Chiaki Tenkumo

Three-dimensional HDlive-rendered images of intrauterine abnormalities during pregnancy

‘HDlive’ is a new surface render mode, and ‘‘its system uses an adjustable light source, giving the operator the opportunity to create lighting and shadowing effects and thereby increasing depth perception’’ [1]. HDlive with the use of new skin-like colors provides examiners with a natural and anatomically realistic appearance of the embryo and fetus. We present our experience of intrauterine abnormalities during pregnancy reconstructed employing the three-dimensional (3D) HDlive render mode. A total of three intrauterine abnormalities (one case each of umbilical cord prolapse through the uterine synechia, placental shelf, and umbilical cord cyst) at 18–26 weeks’ gestation were studied using transabdominal 3D sonography with the HDlive render mode (VOLUSON E8, General Electric Medical Systems, Zipf, Austria). Using a curved array transabdominal transducer (4–8.5 MHz), the sweep took only a few seconds at an angle of 70 –85 . The data set was stored on a 700-Mbyte CD-R, and could be retrieved for further analysis. All volume data for each subject were examined, and optimal images were selected for further analysis. 3D reconstruction was carried out using the HDlive rendering algorithm. The light source was adjusted until the structures of interest were visualized for the operator to create favorable lighting and shadowing effects. All HDlive sonographic examinations were performed by two examiners (T.H. and M.I.). All three cases reported here have been reported previously by our group, using different rendering techniques for 3D examination of the intrauterine abnormality [2–4]. 3D HDlive provided new realistic sensations for the diagnosis of umbilical cord prolapse through

Three‐dimensional volume‐rendered imaging of normal and abnormal fetal fluid‐filled structures using inversion mode

A total of six normal and eight abnormal fetuses at 16–38 weeks of gestation were studied using transabdominal three‐dimensional sonography with an inversion mode. In normal fetuses, the stomach, gallbladder and bladder could be depicted. In particular, peristalsis of the stomach was noted. In the case of holoprosencephaly, fused hemispheres were evident. In the case of hydrocephalus, the enlargement of ventricular cavities was noted. In the case of bilateral pleural effusion, the spatial relationship and size of the effusions were depicted. In the case of meconium peritonitis, the spatial relationship between the dilated intestines and ascites was depicted. In two cases of hydronephrosis, the dilated renal pelvis and calyces were clearly shown. In the case of multicystic dysplastic kidney, the number and size of cysts were clearly identified. In the case of left ovarian cyst, the anatomical relationships among the ovarian cyst, kidney, stomach and bladder could be easily understood.

Three-dimensional HDlive rendering image of cystic hygroma

Three-dimensional (3D) HDlive rendering images with both adjustable lighting and new skin-like colors give the normal embryo and fetus, fetal anomalies, and intrauterine abnormalities a natural and anatomically realistic appearance [1–4]. Cystic hygroma is characterized by septated fluid-filled sacculations of the bilateral neck and nuchal region that result from lymphatic dysplasia [5]. We present our experience of cystic hygroma reconstructed employing the three-dimensional (3D) HDlive rendering mode. A total of three cystic hygromas at 11-17 weeks’ gestation were studied employing transvaginal or transabdominal 3D sonography with the HDlive rendering mode (VOLUSON E8, General Electric Medical Systems, Zipf, Austria). Using a curved array transabdominal transducer (4–8.5 MHz) or mechanical transvaginal transducer (4.5–11.9 MHz), the sweep took less than a few seconds at an angle of 70 –85 . The data set was stored on a 700-MB CD-R and could be retrieved for further analysis [3, 4]. All volume data for each fetus were examined, and optimal images were selected for further analysis. Three-dimensional reconstruction was carried out using the HDlive rendering algorithm. The light source was adjusted until the structures of interest were visualized for the examiner to create favorable lighting and shadowing effects [4]. The 3D HDlive rendering mode provided new realistic sensations for the diagnosis of cystic hygroma (Figs. 1, 23). There have been three reports on conventional 3D sonographic diagnosis of cystic hygroma [5–7]. However, conventional 3D surface rendering images are not realistic. In the present report, the 3D HDlive rendering mode provided extraordinarily natural and realistic imaging of cystic hygroma, with greater detail and clarity than are possible with conventional 3D sonography. In particular, the 3D HDlive rendering mode provides new realistic sensations for the diagnosis of cystic hygroma in utero, and it seems to be almost impossible to differentiate between gross specimens and 3D HDlive rendering images, because nearphotographic images were obtained by employing the 3D HDlive rendering mode.

Three-dimensional HDlive rendering images of the TRAP sequence in the first trimester: reverse end-diastolic umbilical artery velocity in a pump twin with an adverse pregnancy outcome.

The twin reversed arterial perfusion (TRAP) sequence, also known as fetus acardius, occurs in 0.3 % of monozygotic twin gestations, which amounts to a frequency of about 1 per 35,000 deliveries [1, 2]. There have been only two reports on antenatal three-dimensional (3D) sonographic diagnosis of the TRAP sequence during pregnancy [3, 4]. The HDlive is a new surface render mode involving the use of skin-like colors, and ‘‘its system uses an adjustable light source, giving the operator the opportunity to create lighting and shadowing effects and thereby increasing depth perception’’ [5]. There have been four reports on fetal, placental, and umbilical cord ultrasound images using the 3D HDlive rendering mode [5–8]. Employing 3D HDlive with new skin-like colors, we can achieve a natural and anatomically realistic appearance of the embryo and fetus in utero. However, there has been no reports on 3D HDlive rendering displays of the TRAP sequence in the first trimester of pregnancy. There have been five reports on reverse end-diastolic velocity in umbilical artery velocimetry with an adverse pregnancy outcome at less than 14 weeks of gestation, which suggested that reverse end-diastolic umbilical artery velocity waveforms might be an ominous sign in early pregnancy [9–13]. However, there are no sonographic findings in the first trimester that can help to distinguish between pregnancies resulting in death of the pump twin from those that will survive until prophylactic intervention at 16–18 weeks in TRAP sequence cases [14]. In this report, we present our experience of a TRAP sequence reconstructed employing the 3D HDlive rendering mode, and discuss the reverse end-diastolic blood flow velocity waveform in the umbilical artery of a pump twin with an adverse pregnancy outcome in the first trimester. A 33-year-old pregnant Japanese woman, gravida 1, para 0, was referred to our ultrasound clinic because of a suspected TRAP sequence at 11 weeks and 6 days of gestation. The 2D sonography and the 3D surface rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA) showed a normal pump twin and small acardiac twin with acrania and absence of the heart and upper limbs (Fig. 1). The crown-rump length of the pump twin was 43.3 mm (consistent with the corresponding age), and no gross fetal anomaly was noted. The longitudinal distance between the upper pole and rump of the acardiac fetus was 27.6 mm. The 3D HDlive rendering mode provided anatomically realistic images for TRAP sequence diagnosis (Fig. 2). Color and pulsed Doppler sonography revealed a reverse end-diastolic umbilical artery velocity in the pump twin at 13 weeks and 1 day of gestation (Fig. 3a). There was a single-artery umbilical cord between the placenta and acardiac fetus, and a reversed tiny absent diastolic umbilical artery velocity was noted (Fig. 3b). Fetal demise of the pump twin was confirmed at 14 weeks’ gestation. Delivery C. Tenkumo H. Tanaka M. Ito E. Uketa N. Mori U. Hanaoka K. Kanenishi T. Hata (&) Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp

Diagnosis of truncus arteriosus in first trimester of pregnancy using transvaginal four‐dimensional color Doppler ultrasound

We present our experience of using transvaginal three/four-dimensional (3D/4D) color Doppler with glass-body rendering mode and spatiotemporal image correlation (STIC) software to construct an image of persistent truncus arteriosus in the first trimester of pregnancy. There have been numerous reports on the antenatal diagnosis of truncus arteriosus using two-dimensional (2D) grayscale echocardiography, color Doppler and multiplanar display in 3D/4D ultrasound1–3; however, to the best of our knowledge, this is the first report on the antenatal diagnosis of truncus arteriosus using transvaginal

Four-Dimensional Power Doppler Sonography With the HDlive Silhouette Mode in Antenatal Diagnosis of a Right Aortic Arch With an Aberrant Left Subclavian Artery

Aortic arch anomalies develop as a result of abnormal regression of one of the pharyngeal arches, resulting in abnormalities in the aortic arch position or branching pattern.1 They may present alone or associated with other congenital heart defects. The most common type is the right aortic arch (RAA), with an estimated incidence of approximately 0.1%.2 An association of a right aortic arch with 22q11 microdeletion has been reported.1,3 There have been numerous reports on the antenatal diagnosis of a right aortic arch with an aberrant left subclavian artery using 2dimensional (2D) echocardiography, 2D color Doppler sonography, and 3-dimensional (3D) power Doppler sonography.1,2,4–6 However, to the best of our knowledge, the use of 4-dimensional (4D) power Doppler sonography with the HDlive silhouette mode (GE Healthcare Japan, Tokyo, Japan) for the antenatal diagnosis of a right aortic arch with an aberrant left subclavian artery has not been reported previously. A 37-year-old primigravida was referred to our ultrasound clinic at 29 weeks’ gestation because of a suspected right-sided descending arch. Two-dimensional sonography (Voluson E8; GE Healthcare Japan) showed a single living fetus with biometric measurements consistent with gestational age. Two-dimensional fetal echocardiography showed an abnormal 3-vessel and trachea view, and the aortic arch was present on the right side of the trachea, with the ductus arteriosus on the left side of the trachea, connected by a vascular segment behind the trachea (diverticulum of Kommerell). An aberrant left subclavian artery originating from the diverticulum of Kommerell was suspected. There was no other fetal abnormality. At 34 weeks, 2D power Doppler sonography with a 3vessel and trachea view (Voluson E10) showed the pulmonary artery, right aortic arch, superior vena cava, and a vascular ring around the trachea. Also, the azygos vein and right pulmonary vessels were visualized (Figure 1A). Fourdimensional power Doppler sonography with the HDlive silhouette mode clearly showed the vascular ring around the trachea at the level of the upper mediastinum in addition to the spatial 3-vessel view (Figure 1B and Video 1). The descending aorta was noted on the right anterior side of the spine. An aberrant left subclavian artery originating from the diverticulum of Kommerell was clearly identified (Figure 1C and Video 2). A diagnosis of a right aortic arch with an aberrant left subclavian artery was made. At 41 weeks’ gestation, a cesarean delivery was performed because of rupture of membranes while the head was unengaged, resulting in a male neonate weighing 4054 g with a height of 51 cm. The Apgar scores were 8 at 1 minute and 9 at 5 minutes, and the umbilical artery pH was 7.301. Neonatal echocardiography confirmed the diagnosis of a right aortic arch with an aberrant left subclavian artery. The diagnosis of aortic arch anomalies is a challenging task for obstetricians. The axial view of the upper mediastinum (namely, 3-vessel and trachea view) is an approach to evaluating the aortic arch by visualizing the V-shaped configuration formed by the junction of the aortic and ductal arches, with the trachea present posteriorly under normal conditions.2 However, detailed and precise detection of the branching pattern is mandatory to differentiate a right aortic arch from other aortic arch anomalies.7 Aortic arch anomalies have also been reported to be closely associated with genetic disorders and multiple congenital cardiac anomalies; therefore, accurate identification of the anatomic changes is needed for improved postnatal management. In this case, 2D echocardiography showed the loss of the V-shaped confluence of the 3-vessel and trachea view. Two-dimensional power Doppler sonography was beneficial, as it showed the vascular ring around the trachea formed by the ductus arteriosus, descending aorta, diverticulum of Kommerell, and right aortic arch. Fourdimensional power Doppler sonography with the HDlive silhouette mode facilitated a spatial 3-vessel view, which showed the relationship and size comparison among them. Therefore, 3D reconstruction of a typical vascular ring was clearly shown. Moreover, an aberrant left subclavian artery was clearly shown, as well as the azygos vein and right pulmonary vessels. The key point is that the relationship of these vessels with the spine could be understood because the spine can be seen by using the HDlive silhouette mode. The descending aorta was noted on the right anterior side of the spine. This finding is another important diagnostic clue in cases of a right aortic arch,1 which cannot be obtained with conventional 3D power Doppler sonography. Therefore, accurate localization and description of the branching patterns of great arteries and an improved understanding of the spatial relationship are easily possible. Fourdimensional power Doppler sonography with the HDlive silhouette mode combines the advantages of a spatial view of great vessels in addition to visualization of the spine as a landmark. Its use may provide potential advantages in the

HDlive Flow with HDlive silhouette mode in diagnosis of fetal hepatic hemangioma

Tumors affecting the liver are rare in fetal and infant life, with hemangioma being the most common1. Fetal hepatic hemangiomas on two-dimensional (2D) ultrasound are well-defined, mixed solid and cystic tumors with punctate calcifications in 50% of the mass. Hypoechoic areas represent vascular structures with low resistance on color Doppler imaging2. Here we describe our experience of HDlive Flow with HDlive silhouette mode in diagnosing fetal hepatic hemangioma in the third trimester of pregnancy. A 28-year-old Japanese woman, gravida 3 para 1, was referred to our clinic at 29 + 3 weeks of gestation because of a suspected fetal intra-abdominal tumor. Ultrasound examination (Voluson E10, GE Healthcare Japan, Tokyo, Japan) revealed on 2D imaging an intra-abdominal, well-defined, mixed solid tumor (45 × 40 × 23 mm) with cystic lesions and punctate calcification, located on the left side of the fetal stomach (Figure 1a). Imaging with HD-Flow demonstrated moderate blood flow within the mass (Figure 1b). HDlive Flow with HDlive silhouette mode at 30 + 2 weeks demonstrated a vascular pattern within the mass characterized by multiple, closely packed blood vessels with differing directions of blood flow, giving a pomegranate-like appearance (Figure 2 and Videoclip S1). The feeder artery was identified clearly originating from the celiac artery. Magnetic resonance imaging (MRI) showed a well-defined, hypervascularized tumor on the left side of the liver (Figure S1). A diagnosis of fetal hepatic hemangioma was suggested. At 37 + 2 weeks, elective Cesarean section was performed to avoid possible intrapartum rupture of the

Case of maternal and fetal deaths due to severe congenital thrombotic thrombocytopenic purpura (Upshaw–Schulman syndrome) during pregnancy

Upshaw–Schulman syndrome (USS) involves a congenital deficiency of von Willebrand factor‐cleaving metalloprotease (ADAMTS13) activity due to gene mutations. Female patients develop overt thrombotic thrombocytopenic purpura (TTP) caused by a decline of ADAMTS13 activity in pregnancy. A 23‐year‐old nulliparous Japanese woman died due to severe, rapid progression of TTP with intrauterine fetal death at 20 weeks of gestation after its onset, even though she underwent intensive treatment which included plasma exchange. She had a history of idiopathic thrombocytopenic purpura at the age of 3 years. The patients ADAMTS13 activity was of very low level. It should be borne in mind that there is the possibility of rapidly progressive fulminant USS during pregnancy.

OP04.09: 4D ultrasound assessment of facial expressions and their reproducibility in the third trimester

transitory bronchial obstruction. In 5 fetuses, echogenic lung was stable and none of the children had respiratory distress. Post natal Computed Tomography confirmed the emphysema due to bronchial atresia (3 cases), bronchogenic cyst (1 case), esophageal duplication (1 case). The 5 children underwent surgery and final diagnosis was confirmed on anatomical data. Conclusions: High frequency and colour Doppler provide a more precise diagnosis of congenital lobar emphysema.

Flexible magnifying endoscopy with narrow band imaging for the diagnosis of uterine cervical tumors: A cooperative study among gastrointestinal endoscopists and gynecologists to explore a novel microvascular classification system

Narrow band imaging with magnifying endoscopy (NBI-ME), which is useful for the assessment of micro-vessels, has excellent diagnostic potential for early gastrointestinal epithelial neoplasia. Conventional diagnostic tools for uterine cervical epithelial tumors are still unsatisfactory. An accurate diagnostic tool for uterine cervical epithelial tumors is required to preserve the reproductive ability of young women with uterine cervical tumors. Flexible NBI-ME was performed in patients with cervical squamous cell lesions that required further examinations based on their Pap smear results (cytology ≥ low-grade squamous intraepithelial lesion) at Kagawa University Hospital between April 2014 and April 2015. NBI-ME results concordant with the punch biopsy sites were compared with the histological results. A retrospective review of the NBI-ME images identified abnormal NBI-ME results regarding micro-vascular patterns. All images were categorized as having abnormal features. NBI-ME revealed the following vascular pattern differences of different stage tumors: Dot-like vessels without irregular arrangements and high density in cervical intraepithelial neoplasia (CIN) CIN1-CIN2; dot-like vessels with irregular arrangements and high density in CIN3-carcinoma in situ; crawling vessels in minimum invasive cancer; and willow branch vessels and new tumor vessels in invasive cancer. NBI-ME may be an effective diagnostic tool for uterine cervical epithelial tumors, which may lead to the establishment of a novel classification system.