Hélio Antonio Guimarães Filho

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.

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.

Placental blood flow measured by three-dimensional power Doppler ultrasound at 26 to 35 weeks gestation in normal pregnancies.

Objective. To evaluate placental vascular indices, in pregnancies between 26 and 35 weeks, using three-dimensional power Doppler (3DPD) ultrasound and the effect of placental location on these indices. Methods. This was a cross-sectional study involving 283 patients. The placental vascularization index (VI), flow index (FI) and vascularization and flow index (VFI) was obtained using the VOCAL program. Pearsons linear correlation coefficient was used to assess the relationship between gestational age and these indices. Students parametric t-test and Levenes test were used to analyse the results between VI, FI and VFI and placental location. Results. There was no linear correlation between gestational age (GA) and VI (p = 0.390) and VFI (p = 0.053). Only the FI presented a significant linear correlation (p = 0.004), with a slow increase according to GA. It was possible to construct a reliable nomogram only for this index. There were no significant differences in the VI, FI and VFI according to placental location (p = 0.323, 0.172 and 0.120, respectively). Conclusion. Placental FI assessed by 3DPD increases progressively and significantly between 26 and 35 weeks. Placental location has no influence on the three vascular indices studied. The FI reference values obtained in this study can be used as a parameter for future investigations on placental vascularization using 3DPD.

Comparison of two- and three-dimensional ultrasonography in lung volume measurement of normal fetuses.

AIM The purpose of this study was to compare the two- and three-dimensional methods for measuring fetal lung volume of normal fetuses. METHODS A cross-sectional study was performed with 51 normal pregnant women between 20 and 35 weeks. The ellipsoid formula (X*Y*Z*0.52) was used for volume calculation with the two-dimensional (2D) method. With the VOCAL (Virtual Organ Computer-aided Analysis) method, a rotation angle of 30 degrees was used. Intraclass correlation coefficient (ICC), paired Students t-test and Bland-Altman plots were used to compare the techniques. To calculate the intraobserver variability we used the ICC and compared the means between the two measures using the paired Students p-test. RESULTS VOCAL and 2D methods were highly correlated (ICC=0.919 and 0.873 for the right and left lungs, respectively), however, there was a disagreement. The fetal lung volume means calculated by the 2D method were always overestimated in relation to the means obtained by the VOCAL, for the right lung (24.02 mL x 19.15 mL; P<0.001), as well as for the left (16.03 mL x 13.77 mL; P=0.002). As for the intraobserver variability, a good reproducibility was observed for the volume measurement of the left lung by the 2D technique (mean=0.40 mL; P=0.57) and by the VOCAL (mean=-0.22 mL; P=0.63). The 2D method, however, presented low reproducibility for the right lung (mean=1.73 mL; P=0.31). CONCLUSION The two-dimensional method had low agreement and low reproducibility in relation to the three-dimensional method for measurement of fetal lung volume in normal fetuses.Aim: The purpose of this study was to compare the two-and three-dimensional methods for measuring fetal lung volume of normal fetuses. Methods: A cross-sectional study was performed with 51 normal pregnant women between 20 and 35 weeks. The ellipsoid formula (X*Y*Z*0.52) was used for volume calculation with the two-dimensional (2D) method. With the VOCAL™ (Virtual Organ Computer-aided Analysis) method, a rotation angle of 30° was used. Intraclass correlation coefficient (ICC), paired Students t-test and Bland-Altman plots were used to compare the techniques. To calculate the intraobserver variability we used the ICC and compared the means between the two measures using the paired Students p-test. Results: VOCAL™ and 2D methods were highly correlated (ICC =0.919 and 0.873 for the right and left lungs, respectively), however, there was a disagreement. The fetal lung volume means calculated by the 2D method were always overestimated in relation to the means obtained by the VOCAL™, for the right lung (24.02 mLx19.15 mL; P<0.001), as well as for the left (16.03 mL×13.77 mL; P = 0.002). As for the intraobserver variability, a good reproducibility was observed for the volume measurement of the left lung by the 2D technique (mean =0.40 mL; P=0.57) and by the VOCAL™ (mean = -0.22 mL; P=0.63). The 2D method, however, presented low reproducibility for the right lung (mean = 1.73 mL; P=0.31). Conclusion: The two-dimensional method had low agreement and low reproducibility in relation to the three-dimensional method for measurement of fetal lung volume in normal fetuses.

Sonoembryology by three-dimensional ultrasonography: pictorial essay.

ContextThree-dimensional ultrasonography in obstetrics has evolved in the last years, and nowadays it is a methodology that greatly helps prenatal diagnosis. Through its rendering mode it allows the careful evaluation of fetal face and limbs, and in multiplanar mode it allows the assessment of the anatomy through the many possible planes. In the first trimester of gestation, three-dimensional ultrasonography permits the detailed evaluation of embryonic development. Its main advantages over two-dimensional ultrasonography are shorter examination time and the possibility of storage of the volumes for later processing and analysis.AimWe present a pictorial essay with normal embryo development in the first trimester of pregnancy by three-dimensional ultrasonography, from the fifth to ninth week.

Three-dimensional transvaginal sonographic diagnosis of early and asymptomatic interstitial pregnancy

ContextThe interstitial gestation is a rare form of tubal pregnancy which is associated with high morbidity. The diagnosis of an interstitial gestation can be reached through a bidimensional transvaginal ultrasonography (2D-TVUS), however, sometimes when making use of this technique it is not possible to appropriately evaluate the position of the gestational sac in relation to the uterine cavity. The three-dimensional transvaginal ultrasonography (3D-TVUS) allows accessibility to plans that the bidimensional does not, thus it makes it possible to reach a more accurate diagnosis and it also allows for an appropriate therapeutic planning.Case reportWe present a case of interstitial gestation diagnosed in the sixth week in an asymptomatic woman, who had a previous diagnosis of primary infertility. The 2D-TVUS revealed the presence of a gestational sac outside of the uterine cavity; moreover the colored Doppler and the power Doppler indicated a thriving vascular ring. The 3D-TVUS in the surface and transparency mode demonstrated that the gestational sac was located in the interstitial region of the uterine tube, and the niche mode accurately evaluated the relationship between the gestational sac and the uterine cavity. The patient was successfully treated with a local injection of methotrexate guided by a transvaginal ultrasonography. The 3D-TVUS was of great importance to confirm the diagnosis, to allow appropriate therapeutic choices and to decrease the morbidity.

Correlation of the fetal cerebellar volume with other fetal growth indices by three-dimensional ultrasound

Objective. To verify the correlation of fetal cerebellar volume by three-dimensional ultrasound (3D US) with other indices of fetal growth in normal fetuses. Methods. This was a longitudinal prospective study involving 52 normal pregnant women between 20 and 32 weeks of gestation. The assessments of the fetal cerebellar volume were carried out at intervals of two weeks, and the method used was VOCAL (virtual organ computer-aided analysis) with a 30° rotation angle. At each assessment, the following biometric indices were evaluated using the two-dimensional method: biparietal diameter, head circumference, transverse cerebellar diameter, femur length, and estimated fetal weight. We used Pearsons correlation coefficient to evaluate the correlation between fetal cerebellar volume and these indices; we also used polynomial regression analysis with fetal cerebellar volume as the dependent variable and the other indices as the independent variable. Results. The fetal cerebellar volume was highly correlated with gestational age (r = 0.94; p < 0.001) and with all other fetal growth indices (p < 0.001). Conclusions. The assessment of the fetal cerebellar volume by 3D US is an important tool to evaluate fetal growth.OBJECTIVE To ascertain the pattern and management strategies of coital injuries in married females in Pakistan. DESIGN An observational, case series. PLACE AND DURATION OF STUDY Gynaecology and Surgical wings - Fatima Medical Centre, Multan, over a period of seven years from January 1997 to December 2003. SUBJECTS AND METHODS Records of 33 adult married females sustaining coital injuries were studied. Only married females were included. Injuries raising suspicion of indecent assault, sexual abuse and trauma were excluded. Results were recorded and analyzed. RESULTS Three vulvar haematomas (9%) settled on conservative management. One labial (3%), 9 posterior fourchette (27%) and 16 vaginal wall lacerations (48%) were stitched. A broad ligament haematoma (3%) and a ruptured ovarian cyst (3%) were laparoscopically dealt with. One posterior fornix perforation (3%) with secondary peritonitis and a ruptured ectopic pregnancy (3%) with life-threatening haemorrhage underwent laparotomy. No mortality occurred in this series. CONCLUSION Varied presentation of the coital injuries demand careful evaluation to help correct diagnosis, timely management and successful outcome with minimal morbidity.

Diagnosis of Pentalogy of Cantrell by Three-Dimensional Ultrasound in Third Trimester of Pregnancy

The Pentalogy of Cantrell is a rare congenital anomaly characterized by defects in the closing of the supraumbilical abdominal wall, in the anterior portion of the diaphragm, in the diaphragmatic pericardium, ectopia cordis, and intracardiac defects. It may be associated to other anomalies determining the variants of this syndrome. The prenatal ultrasound diagnosis is extremely important for detecting structural malformations and for postnatal surgical planning, when possible. We present a case of Pentalogy of Cantrell diagnosed in the 34th week of gestation, showing the main findings by two-dimensional ultrasound and emphasizing the importance of three-dimensional ultrasound on the assessment of structural malformations and on the better understanding of the origins of the pathology.

Role of 3-D Ultrasound in Clinical Obstetric Practice: Evolution Over 20 Years

The use of 3-D ultrasound in obstetrics has undergone dramatic development over the past 20 years. Since the first publications on this application in clinical practice, several 3-D ultrasound techniques and rendering modes have been proposed and applied to the study of fetal brain, face and cardiac anatomy. In addition, 3-D ultrasound has improved calculations of the volume of fetal organs and limbs and estimations of fetal birth weight. And furthermore, angiographic patterns of fetal organs and the placenta have been assessed using 3-D power Doppler ultrasound quantification. In this review, we aim to summarize current evidence on the clinical relevance of these methodologies and their application in obstetric practice.

Comparison of the two-dimensional and multiplanar methods and establishment of a new constant for the measurement of fetal lung volume

Objectives. To compare the two-dimensional (2D) and multiplanar methods in the measurement of lung volume in normal fetuses, to obtain a new constant to be incorporated into the 2D equation, and to apply the new equation in fetuses with pulmonary hypoplasia (PH) confirmed postnatally. Methods. A cross-sectional study was performed on 51 pregnant women at between 20 and 35 weeks of gestation. The ellipsoid formula (x × y × z × 0.52) was used to calculate lung volume by the 2D method. A sequence of multiple planes with 2.0-mm intervals was used with the multiplanar method. In order to compare the techniques, the intra-class correlation coefficient (ICC) and the Students t-test (p) were used. First-order linear regressions were used to establish a new constant, with three-dimensional (3D) lung volume as dependent variable and gestational age and 2D volume as independent variables. In order to validate it, the new equation was applied to 11 fetuses with confirmed lethal PH. Results. The mean volumes obtained by the 2D method were overestimated when compared to the multiplanar method (right lung: 23.87 vs. 18.26 mL, respectively, p < 0.001 and left lung: 16.18 vs. 14.33 mL, respectively, p = 0.008). Using a first-order polynomial regression, new constants were obtained for the right lung (0.152) and for the left lung (0.167). When compared to the traditional formula, the new equation presented higher sensitivity (18.1%) in predicting lethal PH. Conclusion. The recalculated 2D equation can be a promising alternative to 3D ultrasonography in the prediction of PH.