Mohamed Ahmed Mostafa AboEllail

Diagnosis of truncus arteriosus in first trimester of pregnancy using transvaginal four‐dimensional color Doppler ultrasound

We present our experience of using transvaginal three/four-dimensional (3D/4D) color Doppler with glass-body rendering mode and spatiotemporal image correlation (STIC) software to construct an image of persistent truncus arteriosus in the first trimester of pregnancy. There have been numerous reports on the antenatal diagnosis of truncus arteriosus using two-dimensional (2D) grayscale echocardiography, color Doppler and multiplanar display in 3D/4D ultrasound1–3; however, to the best of our knowledge, this is the first report on the antenatal diagnosis of truncus arteriosus using transvaginal

HDlive imaging of circumvallate placenta

Circumvallate placenta is a morphological placental abnormality in which the chorionic plate is smaller than the basal plate, resulting in the folding back of placental and fetal membranes towards the chorionic surface. There have been numerous reports on the antenatal diagnosis of circumvallate placenta using two-dimensional (2D) and three-dimensional ultrasound1–4, however, to the best of our knowledge, this is the first to present HDlive and HDlive silhouette mode imaging for the prenatal diagnosis of a circumvallate placenta. A 26-year-old pregnant Japanese primigravida was referred to our hospital at 14 + 5 weeks’ gestation because of a suspected placental tumor. 2D sonography (Voluson E8, GE Healthcare Ultrasound, Milwaukee, WI, USA) showed a single live fetus with biometry consistent with gestational age. Placental examination revealed an increased thickness (29 mm) with irregular anechoic areas on the periphery of the fetal surface. Subsequent color Doppler showed no blood flow within these areas. HDlive mode revealed a slightly curved placental edge with the umbilical cord attached at the center of the placenta and demonstrated an elevated lobule located at the center of the placenta. At 16 + 5 weeks’ gestation, HDlive mode depicted clearly a central depression in the placenta with thick edges folded upon themselves, forming rolled-up placental margins (Figure 1). Two weeks later, follow-up ultrasound with HDlive mode revealed the umbilical cord attached to the central depressed area of the placenta, which was surrounded by thick, scalloped placental edges (Figure 2a). HDlive silhouette mode (Voluson E10, GE Healthcare Ultrasound) depicted the thickened, curved edges of the placenta and the central depressed region to which the umbilical cord was attached. Chorionic surface vessels were seen branching out from the umbilical cord over the fetal surface of the placenta to form the villous tree (Figure 2b). Fetal growth was normal and no fetal anomalies were detected during pregnancy. At 38 + 3 weeks’ gestation, Cesarean section was performed due to non-reassuring fetal heart rate patterns, and a 2834-g female, 49 cm in

Four-Dimensional Power Doppler Sonography With the HDlive Silhouette Mode in Antenatal Diagnosis of a Right Aortic Arch With an Aberrant Left Subclavian Artery

Aortic arch anomalies develop as a result of abnormal regression of one of the pharyngeal arches, resulting in abnormalities in the aortic arch position or branching pattern.1 They may present alone or associated with other congenital heart defects. The most common type is the right aortic arch (RAA), with an estimated incidence of approximately 0.1%.2 An association of a right aortic arch with 22q11 microdeletion has been reported.1,3 There have been numerous reports on the antenatal diagnosis of a right aortic arch with an aberrant left subclavian artery using 2dimensional (2D) echocardiography, 2D color Doppler sonography, and 3-dimensional (3D) power Doppler sonography.1,2,4–6 However, to the best of our knowledge, the use of 4-dimensional (4D) power Doppler sonography with the HDlive silhouette mode (GE Healthcare Japan, Tokyo, Japan) for the antenatal diagnosis of a right aortic arch with an aberrant left subclavian artery has not been reported previously. A 37-year-old primigravida was referred to our ultrasound clinic at 29 weeks’ gestation because of a suspected right-sided descending arch. Two-dimensional sonography (Voluson E8; GE Healthcare Japan) showed a single living fetus with biometric measurements consistent with gestational age. Two-dimensional fetal echocardiography showed an abnormal 3-vessel and trachea view, and the aortic arch was present on the right side of the trachea, with the ductus arteriosus on the left side of the trachea, connected by a vascular segment behind the trachea (diverticulum of Kommerell). An aberrant left subclavian artery originating from the diverticulum of Kommerell was suspected. There was no other fetal abnormality. At 34 weeks, 2D power Doppler sonography with a 3vessel and trachea view (Voluson E10) showed the pulmonary artery, right aortic arch, superior vena cava, and a vascular ring around the trachea. Also, the azygos vein and right pulmonary vessels were visualized (Figure 1A). Fourdimensional power Doppler sonography with the HDlive silhouette mode clearly showed the vascular ring around the trachea at the level of the upper mediastinum in addition to the spatial 3-vessel view (Figure 1B and Video 1). The descending aorta was noted on the right anterior side of the spine. An aberrant left subclavian artery originating from the diverticulum of Kommerell was clearly identified (Figure 1C and Video 2). A diagnosis of a right aortic arch with an aberrant left subclavian artery was made. At 41 weeks’ gestation, a cesarean delivery was performed because of rupture of membranes while the head was unengaged, resulting in a male neonate weighing 4054 g with a height of 51 cm. The Apgar scores were 8 at 1 minute and 9 at 5 minutes, and the umbilical artery pH was 7.301. Neonatal echocardiography confirmed the diagnosis of a right aortic arch with an aberrant left subclavian artery. The diagnosis of aortic arch anomalies is a challenging task for obstetricians. The axial view of the upper mediastinum (namely, 3-vessel and trachea view) is an approach to evaluating the aortic arch by visualizing the V-shaped configuration formed by the junction of the aortic and ductal arches, with the trachea present posteriorly under normal conditions.2 However, detailed and precise detection of the branching pattern is mandatory to differentiate a right aortic arch from other aortic arch anomalies.7 Aortic arch anomalies have also been reported to be closely associated with genetic disorders and multiple congenital cardiac anomalies; therefore, accurate identification of the anatomic changes is needed for improved postnatal management. In this case, 2D echocardiography showed the loss of the V-shaped confluence of the 3-vessel and trachea view. Two-dimensional power Doppler sonography was beneficial, as it showed the vascular ring around the trachea formed by the ductus arteriosus, descending aorta, diverticulum of Kommerell, and right aortic arch. Fourdimensional power Doppler sonography with the HDlive silhouette mode facilitated a spatial 3-vessel view, which showed the relationship and size comparison among them. Therefore, 3D reconstruction of a typical vascular ring was clearly shown. Moreover, an aberrant left subclavian artery was clearly shown, as well as the azygos vein and right pulmonary vessels. The key point is that the relationship of these vessels with the spine could be understood because the spine can be seen by using the HDlive silhouette mode. The descending aorta was noted on the right anterior side of the spine. This finding is another important diagnostic clue in cases of a right aortic arch,1 which cannot be obtained with conventional 3D power Doppler sonography. Therefore, accurate localization and description of the branching patterns of great arteries and an improved understanding of the spatial relationship are easily possible. Fourdimensional power Doppler sonography with the HDlive silhouette mode combines the advantages of a spatial view of great vessels in addition to visualization of the spine as a landmark. Its use may provide potential advantages in the

Does ethnicity have an effect on fetal behavior? A comparison of Asian and Caucasian populations.

Abstract Aim: This study aimed to evaluate the ethnic difference in fetal behavior between Asian and Caucasian populations. Methods: Fetal behavior was assesed by Kurjak’s antenatal neurodevelopmental test (KANET) using four-dimensional (4D) ultrasound between 28 and 38 weeks of gestation. Eighty-nine Japanese (representative of Asians) and seventy-eight Croatian (representative of Caucasians) pregnant women were studied. The total value of KANET score and values of each parameter (eight parameters) were compared. Results: The total KANET score was normal in both populations, but there was a significant difference in total KANET scores between Japanese (median, 14; range, 10–16) and Croatian fetuses (median, 12; range, 10–15) (P<0.0001). When individual KANET parameters were compared, we found significant differences in four fetal movements (isolated head anteflexion, isolated eye blinking, facial alteration or mouth opening, and isolated leg movement). No significant differences were noted in the four other parameters (cranial suture and head circumference, isolated hand movement or hand to face movements, fingers movements, and gestalt of general movements). Conclusion: Our results suggest that ethnicity should be considered when evaluating fetal behavior, especially during assessment of fetal facial expressions. Although there was a difference in the total KANET score between Japanese and Croatian populations, all the scores in both groups were within normal range. Our results indicate that ethnical differences in fetal behaviour do not affect the total KANET score, but close follow-up should be continued in some borderline cases.

Three‐dimensional power Doppler with silhouette mode for diagnosis of malignant ovarian tumors

Correspondence to: Dr T. Hata, Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0763, Japan (e-mail: toshi28@med.kagawa-u.ac.jp) chemotherapy, approximately 5 years later. She subsequently presented with abdominal bloating and was referred to our hospital because of suspected bilateral ovarian masses. Ultrasound imaging with HDlive silhouette mode demonstrated cystic components of varying size within the ovarian tumors, producing a lettuce-like appearance (Figure 1). HDliveFlow with HDlive silhouette mode (Voluson E10 GE Healthcare Japan, Tokyo, Japan) showed in both tumors the main penetrating blood vessel, its branches forming a dense vascular network (vascular tree-like pattern) (Figure 2). A preoperative diagnosis of Krukenberg tumors was suggested. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination of both adnexal masses confirmed Krukenberg tumor.

Is there a sex difference in fetal behavior? A comparison of the KANET test between male and female fetuses.

Abstract Aim: To evaluate the sex difference in fetal behavior between male and female fetuses. Methods: Fetal behavior was assesed by Kurjak’s antenatal neurodevelopmental test (KANET) using four-dimensional (4D) ultrasound between 28 and 39 weeks of gestation. Fifty-nine male and 53 female fetuses in middle- and high-class nulliparaous Japanese women were studied. The total value of the KANET score and values of each parameter (eight parameters) were compared. Results: The total KANET score was normal in both groups, and there was no significant difference in the total KANET score. When individual KANET parameters were compared, no significant differences were noted in all eight parameters. Conclusion: Our results show that there is no difference in fetal behavior between male and female fetuses in the third trimester of pregnancy. These results suggest that 4D ultrasound study examining fetal behavior does not need to consider the factor of fetal sex.

New 3D power Doppler (HDliveFlow) with HDlive silhouette mode for diagnosis of malignant ovarian tumor.

Correspondence to: Dr T. Hata, Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0763, Japan (e-mail: toshi28@med.kagawa-u.ac.jp) chemotherapy, approximately 5 years later. She subsequently presented with abdominal bloating and was referred to our hospital because of suspected bilateral ovarian masses. Ultrasound imaging with HDlive silhouette mode demonstrated cystic components of varying size within the ovarian tumors, producing a lettuce-like appearance (Figure 1). HDliveFlow with HDlive silhouette mode (Voluson E10 GE Healthcare Japan, Tokyo, Japan) showed in both tumors the main penetrating blood vessel, its branches forming a dense vascular network (vascular tree-like pattern) (Figure 2). A preoperative diagnosis of Krukenberg tumors was suggested. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination of both adnexal masses confirmed Krukenberg tumor.

HDlive Flow with HDlive silhouette mode in diagnosis of fetal hepatic hemangioma

Tumors affecting the liver are rare in fetal and infant life, with hemangioma being the most common1. Fetal hepatic hemangiomas on two-dimensional (2D) ultrasound are well-defined, mixed solid and cystic tumors with punctate calcifications in 50% of the mass. Hypoechoic areas represent vascular structures with low resistance on color Doppler imaging2. Here we describe our experience of HDlive Flow with HDlive silhouette mode in diagnosing fetal hepatic hemangioma in the third trimester of pregnancy. A 28-year-old Japanese woman, gravida 3 para 1, was referred to our clinic at 29 + 3 weeks of gestation because of a suspected fetal intra-abdominal tumor. Ultrasound examination (Voluson E10, GE Healthcare Japan, Tokyo, Japan) revealed on 2D imaging an intra-abdominal, well-defined, mixed solid tumor (45 × 40 × 23 mm) with cystic lesions and punctate calcification, located on the left side of the fetal stomach (Figure 1a). Imaging with HD-Flow demonstrated moderate blood flow within the mass (Figure 1b). HDlive Flow with HDlive silhouette mode at 30 + 2 weeks demonstrated a vascular pattern within the mass characterized by multiple, closely packed blood vessels with differing directions of blood flow, giving a pomegranate-like appearance (Figure 2 and Videoclip S1). The feeder artery was identified clearly originating from the celiac artery. Magnetic resonance imaging (MRI) showed a well-defined, hypervascularized tumor on the left side of the liver (Figure S1). A diagnosis of fetal hepatic hemangioma was suggested. At 37 + 2 weeks, elective Cesarean section was performed to avoid possible intrapartum rupture of the

HDLiveSilhouette Inversion Mode in Diagnosis of Complete Hydatidiform Mole: HDLiveSilhouette Inversion Mode of Complete Mole

We present our experience of using the HDLive silhouette inversion mode to assess complete hydatidiform mole early in pregnancy. The HDLive silhouette inversion mode clearly depicted the number, size, and spatial position of molar vesicles, compared with conventional two‐dimensional sonography or the HDLive inversion mode. Moreover, spatial relationships among molar vesicles, intrauterine anechoic fluid collection, and the uterine wall enabled the clear localization of the lesion. This technique provides new insights, and has the potential to supplement conventional two‐dimensional sonography in the diagnosis of complete hydatidiform mole.

HDlive imaging in diagnosis of uterine artery pseudoaneurysm during pregnancy

A uterine artery pseudoaneurysm (UAP) is a rare condition during pregnancy1. HDlive Flow with HDlive silhouette mode facilitates the spatial visualization of blood vessels whilst simultaneously displaying landmarks of the surrounding anatomical structures2. We used this imaging technique in the diagnostic work up of a woman with UAP during pregnancy. A 35-year-old Japanese primigravida was referred to our clinic because echo-free spaces had been observed in her cervix on ultrasound examination at 34 weeks