Jeng-Hsiu Hung

Color Doppler ultrasound, pregnancy-induced hypertension and small-for-gestational-age fetuses

Objective: The nomogram of blood velocity flow resistance of the spiral arteries was built at 13–25 gestational weeks. Thereafter, by using the nomogram we tried to assess the results of the color Doppler examination of the uteroplacental circulation at the second trimester to predict pregnancy‐induced hypertension (PIH) and small‐for‐gestational‐age (SGA). Methods: Two groups of patients were studied. Group 1, for the establishment of the nomogram, included 175 uncomplicated pregnancies with gestational ages ranging from 13–25 weeks. The Doppler flow waveforms of the spiral arteries were measured once for each pregnancy in the studies. Group 2 consisted of 305 singletons selected consecutively for prospective study to confirm the occurrence of PIH or SGA. They were scanned twice for the measurements of the spiral artery waveforms at 13–19 and 20–25 weeks, respectively to test which gestational weeks interval in the nomogram is most sensitive in predicting PIH and SGA. Results: The 5th, 50th and 95th percentiles of the pulsatility index (PI) values of the nomogram at the second trimester were used as the cut‐off points to predict pregnancies complicated with SGA or PIH at delivery. Using the receiver operator curve, the 50th percentiles of the PI values of the nomograms were chosen as predictives for the development of PIH and SGA. At 13–19 gestational weeks, the specificities in predicting PIH and SGA were 50.71% and 49.82%, respectively, and the sensitivities were 52.00% and 50.00%, respectively. The calculated Cohens Kappa statistics were 0.008 and 0.001, respectively in predicting PIH and SGA. At 20–25 gestational weeks, the specificities in predicting PIH and SGA were 49.64% and 49.46%, respectively, and the sensitivities were 56.00% and 57.14%, respectively. The calculated Cohens Kappa statistics were 0.017 and 0.022, respectively in predicting PIH and SGA. Conclusion: The measurements of uteroplacental blood flow velocity waveforms at the second trimester are not sensitive enough to be an early screening tool for PIH and SGA in the low risk, non‐selected pregnancy population. The fact suggests that in most gravidas complicated with PIH and SGA, the physiological process of trophoblastic invasion in the spiral artery was not prevented before the 25th gestational week.

Nuchal translucence incorporated into a one-stage multifactorial screening model for Down syndrome prediction at second-trimester pregnancy

The aim of this study was to achieve one-stage screening for trisomy 21 using a combination of nuchal translucency (NuT) measurement and maternal serum alpha-fetoprotein (AFP) and free beta-human chorionic gonadotrophin (hCG) biochemistry levels in the second trimester among a high-risk study population. From January 1998 to June 2001, 45 cases of trisomy 21 were prenatally found and confirmed in the hospital-based cytogenetic diagnosis laboratory. A total of 867 normal singleton pregnancies were enrolled as controls from the antenatal care clinics in the hospital. All study and control subjects between 13 weeks and 18 weeks of gestation with a mean age of 15.2 +/- 1.3 weeks underwent one-stage nuchal translucence measurements and maternal serum biochemical screening for Down syndrome. The final logistic model contained beta-hCG (multiples of the gestational median or MoM), maternal age (matA), nuchal translucence (NuT MoM) and AFP (MoM) as covariates. Also, the estimated coefficients of the regression were highly significant. This model provided the estimated probability of Down syndrome as follows: Pr (Down syndrome) = exp (Z)/ [1 + exp (Z)], where Z = -11.18 + 0.64 x (beta-hCG MoM) + 0.25 x matA + 1.32 x NuT MoM -2.23 x AFP MoM. The logistic regression with estimated coefficients was installed in a Palm digital assistant (PDA) equipped with Excel (Microsoft). The risk probability of Down syndrome could be readily calculated after inputting data for all four predictor variables.

The power Doppler velocity index, pulsatility index, and resistive index can assist in making a differential diagnosis of primary ovarian carcinoma and Krukenberg tumors: a preliminary study.

The aim of this study was to compare the effectiveness of transvaginal power Doppler sonography with spectral Doppler analysis as an aid in preoperatively distinguishing primary ovarian carcinoma and metastatic carcinoma to the ovary (Krukenberg tumors).

Using Ultrasonic Measurement of Cardiac Size in Predicting Congenital Heart Defect

A Duplex Color apparatus equipped with real-time imaging and Doppler sector scanner was used to scan fetal hearts, ranging from 17 to 41 weeks gestational age. A total of 323 normal fetuses were studied. The four-chamber view was obtained in a horizontal section just above the level of the fetal diaphragm. Five variables of the Chinese fetal heart in relation to the width of the right ventricle, width of the left ventricle, ratio of right ventricle/left ventricle (RV/LV), length of the fetal heart and the cardiac volume of a four-chamber view were set against gestational age in weeks and expressed in regression equations. The ratio of RV/LV is quite constant in relation to the gestational age. The mean ranges between 0.9916 for 17 weeks gestation and 1.0045 for a term fetus. In 10 abnormal cases with congenital cardiac defects, using the 5th and the 95th percentiles of this normal data as cutoff points, the RV/LV ratio had the highest sensitivity rate of 70% (7/10) in predicting fetal cardiac anomaly. The width of the left ventricle was the second most sensitive parameter with a sensitivity of 4/10 (40%). The RV/LV ratio of a four-chamber view is a simple, time-saving screening parameter for predicting congenital cardiac defects antenatally.

Two- and three-dimensional Doppler ultrasound analysis of abdominal wall clear cell carcinoma.

The baby was seen by a pediatric surgeon at 4 weeks of age, by which time she was asymptomatic but had developed marked abdominal distention. A magnetic resonance imaging (MRI) examination showed a very large (15 × 10 × 7 cm) apparently unilocular cystic mass with some septa arising in the pelvis and extending into the upper abdomen (Figure 2). At 6 weeks of age an episode of vomiting together with the MRI findings and marked abdominal distention prompted surgical intervention. The infant underwent a laparotomy with excision of a large cyst in the mesentery of the sigmoid colon together with sigmoidectomy with primary anastomosis of the bowel. Postoperative recovery was uneventful. Subsequent histology confirmed the lesion to be a lymphangioma. The baby was discharged home 1 week postoperatively, bottle-feeding well. An abdominal ultrasound examination 4 weeks and 5 months postoperatively were normal. Intra-abdominal cystic masses in newborn infants are not uncommon, and their antenatal detection can improve monitoring and intervention postnatally. Antenatal detection of intra-abdominal lymphangiomas has been reported previously1,2. We report this case

Color Doppler Waveforms of Maternal Cervical Internal Carotid Arteries in Normotensive and Preeclamptic Gravidas

The objective of this study was to investigate and determine fitted percentiles of blood flow resistance of cervical internal carotid arteries in normal pregnancies from gestational weeks 20 to 42 and to compare the resistance indices and mean velocities of the these arteries in normotensive and preeclamptic gravidas. A duplex color apparatus with pulsed Doppler ultrasound scanner (7.5 MHz) was used to determine the resistance index and mean velocity values of maternal cervical internal carotid arteries in 310 healthy singleton gravidas (group 1) and 74 singleton preeclamptic gravidas (group 2). The resistance index and mean velocity values of the maternal cervical internal carotid arteries decrease as the gestational age increases in normal gravidas, whereas in preeclamptic pregnancies these values are no different from those in normal gravidas during the second half of the gestational period.

Two‐ and three‐dimensional transvaginal Doppler ultrasound analysis of urethral clear cell carcinoma

basally located nuclei. Immunohistochemical examination of the cyst wall showed positive staining with cytokeratin 7 (CK7) antibodies and negative staining with CK20. Smooth muscle actin confirmed the presence of smooth muscle fibers, leukocyte common antigen the lymphoid aggregates, and S-100 the peripheral nerve fibers. There was no positive staining for glial fibrillary acidic protein in the cyst wall, ruling out the presence of a neural component to the cyst. There are only three prenatally diagnosed cases of SNS reported in the literature (two by Almog et al.3 and one by Agangi et al.4). In two of these SNS with thoracic openings is described, whereas in the third SNS in the sacrococcygeal region is reported3,4. In one of these cases, SNS was diagnosed just following delivery, whereas in the other two it was diagnosed at 25 and 31 weeks of gestation. Two cases had polyhydramnios. One case delivered following preterm premature rupture of membranes; the other two delivered at term. Two cases were followed up by neurosurgery and pediatric surgery. Four years postnatally, one case, reported by Almog et al., underwent relocation of the stomach to below the diaphragm from its previous location in the posterior mediastinum. The other case, reported by Agangi et al., underwent an initial colostomy followed by anorectoplasty, an anorectal fistula operation and a lipomyelomeningocele operation to help improvement of the neurogenic bladder and bowel function. Both cases reported by Almog et al. were severely kyphoscoliotic, with one exhibiting severe developmental delay most probably due to feeding problems. In the case reported by Agangi et al., neurogenic bladder and bowel dysfunction persisted despite intervention. Unlikely differential diagnoses in this case were a diaphragmatic hernia, usually visualized in the left hemithorax, a thymic cyst, usually located in the anterior mediastinum, and a bronchogenic or pulmonary abnormality, not usually associated with vertebral malformations. The vertebral deformity was far larger than that of a vertebral ‘dissipation’ potentially caused by a neuroblastoma. The prognosis of SNS cases diagnosed postnatally has been revised and reported to be poor by Akgur et al., with 9/14 cases undergoing termination, four surviving and one being lost to follow-up5. It therefore seemed reasonable to offer termination of pregnancy to the couple as a complex malformation possibly involving the neural axis pointed to a probable diagnosis of SNS. The prenatal identification of a thoracic cyst necessitates ruling out the presence of any associated defect in the vertebral column and the gastrointestinal tract. A neuroenteric cyst or SNS should be considered among other possible pathologies.

P43.04: The mean gray value of VOCAL technique can assist in making differential diagnosis of chocolate cyst and other benign ovarian tumor: a preliminary study

Objectives: The first aim was to compare the effectiveness of power Doppler ultrasound with VOCAL technique as an aid in preoperative distinguishing of chocolate cyst (endometrioma) and other benign ovarian tumor. Materials and methods: Eight-seven patient previously diagnosed with benign ovarian tumors received transvaginal, transrectal or transabdominal ultrasounds before they had conservative or operative treatment. Six basic parameters were measured including tumor volume (TV), mean gray value (MGV), vascularity index (VI), flow index (FI), vascularity/flow index (VFI) and serum CA125. VOCAL technique was applied to all patients. After the operations, the data of six parameters were analyzed between two groups. Group 1 was pathologically diagnosed as benign ovarian tumors (serous cystadenoma, mucinous cystadenoma or dermoid cyst) and Group 2 was chocolate cyst. The t test was applied. Results: Sixty-nine patients received laparoscopic tumor resection or laparotomy and 18 patients decided to take regular outpatient follow-up instead of operation. Among 69 patient receiving operations, 43 patients were pathologically diagnosed as chocolate cyst or endometrioma and 26 patients were other benign ovarian tumors including serous cystadenoma, mucinous cystadenoma, dermoid cyst, etc. The MGV was significantly lower in patients with chocolate cyst compared to those with other benign ovarian tumors (P = 0.038). There were no significant correlations between volume, MGV and CA125 in the chocolate cyst group. Conclusion: This study is still ongoing and the present data is preliminary. However, it seems that MGV of VOCAL technique can assist us in making differential diagnosis of chocolate cyst and other benign ovarian tumors.

P02.77: Abnormal Doppler waveforms of umbilical vein, portal vein and ductus venosus in prenatal diagnosis of pentalogy of Cantrell

bones were constantly lying in a side-by-side position and there were only two separate tibias but no fibula. The lower extremities were completely fused, moving together slightly and two feet were fused with the heels. Blood sampling was obtained by cordocentesis for fetal karyotype analyses. The pregnancy was terminated. Karyotype result could not be obtained due to failure in laboratory and plain radiographs of the aborted fetus revealed two femora and two tibias in lower limb of fetus with sirenomelia. Autopsy also revealed a fetus with sirenomelia associated with limb-body wall defect with evisceration of intestine and liver and associated diaphragmatic hernia. Bilateral kidneys were present and fetal bladder was noted. Fetal gender was not distinct. Lower limbs were fused and two femora, two tibias and two feet with disarranged digits were noted. Anomaly was classified as ‘symelia dipus’ according to Foster, and as ‘Type III’ according to Stocker classification.