Edward Araujo Júnior

Fetal growth restriction: current knowledge

BackgroundFetal growth restriction (FGR) is a condition that affects 5–10% of pregnancies and is the second most common cause of perinatal mortality. This review presents the most recent knowledge on FGR and focuses on the etiology, classification, prediction, diagnosis, and management of the condition, as well as on its neurological complications.MethodsThe Pubmed, SCOPUS, and Embase databases were searched using the term “fetal growth restriction”.ResultsFetal growth restriction (FGR) may be classified as early or late depending on the time of diagnosis. Early FGR (<32 weeks) is associated with substantial alterations in placental implantation with elevated hypoxia, which requires cardiovascular adaptation. Perinatal morbidity and mortality rates are high. Late FGR (≥32 weeks) presents with slight deficiencies in placentation, which leads to mild hypoxia and requires little cardiovascular adaptation. Perinatal morbidity and mortality rates are lower. The diagnosis of FGR may be clinical; however, an arterial and venous Doppler ultrasound examination is essential for diagnosis and follow-up. There are currently no treatments to control FGR; the time at which pregnancy is interrupted is of vital importance for protecting both the mother and fetus.ConclusionEarly diagnosis of FGR is very important, because it enables the identification of the etiology of the condition and adequate monitoring of the fetal status, thereby minimizing risks of premature birth and intrauterine hypoxia.

Associated ultrasonographic findings in fetuses with microcephaly because of suspected Zika virus (ZIKV) infection during pregnancy

To describe fetal ultrasonographic findings and outcomes in a series of cases of fetal microcephaly associated with Zika virus infection.

Heart stroke volume, cardiac output, and ejection fraction in 265 normal fetus in the second half of gestation assessed by 4D ultrasound using spatio-temporal image correlation

Objectives. The aim of this study was to establish nomograms for fetal stroke volume (SV), cardiac output (CO), and ejection fraction (EF) using four-dimensional ultrasound with spatio-temporal image correlation (STIC) modality. Methods. The fetal heart was scanned using STIC modality, starting with classic four-chamber view plane, during fetal quiescence with abdomen uppermost, at an angle of 20–30°, without color Doppler flow mapping. In post-processing virtual organ, computer-aided analysis technique was used to obtain a sequence of six sections of each ventricular volume in end-systolic volume (ESV) and end-diastolic volume (EDV). The SV (SV = EDV–ESV), CO (CO = SV × fetal heart rate), and EF (EF = SV/EDV) for each ventricle were then calculated. Intra- and interobserver agreement were then calculated. Results. Two hundred sixty-five fetuses, ranging in gestational age (GA) from 20 to 34+6 weeks, were included in the study. The left and right SV and CO increased exponentially with gestation and EF remained fairly stable through gestational. Mean left and right SV increased from 0.211 ml and 0.220 ml at 20 weeks to 1.925 ml and 2.043 ml, respectively, at 34 weeks. Mean left and right CO increased from 30.25 ml/min and 31.52 ml/min at 20 weeks to 268.49 ml/min and 287.80 ml/min, respectively, at 34 weeks. Both left and right mean EF remained constant at around 0.63 with advancing GA. Nomograms were created for LSV, RSV, LCO, RCO, LEF, and REF vs. gestational age. Intra- and interobserver agreement reached 95%. Conclusions. Four-dimensional ultrasound using STIC represents a simple and reproducible method for estimating fetal cardiac function. STIC seems to overcome many of the pitfalls of conventional ultrasound methods and has the potential to become the method of choice.

Intrauterine Zika virus infection and microcephaly: perinatal imaging correlations with 3D virtual physical models

*Department of Radiology, Clı́nica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, Brazil; †Department of Arts and Design, Pontifı́cia Universidade Católica (PUC Rio), Rio de Janeiro, Brazil; ‡Department of Obstetrics and Gynecology, Guastalla Civil Hospital, AUSL Reggio Emilia, Reggio Emilia, Italy; §Create Health Clinic, London, UK; ¶Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil

Placenta: angiogenesis and vascular assessment through three-dimensional power Doppler ultrasonography.

The placenta is fundamental for fetal development. It combines the functions of an endocrine organ, kidneys, lungs and intestines, purifying catabolites, oxygenating and nourishing the conceptus. Its fetal portion is the largest part develops from the chorionic sac. The maternal portion, which is smaller, is originated in the endometrium, more specifically in the decidua basalis. The placenta starts its function closer to the fourth week of gestation, when anatomical arrangements for the physiological exchanges are already established. The circulatory function of the placenta appears at an early stage of embryo-placental development and it is strongly related to fetal growth, to the placental size and to uterine and umbilical blood flows. Therefore, an adequate placental angiogenesis is critical for the establishment of a normal placental vascularization with consequent normal development of the fetus. In this review article, the authors discuss about placental ontogeny, focusing on the main aspects of its normal development, and about the recent advances in ultrasonography for the study of the vascular architecture of the placenta through three-dimensional power Doppler ultrasonography.

Reliability and Validity of In Vitro Volume Calculations by 3-Dimensional Ultrasonography Using the Multiplanar, Virtual Organ Computer-Aided Analysis (VOCAL), and Extended Imaging VOCAL Methods

Objective. The purpose of this study was to assess the reliability and validity of in vitro volume calculations by 3‐dimensional ultrasonography. Methods. This observational study was performed by 2 examiners to obtain volumes of 3 objects of different shapes and sizes filled with ultrasound gel and immersed in water. The examiners used the multiplanar (5‐mm interval), virtual organ computer‐aided analysis (VOCAL, 30°) and extended imaging (XI) VOCAL (5, 10, 15, and 20 planes) methods to estimate the volumes of each object. A paired Student t test (P) and intraclass correlation coefficients (ICCs) were used to assess reproducibility of the methods. Validity was assessed comparing the percent differences between the estimated and the real volumes using the P value, mean differences, and ICC for each method. Results. All methods were highly reliable and valid. There were no significant differences in interobserver variability; there was a strong interobserver correlation. There were no significant differences in the percent differences between the estimated and real volumes of the objects using the 3 methods. The XI VOCAL method was superior to the multiplanar and VOCAL methods in the measurement of irregularly shaped objects. The XI VOCAL method with 10 planes estimated volumes closest to the real volumes. Conclusions. All 3 methods were reliable and valid; however, XI VOCAL was superior to the other methods in the measurement of irregularly shaped objects.

XI VOCAL (eXtended Imaging VOCAL): a new modality for three-dimensional sonographic volume measurement

AbstractIntroductionThe important technological evolutions that three-dimensional ultrasonography devices have gone through in the last years have brought great benefits for the volumetric measurement of fetal organs and structures. In clinical practice, three-dimensional volumetry has helped to identify abnormalities in fetal compartment and other related organs, assisting in the diagnosis and risk estimation of several pathological conditions in fetal medicine.AimThe authors describe a new methodology for volumetric calculation through three-dimensional ultrasonography called eXtended Imaging VOCAL (XI VOCAL), which is part of the software Three-dimensional eXtended Imaging (3DXI)TM. This software virtualizes real organs, by analyzing the volume through a diagram of slice sections (Multi-slice view) that simultaneously shows a sequence of images in parallel planes, and establishes the volume of the organ. Because of the importance of accurate volumetric measurements in obstetric ultrasonography, a new method allowing this measurement should be regarded as of great interest.

Maternal Thyroid Disease and Preterm Birth: Systematic Review and Meta-Analysis

CONTEXT Thyroid disease in pregnancy is increasing with rising average maternal ages in developed countries. The evidence for an association between preterm birth and thyroid disease has been confounded by small studies with varying outcomes and methodology. OBJECTIVE The aim of this meta-analysis is to review the literature regarding thyroid disease including subclinical and overt hypothyroidism, hyperthyroidism, and isolated hypothyroxinemia and the specific outcome of preterm birth. DATA SOURCES A search of PubMed and Embase databases was performed in May 2015. A fixed-effects model was used to calculate the overall combined odds ratio (OR) with its corresponding 95% confidence interval (95% CI) to evaluate the relationship between thyroid disease and preterm delivery. STUDY SELECTION Studies were considered eligible if they met the following criteria: prospective cohort study or a case control study; the exposure of interest was maternal thyroid disease, including subclinical hypothyroidism, overt hypothyroidism, hyperthyroidism, or isolated hypothyroxinemia; the outcome of interest was preterm delivery; and data regarding numbers of preterm births in each cohort were reported. DATA EXTRACTION Data were recorded in a database evidence table including any incidence data for maternal thyroid disease and preterm birth compared to a reference group. DATA SYNTHESIS Fourteen cohort studies and one case control study involving 2 532 704 participants were included. The combined OR of preterm delivery for pregnant women with overt hypothyroidism compared with the reference group was 1.19 (95% CI, 1.12-1.26; P < .00001). There was also a significant risk of preterm birth in women with hyperthyroidism (OR, 1.24 [95%, CI 1.17-1.31]; P < .00001). Subclinical hypothyroidism and isolated hypothyroxinemia showed no significant increase in OR. Sensitivity analysis made no change to these results. CONCLUSION Both overt hypothyroidism and hyperthyroidism are associated with a small but statistically significant increase in OR for preterm birth not seen in subclinical hypothyroidism or isolated hypothyroxinemia.

Evolution of 3-D power Doppler indices of fetal brain in normal pregnancy.

We assessed the vascular indices of the anterior territory of the middle cerebral artery (MCA) in normal pregnancies using 3-D power Doppler (3DPD). A cross-sectional study was carried out on 90 normal pregnancies between 24 and 35 weeks. All examinations were performed by a single operator using a volumetric transducer. The anterior territory of the MCA was scanned and the volumes were captured using 3DPD. The sphere mode of the VOCAL program was used to calculate the following vascular indices: vascularization index (VI), flow index (FI) and vascularization and flow index (VFI). Models of polynomial regression and Pearsons correlation coefficient were used to evaluate the correlation between gestational age (GA) and the vascular indices. The 3DPD vascular indices had a low correlation with gestational age (VI - r = 0.324, p = 0.002; FI - r = 0.375, p < 0.001; VFI - r = 0.374, p < 0.001). There was a low correlation between GA and the 3DPD vascular indices of the anterior territory of the MCA.

Reference Range of Fetal Renal Volume by Three-Dimensional Ultrasonography Using the Vocal Method

Objective: To establish reference values for fetal renal volume by three-dimensional sonography using the VOCAL (Virtual Organ Computer-Aided Analysis) method. Methods: This prospective longitudinal study involved 57 healthy pregnant women who were examined between 24 and 34 weeks of pregnancy. Each fetal kidney was evaluated separately using the VOCAL method with a 30° rotation angle. For each gestational age, the following measures were obtained for the right and left kidneys: mean, standard deviation, minimum and maximum values, and the 5th, 10th, 25th, 50th, 75th and 90th percentiles. Polynomial regression models were constructed to assess the relationship between renal volume and gestational age, adjusted by the determination coefficient (R2). The Wilcoxon test was used to evaluate the concordance between the right and left renal volumes. Bland-Altman graphs were used to assess intra- and inter-observer variability. Results: The right renal volume increased from 4.5 ± 1.3 cm3 at 24 weeks to 12.1 ± 1.5 cm3 at 34 weeks. The left renal volume increased from 4.6 ± 0.8 cm3 at 24 weeks to 11.9 ± 1.1 cm3 at 34 weeks. There was a strong correlation between both the right and left renal volumes and gestational age (R2 = 0.975 and 0.970, respectively). There were no significant differences between the right and left renal volumes. The mean difference between repeated measures by the same examiner was –0.07 cm3 (–0.88 to 0.75) for the right kidney and –0.21 cm3 (–0.95 to 0.75) for the left kidney. The mean difference between repeated measures obtained by two different examiners was –0.07 cm3 (–1.25 to 1.12) for the right kidney and 0 cm3 (–1.53 to 1.53) for the left kidney. Conclusion: Reference values were generated for fetal renal volume assessed by three-dimensional ultrasonography using the VOCAL method.