Uiko Hanaoka

Three‐dimensional sonographic features of fetal central nervous system anomaly

Objective. To visualize an intracranial structure of the fetal central nervous system (CNS) anomaly using transabdominal three‐dimensional (3D) sonography.

4D ultrasound evaluation of fetal facial expressions during the latter stages of the second trimester

To assess the frequency of fetal facial expressions at 25–27 weeks of gestation using 4D ultrasound.

Three‐dimensional volume‐rendered imaging of normal and abnormal fetal fluid‐filled structures using inversion mode

A total of six normal and eight abnormal fetuses at 16–38 weeks of gestation were studied using transabdominal three‐dimensional sonography with an inversion mode. In normal fetuses, the stomach, gallbladder and bladder could be depicted. In particular, peristalsis of the stomach was noted. In the case of holoprosencephaly, fused hemispheres were evident. In the case of hydrocephalus, the enlargement of ventricular cavities was noted. In the case of bilateral pleural effusion, the spatial relationship and size of the effusions were depicted. In the case of meconium peritonitis, the spatial relationship between the dilated intestines and ascites was depicted. In two cases of hydronephrosis, the dilated renal pelvis and calyces were clearly shown. In the case of multicystic dysplastic kidney, the number and size of cysts were clearly identified. In the case of left ovarian cyst, the anatomical relationships among the ovarian cyst, kidney, stomach and bladder could be easily understood.

Naturally conceived twin pregnancy with hyperreactio luteinalis, causing hyperandrogenism and maternal virilization

Hyperreactio luteinalis (HL) is a marked cystic enlargement of the ovary due to multiple benign theca lutein cysts (1). It is an uncommon condition, and the cause of this disorder is not well known. HL is believed to be induced by elevated serum levels of human chorionic gonadotropins (hCG) (1). It occurs commonly in pregnant patients with trophoblastic disease, occasionally in multiple pregnancies, and rarely in normal pregnancy (2). Maternal virilization occurs in approximately 15% of cases with HL (3). We herein report a case of HL with maternal virilization in spontaneously conceived twin pregnancy. We also report twoand three-dimensional ultrasonographic and MRI features of HL, and discuss its management.

HDlive imaging of intra-amniotic umbilical vein varix with thrombosis

We present a case of intra-amniotic umbilical vein varix with thrombosis using conventional two-dimensional (2D) sonography, power Doppler, three-dimensional (3D) HD-flow, and HDlive at 35 weeks of gestation. 2D sonography showed a large banana-like umbilical cord enlargement (100 × 43.3 × 45.9 mm) including umbilical vein varix (maximum vein diameter = 25.5 mm) with massive thrombosis. Power Doppler and 3D HD-flow revealed bidirectional turbulent blood flow inside the varix. The HDlive clearly demonstrated fragile massive thrombosis inside the varix. Elective cesarean section was performed on the same day in order to avoid additional risks of umbilical cord complications and umbilical venous embolism. A male infant weighing 2501 g was delivered with an umbilical artery pH of 7.334, and Apgar score of 8/9 at 1 and 5 min, respectively. The macroscopic and microscopic findings revealed umbilical cord vein varix with thrombosis. On the basis of the laboratory date of the neonate, the diagnosis of consumptive coagulopathy was made. However, the neonate followed a favorable course after delivery.

Three-dimensional HDlive rendering image of cystic hygroma

Three-dimensional (3D) HDlive rendering images with both adjustable lighting and new skin-like colors give the normal embryo and fetus, fetal anomalies, and intrauterine abnormalities a natural and anatomically realistic appearance [1–4]. Cystic hygroma is characterized by septated fluid-filled sacculations of the bilateral neck and nuchal region that result from lymphatic dysplasia [5]. We present our experience of cystic hygroma reconstructed employing the three-dimensional (3D) HDlive rendering mode. A total of three cystic hygromas at 11-17 weeks’ gestation were studied employing transvaginal or transabdominal 3D sonography with the HDlive rendering mode (VOLUSON E8, General Electric Medical Systems, Zipf, Austria). Using a curved array transabdominal transducer (4–8.5 MHz) or mechanical transvaginal transducer (4.5–11.9 MHz), the sweep took less than a few seconds at an angle of 70 –85 . The data set was stored on a 700-MB CD-R and could be retrieved for further analysis [3, 4]. All volume data for each fetus were examined, and optimal images were selected for further analysis. Three-dimensional reconstruction was carried out using the HDlive rendering algorithm. The light source was adjusted until the structures of interest were visualized for the examiner to create favorable lighting and shadowing effects [4]. The 3D HDlive rendering mode provided new realistic sensations for the diagnosis of cystic hygroma (Figs. 1, 23). There have been three reports on conventional 3D sonographic diagnosis of cystic hygroma [5–7]. However, conventional 3D surface rendering images are not realistic. In the present report, the 3D HDlive rendering mode provided extraordinarily natural and realistic imaging of cystic hygroma, with greater detail and clarity than are possible with conventional 3D sonography. In particular, the 3D HDlive rendering mode provides new realistic sensations for the diagnosis of cystic hygroma in utero, and it seems to be almost impossible to differentiate between gross specimens and 3D HDlive rendering images, because nearphotographic images were obtained by employing the 3D HDlive rendering mode.

Three‐dimensional sonographic volume measurement of the fetal spleen

Aim:  The objective of this longitudinal study was to evaluate the growth of the fetal lung in normal pregnancies, using 3‐D ultrasound.

4D ultrasound study of fetal facial expressions at 20–24 weeks of gestation

To assess the frequency of fetal facial expressions at 20–24 weeks of gestation using four‐dimensional (4D) ultrasonography and to determine whether there was any correlation between facial expression and gestational age (20–34 weeks).

Three-dimensional HDlive rendering images of the TRAP sequence in the first trimester: reverse end-diastolic umbilical artery velocity in a pump twin with an adverse pregnancy outcome.

The twin reversed arterial perfusion (TRAP) sequence, also known as fetus acardius, occurs in 0.3 % of monozygotic twin gestations, which amounts to a frequency of about 1 per 35,000 deliveries [1, 2]. There have been only two reports on antenatal three-dimensional (3D) sonographic diagnosis of the TRAP sequence during pregnancy [3, 4]. The HDlive is a new surface render mode involving the use of skin-like colors, and ‘‘its system uses an adjustable light source, giving the operator the opportunity to create lighting and shadowing effects and thereby increasing depth perception’’ [5]. There have been four reports on fetal, placental, and umbilical cord ultrasound images using the 3D HDlive rendering mode [5–8]. Employing 3D HDlive with new skin-like colors, we can achieve a natural and anatomically realistic appearance of the embryo and fetus in utero. However, there has been no reports on 3D HDlive rendering displays of the TRAP sequence in the first trimester of pregnancy. There have been five reports on reverse end-diastolic velocity in umbilical artery velocimetry with an adverse pregnancy outcome at less than 14 weeks of gestation, which suggested that reverse end-diastolic umbilical artery velocity waveforms might be an ominous sign in early pregnancy [9–13]. However, there are no sonographic findings in the first trimester that can help to distinguish between pregnancies resulting in death of the pump twin from those that will survive until prophylactic intervention at 16–18 weeks in TRAP sequence cases [14]. In this report, we present our experience of a TRAP sequence reconstructed employing the 3D HDlive rendering mode, and discuss the reverse end-diastolic blood flow velocity waveform in the umbilical artery of a pump twin with an adverse pregnancy outcome in the first trimester. A 33-year-old pregnant Japanese woman, gravida 1, para 0, was referred to our ultrasound clinic because of a suspected TRAP sequence at 11 weeks and 6 days of gestation. The 2D sonography and the 3D surface rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA) showed a normal pump twin and small acardiac twin with acrania and absence of the heart and upper limbs (Fig. 1). The crown-rump length of the pump twin was 43.3 mm (consistent with the corresponding age), and no gross fetal anomaly was noted. The longitudinal distance between the upper pole and rump of the acardiac fetus was 27.6 mm. The 3D HDlive rendering mode provided anatomically realistic images for TRAP sequence diagnosis (Fig. 2). Color and pulsed Doppler sonography revealed a reverse end-diastolic umbilical artery velocity in the pump twin at 13 weeks and 1 day of gestation (Fig. 3a). There was a single-artery umbilical cord between the placenta and acardiac fetus, and a reversed tiny absent diastolic umbilical artery velocity was noted (Fig. 3b). Fetal demise of the pump twin was confirmed at 14 weeks’ gestation. Delivery C. Tenkumo H. Tanaka M. Ito E. Uketa N. Mori U. Hanaoka K. Kanenishi T. Hata (&) Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp

HDlive rendering image of cyclopia and a proboscis in a fetus with normal chromosomes at 32 weeks of gestation

The HDlive rendering mode with both adjustable lighting and new skin-like colors gives the embryo and fetus a natural and anatomically realistic appearance, and there have been a few reports on antenatal 3D HDlive rendering images of fetal superficial abnormalities [1]. We present our first experience of cyclopia and a proboscis in a fetus with normal chromosomes at 32 weeks of gestation reconstructed employing the 3D HDlive rendering mode. A 34-year-old woman, gravida 4, para 3, was referred to our ultrasound clinic at 32 weeks of gestation because of fetal holoprosencephaly, fetal proboscis, suspected diaphragmatic hernia, suspected fetal growth restriction (FGR), and hydramnios. She had received insulin injections since 21 weeks of gestation during this pregnancy because of type 2 diabetes. Two-dimensional (2D) sonography (Voluson E8, GE Healthcare, Milwaukee, WI, USA) revealed fetal alobar holoprosencephaly, cyclopia, a proboscis, diaphragmatic hernia, ventricular septal defect, FGR [estimated fetal weight was 1,418 g (-1.6 SD)], and hydramnios. The 3D HDlive rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA; curved array transabdominal transducer, 2–8 MHz) clearly depicted cyclopia and a proboscis (Fig. 1). Amniocentesis was performed at 32 weeks and 4 days, and chromosome analysis showed 46XY. At 36 weeks of gestation, a male infant weighing 2,140 g was delivered vaginally, with an umbilical artery pH of 7.431, and Apgar scores of 4 and 2 at 1 and 8 min, respectively. The baby died 2 h after delivery. Permission to conduct an autopsy was not granted by the parents. However, postmorten examination of the neonate confirmed the presence of cyclopia and a proboscis (Fig. 2). The 3D HDlive rendering images of the fetal face are more readily discernible than those obtained by conventional 3D sonography because the 3D HDlive rendering mode provides such extraordinarily realistic imaging of the fetal face that it is almost impossible to differentiate between actual photographs and HDlive scans [2]. In the present case, the 3D HDlive rendering mode showed the same anatomically realistic images with macroscopic findings of cyclopia and a proboscis. The 3D HDlive rendering mode has the potential to supplement conventional 2D ultrasound in diagnosing fetal facial anomalies, and it can assist in the prenatal understanding of the diagnostic challenges of complicated fetal facial anomalies [1].