephaly: Report of two cases and literature review

Anencephaly is a lethal diagnosis. In the unique situation of a twin pregnancy discordant for anencephaly, early ultrasound diagnosis based on the discrepancy in the appearance of the heads can facilitate management and potentially decrease morbidity and mortality for the unaffected twin. We report two such cases of dichorionic, diamniotic twin pregnancies and provide a review of the literature.

Clinical Utility of Fetal Short-Lag Spatial Coherence Imaging

In this study, we evaluate the clinical utility of fetal short-lag spatial coherence (SLSC) imaging. Previous work has documented significant improvements in image quality with fetal SLSC imaging as quantified by measurements of contrast and contrast-to-noise ratio (CNR). The objective of this study was to examine whether this improved technical efficacy is indicative of the clinical utility of SLSC imaging. Eighteen healthy volunteers in their first and second trimesters of pregnancy were scanned using a modified Siemens SC2000 clinical scanner. Raw channel data were acquired for routinely examined fetal organs and used to generate fully matched raw and post-processed harmonic B-mode and SLSC image sequences, which were subsequently optimized for dynamic range and other imaging parameters by a blinded sonographer. Optimized videos were reviewed in matched B-mode and SLSC pairs by three blinded clinicians who scored each video based on overall quality, target conspicuity and border definition. SLSC imaging was highly favored over conventional imaging with SLSC scoring equal to (28.2 ± 10.5%) or higher than (63.9 ± 12.9%) B-mode for video pairs across all examined structures and processing conditions. Multivariate modeling revealed that SLSC imaging is a significant predictor of improved image quality with p ≤ 0.002. Expert-user scores for image quality support the application of SLSC in fetal ultrasound imaging.

Can we improve the gestation-adjusted projection (GAP) method for prediction of birth weight in morbidly obese women?

Abstract Objective: The gestation-adjusted projection (GAP) is a method to predict birthweight using population birth data and third trimester ultrasound fetal weight. This method usually utilizes population birth weight data from almost 40 years ago. In 2011, a large cohort of racially diverse infants across the US was included to validate updated birth curves. Our objective was to determine if the updated data would improve the accuracy of the GAP method during the third trimester among obese women. Methods: This secondary analysis of a cohort study included singleton pregnancies of obese women who had fetal growth assessment(s) in the third trimester. The first subgroup (N = 235) included women with a BMI >40 kg/m2 who had ultrasounds during 30 + 0–35 + 0 weeks (EARLY) and greater than 35 + 0 weeks (LATE). The second subgroup (N = 431) included women with a BMI 30–35, 40–50, or >50 kg/m2 who had an ultrasound during 34 + 0–36 + 6 weeks. Mean absolute percent error was calculated for all GAP methods and compared using paired t-tests. Sensitivity, specificity, and area under the curve for diagnosis of birth weight >4000 grams were also estimated for each GAP method. Results: The mean absolute percent error for the first subgroup (N = 235) using historical population birth weights was 7.4–7.9%. After using updated population birth weight curves using all neonates, the mean absolute percent error for the first subgroup ranged between 7.6 and 9.4%. GAP predictions using all neonates, as well as male and female-specific birth data compared to the historical population data during both the EARLY and LATE periods were significantly worse (p < .01). The mean absolute percent error for the second subgroup (N = 431) using historical population birth weights ranged from 7.2 to 7.9%. The absolute percent error using gender-specific compared to historical data was significant in the BMI 30–35 group (male 8.1% versus historical 7.6%, p < .01, female 8.1% versus historical 7.6%, p < .01). The differences in absolute percent error between historical and updated population data became less evident in the BMI 40–50 and >50-kg/m2 groups (p = .05 and p = .15, respectively) though still overall performed worse with the updated data. Conclusions: Prediction of birth weight using the GAP method does not seem to be improved among obese women after using updated population data. Alternatively, modeling techniques may need to be applied to improve the accuracy of the GAP method.

P39.08: Cervicovaginal fistula presenting during spontaneous abortion

myxo-fibroblastic proliferation. There was focal chorangiosis with intervening normal placental mesenchyme. The fetal chorionic plate vessels were massively dilated, tortuous and congested. There was a 3-vessel umbilical cord with furcated marginal cord insertion. Immunohistochemical studies of the abnormal myxoid villi showed minimal staining for smooth muscle actin and positive p57KIP2 protein staining. This is only the third case of PMD with normal fetus where the p57KIP2 protein staining was used in the diagnosis. The p57KIP2 gene is paternally imprinted and maternally expressed. The presence of this protein indicates a functional maternal allele. This case supports the utility of p57KIP2 protein staining in distinguishing this disorder from molar pregnancy. In our case elevated free beta-hCG level was detected in the first trimester before placental abnormalities were visualized on ultrasound.

P39.18: Diagnosis and management of uterine cervical varix in pregnancy

Uterine rupture during trial of vaginal birth after caesarean (VBAC) remains a rare but dramatic obstetrical emergency. Although several studies have shown that sonographic evaluation of the lower uterine segment (LUS) near term can predict uterine rupture, the best measuring technique and the cut-off values to be used remain controversial. While a large prospective study demonstrated that an abdominal measurement of the full LUS thickness over 3.5 mm had a strong negative predictive value, other authors suggested to measure the muscular layer only with a cut-off value of 1.5 to 2.0 mm. We report a case of uterine rupture in a healthy 31-year-old patient, which had a prior low transverse caesarean seven years earlier with a single layer closure of hysterotomy. At 36 weeks of gestation, the transvaginal sonographic measurement of the LUS was respectively 3.6 mm for the full thickness and 1.1 mm for the muscular layer only. At 39 weeks’, induction of labor for premature rupture of membranes was initiated with oxytocin. A fetal bradycardia occurred approximately 12 hours after the initiation of induction. The patient underwent an emergency caesarean for clinical evidence of uterine rupture. Operative findings revealed a large uterine lateral tear from the cervix to the uterine cornu with the infant lying in the upper abdomen. In this case, there was a discrepancy between the normal full LUS thickness and the thin muscular layer. As the myometrium measurement could be more representative of the LUS resistance, we should perhaps give more credit to result of the later before proposing a trial of VBAC. Evidently, other risk factors must be taken into account, such as the type of closure of the uterine segment at prior caesarean and the intrapartum assessment. This case emphasizes the need for a consensus on the measuring techniques and cut-off values of the LUS thickness and to investigate its role in estimating the risk of uterine rupture among other predicting factors.