J. M. Levaillant

Normal fetal urine production rate estimated with 3-dimensional ultrasonography using the rotational technique (virtual organ computer-aided analysis)

OBJECTIVE The aim of this study was to assess hourly fetal urine production rates (HFUPRs) and establish a nomogram by measuring bladder volumes with 3-dimensional ultrasound. STUDY DESIGN Fetal urine bladder volume was estimated in 167 normal singleton pregnancies with neither oligohydramnios nor polyhydramnios, at a gestational age of 20-41 weeks. HFUPR was estimated in a regression analysis that included at least 3 volumes calculated during the filling phase with the Virtual Organ Computed-aided AnaLysis (VOCAL) technique. We estimated interoperator variability for HFUPR less than 10 mL/h and HFUPR greater than 10 mL/h. RESULTS Fetal urine production rates at 25, 30, 35, and 40 weeks were 7.5, 22.2, 56.1, and 125.1 mL/h, respectively. The intraclass correlation coefficients for interoperator variability were 99.2% for HFUPR less than 10 mL/hour and 97.1% for HFUPR greater than 10 mL/h. CONCLUSION Prenatal measurement of HFUPR with 3-dimensional VOCAL ultrasound is reproducible and may help to determine the cause and prognosis of amniotic fluid volume abnormalities.

Real‐time transvaginal elastosonography of uterine fibroids

Uterine fibroids are the most frequently occurring benign tumors originating in the uterus, and are usually round or partially rounded in shape (Figure 1). Although they are composed of the same smooth-muscle fibers as the uterine wall, they are many times more dense than is normal myometrium. This characteristic is frequently responsible for the poor visualization of fibroids on transvaginal ultrasonography, due to strong acoustic shadowing.

Factors affecting feasibility and quality of second‐trimester ultrasound scans in obese pregnant women

To evaluate the feasibility of completing in one session a second‐trimester ultrasound scan in obese pregnant women, to compare the quality of images obtained with those of non-obese women and to analyze factors that can improve the completion rate.

Correlation between referral ultrasound with suspected foetal anomalies and autopsy examination in two prenatal diagnosis centres. Impact of the routine use of 3D/4D scan

To compare ultrasound diagnosis with autopsy findings in two tertiary referral foetal medicine centres, only one routinely using 3D and 4D ultrasound, and to compare results between the centres.

Clinical application of fetal urine production rate in unexplained polyhydramnios

To evaluate the clinical use of hourly fetal urine production rate (HFUPR) in polyhydramnios.

Classical West "syndrome" phenotype with a subtelomeric 4p trisomy.

We report a girl with mild mental retardation with onset of infantile spasms at age of 9 months. Treatment with a short course of adrenocorticotropic hormone (ACTH) was successful. Initially, a diagnosis of idiopathic West syndrome, with good neurological outcome and disappearance of epilepsy after treatment, was made. Conventional karyotype was normal. Reinvestigations were done at age 8 years, because of a new pregnancy. Karyotyping of both parents was done because of mild dysmorphic features in the proband, and to eliminate other causes than early age epilepsy as the etiology of her mental retardation. Parental karyotypes showed a balanced paternal translocation (4p;17q) resulting in partial 4p trisomy, without significant 17q monosomy in the proband. Chromosomal abnormalities usually lead to a severe West syndrome with poor prognosis of neurological outcome (persistent severe epilepsy, mental retardation, and behavioral disturbances). The presence of an undetected cytogenetic anomaly in our proband with transient hypsarythmia is unusual and led us to propose systematic telomeric screening in apparently “idiopathic” West syndrome patients with mild mental retardation and subtle dysmorphic features.

Uterine arteriovenous malformation involving the whole myometrium

Uterine arteriovenous malformations (AVMs) are uncommon but potentially life-threatening. They can be congenital or acquired (arteriovenous fistulae) and should be suspected in cases of severe or persistent uterine bleeding following endouterine procedures (curettage or operative hysteroscopy), miscarriage or Cesarean section1. Sonographic examination using color Doppler ultrasound is the first step in diagnosis1,2. Uterine AVMs are often limited to a particular area of the myometrium3. We present a rare case of an extensive AVM involving the whole myometrium in a 32-year-old woman. The patient’s first pregnancy, in 2003, was complicated by intrauterine growth restriction (IUGR). She gave birth to a 1500-g infant by Cesarean section at 35 weeks’ gestation. An AVM was discovered after delivery and an embolization was performed with success. During her second pregnancy, in 2008, a uterine AVM of 60 mm × 40 mm was observed in the myometrium in front of the placenta. The patient gave birth to a 2350-g healthy infant by Cesarean section at 36 + 2 weeks of gestation with hemorrhagic complications that were managed by ligation of the internal iliac arteries. Following her second pregnancy, annual sonographic monitoring of the patient was performed, during which an increase in the size of the uterine AVM, associated with menorrhagia, was observed. By February 2012, the uterine AVM involved the whole myometrium (Figure 1). Three-dimensional (3D) ultrasound reconstruction of the uterus using a glass body technique was used to differentiate tissue and vessels (Figure 2). Threedimensional tomographic imaging (Figure 3a) revealed a heterogeneous structure of the myometrium with no signs of a cavity. Reconstruction of the same area with color Doppler ultrasound revealed heavy vascularization of the myometrium and the presence of a small cavity without any vessels (Figure 3b). Owing to the failure of previous conservative management of the AVM, and given the risk of severe hemorrhage, a vaginal hysterectomy was performed. Pathological findings included the presence of numerous

Agenesis of the ductus venosus: three-dimensional power Doppler reconstruction

The ductus venosus (DV) is an important fetal vascular structure that connects the umbilical venous system to the inferior vena cava (IVC) near its insertion point into the right atrium1. It allows 20–30% of the umbilical blood to bypass the liver in utero and reach the heart rapidly, thus increasing the flow of well-oxygenated blood to the cephalic and coronary circulation. The DV therefore plays a key role in increasing the shunt of oxygenated blood to the heart and decreasing placental return during hypoxemia and hypovolemia1,2. For several years, improvements in ultrasound techniques, such as two-dimensional (2D) and threedimensional (3D) ultrasound reconstruction, have made it possible to identify numerous malformations that were previously undetectable antenatally, including agenesis of the DV3, which is associated with various morphological and cytogenetic abnormalities. Examination of the DV has been used in referral centers to refine diagnoses involving cardiac, extracardiac and chromosomal anomalies2 as well as in first-trimester screening for Down syndrome in the high-risk population4. The DV pulsatility index for veins can be used as a continuous variable, in combination with nuchal translucency (NT) measurement, to increase specificity in the identification of congenital heart defects5. We report here the case of a 31-year-old primigravida, referred at 35 weeks of gestation to our prenatal center after the abnormal finding at third-trimester ultrasound of a highly dilated IVC (4.1 mm) and umbilical vein. Firstand second-trimester findings had been unremarkable. Combined marker screening in the first trimester indicated a 1/554 risk for Down syndrome, with NT on the 60th percentile. The only morphological abnormalities found during the third-trimester examination were the dilated IVC and umbilical vein. Suspecting agenesis of the DV, we performed a color Doppler ultrasound examination. Looking for an abnormal course or flow in the umbilical vein, we found that it was connected directly to the IVC and the flow velocity was high. To clarify the situation, 3D volume datasets were acquired with transverse and sagittal sweeps over the abdominal region. The umbilical vein and IVC were reconstructed using the glass-body rendering (angiographic) mode to optimize examination of these vessels. To highlight their abnormal connection, we then used the Magicut postprocessing application (Figure 1). This 3D power Doppler reconstruction demonstrated the anomalous course of the dilated umbilical vein, which was connected directly to the dilated subdiaphragmatic IVC and bypassed the liver. Fetal echocardiography showed substantial disproportion in the diameters of the IVC and superior vena cava at the points of insertion into the heart: 4.1 mm vs 1.2 mm. No features of cardiac decompensation or morphological abnormality were seen. The patient was offered amniocentesis for karyotype determination because agenesis of the DV is associated with a high rate (17%) of chromosomal abnormalities2; the karyotype was normal. The remainder of the pregnancy and delivery were uneventful, and the child appeared healthy. Little is known about the consequences and clinical implications of agenesis of the DV6. This anomaly affects approximately 6/1000 fetuses in a high-risk population. The few reports in the literature of an absent DV are associated with three different abnormal patterns: the umbilical vein may bypass the liver and then connect to the subdiaphragmatic IVC or to the iliac or renal veins, it may connect directly to the right or left atrium, or it may connect directly to the portal vein without giving rise to the DV2,7. DV agenesis is associated with congenital morphological abnormalities in approximately 65% of cases and with cytogenetic abnormalities in 17%2,8. The cardiac anomalies associated with DV agenesis, which occur in 48% of cases, include atrial and ventricular septal defects, tricuspid atresia, double outlet right ventricle, pulmonary atresia and transposition of the great arteries7,9. Other common associated anomalies involve the gastrointestinal system (duodenal atresia and tracheoesophageal fistula), the genitourinary system (bilateral hydronephrosis and ectopic kidney) and the musculoskeletal system

Prenatal features of a fetal frontal hemangioma assessed by 3D ultrasound and color Doppler imaging

*Correspondence to: O. Picone, Service de Gynécologie Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, 157, Rue de la Porte de Trivaux, 92141 Clamart Cedex, France. E-mail: olivier.picone@abc.aphp.fr that is routine in France. The patient’s medical and obstetrical history was unremarkable. The couple was not consanguineous. The first ultrasound scan at 13 weeks was considered normal. The second ultrasound screening, at 22 weeks, revealed a median subcutaneous and vascularized tumor of the face, 8 mm in diameter in the midsagittal plane (Figure 1(A)). Color Doppler ultrasound HD (PRF 0.6 KHz) analysis showed a highly vascularized mass with low flow,

OP09.15: Prenatal features of a fetal frontal hemangioma assessed by 3D ultrasound and color Doppler imaging

Methods: A total of 124 women attending the prenatal diagnostic clinic of a teaching hospital were randomized into the intervention (2DUS followed by 3D/4DUS) or control (2DUS alone) group. One operator performed all the ultrasound examinations. The primary outcome was maternal anxiety levels which were assessed by the Spielberger State-Trait Anxiety Inventory. The secondary outcome was breastfeeding rate. We measured the anxiety levels in all women at the first visit, around 18 weeks’ (immediately after ultrasound examinations) and finally at 28 weeks’ gestation. Results: A short-term reduction of stateanxiety score (by around two) from the first visit to after ultrasound examinations was similarly observed in both the intervention group and control group. Repeated measures ANOVA showed that there was no significant interaction effect between groups and time of assessment on the stateanxiety scores (F value = 1.072 and P value = 0.344). There was also no significant difference in the breastfeeding rate on discharge from the hospital after delivery between the control group (33.3%) and the intervention group (43.6%). About 80% of women reported a better understanding that their baby was normal after viewing 3D than 2D images. Conclusion: This randomized study indicates that the addition of 3D/4DUS does not cause a significant reduction on maternal anxiety or increase in breastfeeding rate in pregnancies at risk of fetal abnormalities compared with conventional 2DUS alone.