M. Dalloul

Fetal clavicle length throughout gestation: a nomogram

To create a nomogram of fetal clavicle length (CL) throughout gestation.

Nomograms of the axial fetal cerebellar hemisphere circumference and area throughout gestation

The widely applied transcerebellar diameter (TCD) obtained at axial cranial imaging, measures the distance between the lateral aspects of the cerebellum and incorporates the width of the cerebellar vermis. Our objective was to create reference ranges of axial fetal cerebellar hemisphere circumference (CHC) and area (CHA), independent of the cerebellar vermis, throughout gestation.

Nomograms of sonographic measurements throughout gestation of the fetal hard palate width, length and area

To assess the feasibility of sonographic depiction of the fetal hard palate and secondarily to create nomograms throughout gestation of its sonographic width, length and area.

Transient bilateral ovarian enlargement associated with large retroperitoneal lymphoma.

Bilateral ovarian enlargement may reflect benign or malignant processes of the ovary. Benign causes of ovarian enlargement include luteomas, tumors such as mature cystic teratomas, fibrothecomas, cystadenomas and rare conditions including capillary hemangioma and massive edema of the ovaries. Ovarian malignancies include epithelial, stromal and germ‐cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma. We present an unusual case in which a patient presenting with weakness and mild lower abdominal and pelvic pain was noted at sonography to have bilaterally enlarged ovaries with features similar to those of massive ovarian edema as described previously, which has been associated with venous and lymphatic obstruction. Subsequent computerized tomography (CT) imaging depicted a large retroperitoneal tumor, CT‐guided biopsy of which revealed diffuse large B cell lymphoma. The patient responded well to chemotherapy with significant shrinkage of the tumor, and reappearance of normal findings on ovarian sonography. This case demonstrates that bilaterally enlarged ovaries may be the first clinical evidence of a large retroperitoneal tumor and that in such cases CT imaging may be warranted. Copyright

Is fetal cerebral vascular resistance affected by the presence of nuchal cord(s) in the third trimester of pregnancy

To assess whether fetal cerebral vascular resistance is affected by the presence of nuchal cord(s) in the third trimester.

Mature cystic teratoma of the sigmoid colon

A 38-year-old woman, gravida 4 para 2, was followed at the State University of New York (SUNY), Downstate Medical Center, during her current pregnancy. Her medical history was unremarkable other than asymptomatic bilateral ovarian dermoid cysts documented sonographically prior to pregnancy, for which she declined surgical management. She denied any history of pelvic pain. Her pregnancy was uneventful but, because of fetal macrosomia, she elected to undergo primary Cesarean delivery at term with concurrent bilateral resection of the dermoid cysts. A male infant weighing 4200 g was delivered through a transverse lower segment uterine incision. Apgar scores were 9 and 9 at 1 and 5 min, respectively. Dense pelvic adhesions were encountered. Bilateral ovarian cystectomy (left and right cysts measuring 10 × 7 × 4 cm and 8.5 × 8 × 4 cm, respectively), was performed without difficulty. The sigmoid colon was inseparable from the right utero-ovarian ligament, yet distinctly separate from the right ovary, and contained a palpable solid intraluminal mass measuring 5 cm. Due to the suspicion of gastrointestinal malignancy, resection of the sigmoid colon containing this mass was performed with end-to-end anastomosis. Pathological examination of the resected sigmoid colon demonstrated a 5-cm mature cystic teratoma (containing hair and a tooth) within the lumen and in continuation with its wall (Figure 1). The patient’s postoperative course was unremarkable, and both mother and infant were discharged in good health on postoperative day 6. Distinctive sonographic features of mature cystic teratomas of the ovary include the presence of highly

Anterior (nasofrontal) encephalocele and chondrodysplasia at 21 weeks' gestation

Neural tube defects affecting the cranial vault are termed encephaloceles. The incidence of encephalocele is approximately one to four in 10 000 live births (Monteagudo et al., 1992; Tsai et al., 2006). The vast majority 75 to 80% of encephaloceles involve the occipital area, 15% the frontal area, and the remainder the parietal area (Monteagudo et al., 1992; Tsai et al., 2006). Encephaloceles are often associated with a wide spectrum of additional anomalies (Budorick et al., 1995). We present the first report of a fetus with an encephalocele and (pathology proven) chondrodysplasia, describe three-dimensional sonographic features of an anterior (nasofrontal) encephalocele at 21 weeks’ gestation, and depict the associated bony defect in the ethmoid bone. A 30-year-old para 1 late registrant presented at 21 weeks’ gestation. Her medical and family history were unremarkable and her previous pregnancy and delivery were uncomplicated. Ultrasound depicted a singleton fetus with overall normal appearing fetal anatomy, appropriate for gestational age biometry (including all long bones that were normal in length and appearance) and amniotic fluid volume. Sagittal and axial sonography of the fetal face depicted a midline soft-tissue mass measuring 1.5 × 1.5 × 1 cm projecting anteriorly from the lower aspect of the fetal forehead above the nasal bridge and between the fetal orbits (Figure 1). A markedly widened junction was noted between the frontal and nasal bones (Figure 1). In addition, a deficit in the ethmoid bone underlying the mass was suspected at axial scanning (Figure 2). The softtissue mass appeared to contain both tissue and fluid. The fetal nose, nostrils, upper, and lower lips appeared normal, with no midline defects. Other than the abovementioned frontal soft-tissue mass, cranial (including orbits), intracranial structures, and spine were normal, without evidence of hydrocephalus. Three-dimensional ultrasound frontal and oblique views of the fetal face

Point‐of‐care sonographic diagnosis of maternal small bowel obstruction during pregnancy

The incidence of bowel obstruction in pregnancy is approximately 1 in 17 000 deliveries and is not increased in comparison to the non-pregnant population1. Approximately 50% of cases result from postsurgical adhesions, including those associated with Cesarean delivery1,2. Small bowel obstruction is considered a catastrophic complication of pregnancy with a reported overall risk of fetal loss of 17% and a maternal mortality rate of 2%2. Sonography has been demonstrated to be superior to plain radiography in the assessment of non-pregnant patients with suspected small bowel obstruction3, however, diagnosis is considered more difficult during pregnancy2. Here we describe two cases of maternal small bowel obstruction diagnosed during pregnancy by point-of-care transabdominal ultrasound. A 30-year-old primiparous woman presented at 27 weeks’ gestation, complaining of abdominal discomfort, nausea, vomiting and obstipation. Her medical history included right salpingectomy for a tubal pregnancy. Transabdominal ultrasound examination was performed and the fetus was considered appropriate in size for gestational age (AGA). Markedly dilated loops of maternal small bowel containing fluid and edematous bowel wall were observed (Figure 1). Prominent ‘to and fro’ peristalsis was visualized in the small bowel and free fluid was noted in the cul-de-sac. Maternal small bowel obstruction was suspected and was confirmed by computed tomography. Following unsuccessful conservative treatment, laparotomy was performed and a mechanical obstruction due to adhesions was identified and released. On the third postoperative day, the patient delivered precipitously a 1260-g infant. Both mother and infant were well at the time of writing. A 26-year-old primiparous woman presented at 34 weeks’ gestation with worsening abdominal discomfort, nausea, vomiting and obstipation. Her medical history included laparoscopic cholecystectomy and right ovarian cystectomy. Serum levels of aspartate aminotransferase and alanine aminotransferase were elevated at 113 U/L and 175 U/L, respectively. Qualitative urine dipstick analysis revealed proteinuria of 2+ and ketonuria of 4+. Transabdominal ultrasound examination showed the fetus to be AGA. Sonography of the maternal upper abdomen revealed numerous dilated loops of small bowel, edematous small bowel walls (Figure 2), marked ‘to and fro’ peristalsis and free fluid in the peritoneal cavity. Small bowel obstruction was suspected and was confirmed by magnetic resonance imaging. The patient received 4 L of intravenous fluids and Figure 1 Transabdominal ultrasound images in a pregnant woman at 27 weeks’ gestation, showing dilated loops of maternal small bowel and small bowel wall edema (a) and prominent mucosal folds projecting perpendicular to the edematous small bowel wall (b).

Spontaneous first-trimester perforation of the uterus following Cesarean scar pregnancy choriocarcinoma.

Gestational trophoblastic disease (GTD) encompasses a heterogeneous group of lesions with specific clinical features, morphological characteristics and pathogenesis1. The World Health Organization (WHO) modified classification of GTD includes: complete and partial hydatidiform mole, invasive mole, choriocarcinoma, placental site trophoblastic tumor, exaggerated placental site and placental site neoplasms1. Gestational choriocarcinoma is a highly malignant epithelial tumor originating from the trophoblast of any type of gestational event, most often a hydatidiform mole1, and usually arises in the uterine body. Extrauterine choriocarcinoma is a rare entity, with the incidence of primary Fallopian tube choriocarcinoma estimated to be one in every 1.6 million intrauterine pregnancies1. Although symptoms of gestational choriocarcinoma are highly variable, abnormal uterine bleeding is one of the most frequent presentations. Uterine perforation by choriocarcinoma is an unusual event, which has been reported previously2. We report an unusual case in which a patient undergoing evaluation for a suspected late first-trimester ectopic pregnancy was found at laparotomy to have choriocarcinoma perforating through a ruptured previous transverse anterior lower uterine scar. A 34-year-old woman, para 3, presented at 13 + 5 weeks’ gestation, according to last menstrual period, complaining of mild pelvic discomfort and mild uterine hemorrhage lasting for 24 h. Her obstetric history was significant for a Cesarean delivery in her first pregnancy followed by successful vaginal birth in her second pregnancy. Her third delivery was by repeat Cesarean section. Her current pregnancy was unplanned and she had not received prenatal care. On evaluation she was in good general health and in no acute distress. She was afebrile with blood pressure of 120/80 mmHg and heart rate of 84 bpm. Her abdomen was soft with mild lower tenderness, yet no signs of peritoneal irritation were present. Bimanual examination was suggestive of an ill-defined enlarged, mildly tender uterus, with no abnormal adnexal findings. Her cervix was long and closed. Laboratory examinations revealed

Prenatal sonographic diagnosis of acardiac twin embedded within placenta

Twin reversed arterial perfusion (TRAP), sequence resulting in an acardiac twin is a unique complication of monozygotic twin pregnancies sharing a monochorionic (and usually monoamniotic) placenta, in which anastomoses connect the two fetoplacental circulations.1,2.