Callosal injuries in cytomegalovirus fetopathy: a neurosonographic study.

Introduction - This study aimed to describe the rate and pattern of callosal injury in CMV fetopathy. Methods - This retrospective study included fetuses with confirmed CMV-PCR. Dedicated US including neurosonography was performed. Callosal Length below the 5th centile or morphological abnormalities were considered abnormal. Any additional abnormal findings were reported. Results - Seventy-two patients were included. In 76% infection occurred in the 1stT or periconceptional. In 34.7% a callosal anomaly was observed and it was never isolated. CNS abnormalities included: periventricular hyperechogenicity (PVHE) 55.5%, calcifications 52%, ventriculomegaly 33%, periventricular pseudocysts 31.4%, occipital cysts 22.2%, echogenic precaudate germinal matrix 30.5%, LSV 26.4%, sulcation abnormalities 22.2%, cerebellar findings 18% and HC below -2SD 18%. The most common association with CC insult was PVHE (56%) and calcifications (52%). Conclusion - Although not referred to as a classic brain structure affected by CMV infection, the CC was injured in one-third of our patients, including cases of late infection. The mechanism of disease and the prenatal patterns of callosal involvement in these cases appear to be different from the postnatal patterns and are not reversible. The presence of a callosal injury would imply a worse prognosis and a significant increment in the risk of neurodevelopmental impairment.

The normal 14-18 gestational weeks "parasagittal complex" view of the fetal brain. A 3D transvaginal neurosonographic study.

OBJECTIVE: To study the early second trimester development of brain hemispheres, lateral ventricles, choroid plexus, and ganglionic eminence/basal ganglia complex (GEBG). METHODS: A retrospective analysis of TVUS 3D volumes of 14-18 gestational weeks (GW) fetuses. Hemispheres were analyzed for wall thickness, choroid plexus extension, GEBG height and length, lamination pattern (intermediate zone and the subplate border, IZ-SP), ventricle height, width, and angle. Measurements were correlated with GW and assessed for symmetry and impact of probe resolution. RESULTS: We included 84 fetuses (168 hemispheres). The CP location is variable at 14-16 GW, becoming consistently and symmetrically posterior at 18 GW. Hemispheric thickness, GEBG height and length grow significantly with fetal age, whereas ventricle height, width, and angle regress. The detection rate of the IZ-SP line at 14, 15, 16, 17, and 18 weeks was 0%, 24%, 78.26%, 100%, and 100%, respectively. The ratio between the upper and lower segments of the cerebral lamination grows with GW. For all brain structures, the asymmetry between sides was significant only for ventricular height. The transducer type did not have a significant effect on any outcome except for ventricle height. CONCLUSION: These normal features of the parasagittal view should aid clinicians in fetal brain assessment during the early weeks of the second trimester.

A unique brain germinal matrix involvement in cytomegalovirus infected fetuses: A retrospective neurosonographic analysis with outcome correlation.

OBJECTIVE: To study the clinical significance of brain germinal matrix (GM) changes in cytomegalovirus (CMV) infected fetuses. METHOD: This is a retrospective analysis. Group A; isolated GM finding, with or without lenticulostriatal vasculopathy (LSV). Group B; non-isolated lesion. Amniocentesis, urinalysis, postnatal US and developmental assessment, were obtained. RESULTS: Group A and B included 18 and four fetuses, respectively. In group A, mean fetal age at diagnosis was 34.3 weeks (31-38 weeks). In 15/18 (83.3%), the lesion was bilateral and LSV was present in 8/18 (44.4%). Small cysts appeared inside the lesion in 5/18 (27.7%). MRI was normal in 8/18 (44.4%). Subtle or inconclusive findings were reported in the remaining fetuses. Brain ultrasound was normal in 10/18 (55.5%) of newborns. In the remaining, caudothalamic cyst with or without LSV, or isolated LSV were found. All newborns are developing normally at a mean follow-up age of 33.3 months (+/- 19.6 moths). In group B, all four patients requested for termination of pregnancy. CONCLUSION: Fetal CMV infection may cause focal GM changes, frequently accompanied by LSV, late in pregnancy. These changes may be isolated, or as part of a more generalized brain damage. When isolated, favorable prognosis is expected.

The early pattern of human corpus callosum development: A transvaginal 3D neurosonographic study.

OBJECTIVE: To provide an in-vivo description of early corpus callosum (CC) development. METHODS: We reviewed 3D US volumes acquired transvaginally (TVUS) through the anterior fontanelle, between 14 to 17 weeks. The following landmarks were recognized: tela-choroidea (TC), foramina of Moro, early CC and the evolving cavum septi pellucidi. The following measurements were taken: total, anterior and posterior sections, and height of the CC (referenced to the anterior TC border). All measurements were correlated to both the gestational age and the transverse cerebellar diameter (TCD). RESULTS: Eighty nine volumes were included in the study (mean 15.1 weeks ± 0.84, TCD range, 13.1-18.4 mm) with high inter and intra observer correlation of the measurements. We found high correlation between CC length and height, and TCD. The anterior segment of the CC appear earlier than the posterior one, and growth continues bi-directionally. Initially, the posterior elongation is significantly larger than the anterior one. Association of all CC measurements with TCD remained significant when co-varying for maternal age and fetal sex. CONCLUSIONS: imaging the fetal CC is feasible from 14 weeks by TVUS, by following the suggested insonation approach. The early CC develops bi-directionally, and the posterior elongation is more significant than the anterior one.

Ultrasound imaging of the fetal secondary palate: Methodological description of a two-dimensional approach and a case series.

OBJECTIVE: The study aims to describe our two-dimensional (2D) ultrasound approach to visualize the fetal secondary palate and plot its growth curve and to describe and demonstrate its clinical implementation. METHODS: This is a two parts retrospective study. First, we measured the antero-posterior length of the bony secondary palate, from the soft to hard palate interface (SHPI) line to the alveolar ridge, blindly by two operators during routine scans of low-risk fetuses, and plot a longitudinal growth curve. In the second part, we describe four cases of prenatal diagnosis of secondary palate cleft. RESULTS: Sixty-eight fetuses were included: 14 to 15 weeks (n = 20), 21 to 24 weeks (n = 32), and 29 to 35 weeks (n = 16). The bony secondary palate elongates along gestation from a mean of 5.3 mm (+/-0.46 mm) at 14 to 15 weeks to 15.9 mm (+/-1.7 mm) at 29 to 35 weeks. We found high intraobserver and interobserver correlation between measurements. All four cases diagnosed by this approach were confirmed postnatally. CONCLUSIONS: The SHPI, representing the normally developed secondary bony palate, can be imaged in the fetus by direct 2D ultrasound as early as 14 weeks. A gap within or nonvisualization of the SHPI is highly suggestive for a secondary palate cleft.

Early Transient Prenatal Ultrasound Features of Choanal Atresia.

We present a case series of early second-trimester prenatal ultrasound (US) features in 4 fetuses with a confirmed diagnosis of choanal atresia. The clinical characteristics and outcomes evaluated included prenatal US findings, genetic analyses, postmortem autopsies (2 cases), and computed tomographic findings. A transient large nasal cavity was detected by US in all 4 fetuses. This finding disappeared a few weeks later. Three cases were unilateral choanal atresia, and 1 was bilateral. Transient enlargement of the nasal cavity in early pregnancy appears to be a US sign of choanal atresia.

Detection Rate and Sonographic Signs of Trisomy 21 Fetuses at 14-17 Weeks of Gestation.

BACKGROUND: Early prenatal ultrasound is an important part of prenatal screening in Israel. No studies have described the rate of trisomy 21 [T21] identification at 14-17 weeks gestation. OBJECTIVES: To describe the rate of T21 identification by transvaginal sonograms (TVS) at 14-17 weeks gestation. METHODS: We conducted a historical prospective study. Since 1986, early TVS of 72,000 fetuses at 14-17 weeks gestation have been prospectively recorded together with prenatal screening data at a private ultrasound center (AL-KOL, Haifa). We calculated the fraction of T21 cases by dividing the total number of cases with abnormal sonographic findings by the total number of diagnosed T21 cases. We also examined the percentage of verified T21 cases that had completely normal prenatal screening tests prior to the early prenatal TVS, thus revealing the contribution of this examination to the existing prenatal screening. Fisher's exact test was used to calculate odds ratios for each sonographic marker. RESULTS: Of 137 T21 fetuses, 123 had sonographic markers on early TVS, yielding a prediction capability of at least 89.87%. Of all T21 cases, 14% had completely normal nuchal translucency/first-trimester screening prior to the abnormal 14-17 week TVS findings. Isolated abnormal sonographic findings, which were found to increase the risk for T21, were common atrioventricular septal canal (odds ratio 88.88), duodenal atresia (OR 88.23), nuchal edema (OR 39.14), and hydrocephalus (OR 15.78). Fetal hydronephrosis/pyelectasis was non-significant when isolated (OR 1), and cardiac echogenic focus was associated with a decreased risk (OR 0.13). CONCLUSIONS: Early prenatal TVS at 14-17 weeks may identify almost 90% of T21 and adds 14% to the identification rate at the first-trimester screening.

Improving renal phenotype and evolving extra-renal features of 17q12 deletion encompassing the HNF1B gene.

BACKGROUND: HNF1B deletion/intragenic mutations are the most commonly identified genetic cause of congenital anomalies of the kidney and urinary tract (CAKUT) suggested by fetal ultrasound findings such as: parenchymal hyperechogenicity, overt cystic changes or gross morphological urinary system (UT) abnormalities. The postnatal evolution of these 17q12 deletions encompassing the HNF1B gene-associated findings has not been assessed in depth. METHODS: In this observational study, we present postnatal follow-up findings in 5 of 6 cases (one pregnancy was terminated on parental request) of fetal-onset cystic/hyperechogenic kidneys eventually diagnosed with 17q12 microdeletion encompassing the HNF1B gene between 2009 and 2017. RESULTS: Complete normalization of kidney parenchymal abnormalities and of depressed neonatal renal function was observed in 4/5 and 5/5 patients within 2-4.9 years and 1.5-8 months, respectively. All 5 patients had preserved normal renal function at 3-11 years of follow-up. The evolving later-onset renal features included: hypomagnesemia, hyperuricemia, urinary tract infection (UTI), and bilateral grade 3-4 vesicoureteral reflux and bladder diverticula in 3, 3, 2, and 1 patient, respectively. HNF1B gene deletion-associated extra-renal manifestations with delayed presentation were global developmental delay/autistic spectrum disorder (ASD), rolandic-type seizures, overweight, and borderline fasting hyperglycemia observed in 1-2 patients each. Family history was positive for small-size or asymptomatic cystic kidneys with normal function, diabetes mellitus, seizures, and mental/psychiatric problems in 3/6 cases. CONCLUSIONS: Fetal-onset HNF1B deletion-associated kidneys' parenchymal abnormalities confirmed postnatally with initially depressed renal function might undergo complete resolution within several years and few months, respectively. However, later-onset urinary tract, metabolic, and neurodevelopmental features of this mutation might appear over years. Therefore, genetic molecular evaluation/diagnosis and continuous follow-up for evolving features are mandatory in affected children.

A prospective follow-up of two 21/7 cycles followed by two extended regimen 84/7 cycles with contraceptive pills containing ethinyl estradiol and drospirenone.

BACKGROUND: Continuous use of combined oral contraceptives is currently attracting growing interest as a means of improving menstrual related symptoms and reducing the number of bleeding days. OBJECTIVES: To evaluate bleeding patterns, menstrual symptoms and quality of life with an extended 84/7 oral contraceptive regimen versus 21/7 cycles. METHODS: In two consecutive run-in cycles, 30 microg ethinyl estradiol and 3 mg drospirenone tablets taken on days 1-21 were followed by a tablet-free period from days 22 to 28 of each cycle and then by two 84 day cycles of pill use with a 7 day tablet-free interval. The primary outcome was the total number of bleeding/spotting days. Secondary outcomes were severity of daily symptoms, general well-being determined by the PGWBI questionnaire, and overall treatment satisfaction. RESULTS: Of the 137 women invited to participate in the study 109 (aged 18-40 years) were enrolled. The number of bleeding days decreased by about one-third from a calculated 31.8 days of bleeding under a cyclic 21/7 regimen to an expected total of 21.8 days for the extended 84/7 regimen. The incidence of menorrhagia, intermenstrual bleeding, dysmenorrhea, abdominal bloating, breast tenderness, depressive moods and irritability - when compared at enrollment and at the end of the second extended study period--was significantly lower (P < 0.005) among women on the continuous pill regimen. The median (range) global PGWBI scores were not substantially different before and after the extended use cycles: 78.2 (39.1-96.4) and 77.3 (30.9-96.4), respectively. Body weight and skin condition also remained constant. At the completion of the study: 65.5% of the women were either highly satisfied (41.4%) or satisfied (24.1%) with the extended regimen. CONCLUSIONS: The extended 84/7 regimen was found to be satisfactory for the majority of participants and was associated with a decrease in the number of bleeding days and an improvement in menstrual symptoms compared to 21/7 cycles.

Antibubble trajectory during embryo transfers in donor egg IVF does not predict success.

Transient motion of embryo transfer-associated antibubbles was observed. This prospective study was performed to determine if this antibubble movement can predict a successful outcome. Transabdominal ultrasound-guided embryo transfers were performed in 187 recipients receiving identical hormone replacement therapy. All embryo transfers were performed by the first author, using the Sureview embryo transfer catheter, in 30 mul of culture media. Observation was made of the catheter placement in relation to the endometrial surface and uterine fundus during embryo transfer. Ultrasound-guided tracking of antibubble within the uterine cavity was done immediately after the piston was depressed at the time of embryo deposition. The antibubble movement was upwards (group A) in 104 embryo transfers and downwards (group B) in 83 transfers. No movement of embryo-associated air out of the uterine cavity, either into the cervix or the intramural portion of the Fallopian tube, was observed. The clinical pregnancy rate was similar in both groups: 47.12% in group A versus 45.78% in group B. The total implantation rate/embryo transferred was 19.34% in group A compared with 20.07% in group B. The movement of the embryo transfer-associated antibubble is unlikely to be a factor in predicting success in donor egg IVF cycles.

The clinical significance of postpartum transperineal ultrasound of the anal sphincter.

BACKGROUND AND OBJECTIVE: To evaluate the clinical significance of postpartum anal sphincter damage by transperineal ultrasonography (TPUS) performed on the day of delivery. METHODS: Continence questionnaires were handed out and TPUS was performed on 154 consecutive primiparous women 6-24h after vaginal delivery. At 2 and 6 months later, complaints and sphincteric sonographic appearance were reassessed. The puerperal women's clinical status and sonographic findings in the immediate and late postpartum period were evaluated. RESULTS: Thirty-five (23%) women complained of anal incontinence on the first postpartum day and anal sphincter damage was demonstrated by TPUS in 31 (89%) of them. Four women with anorectal complaints had an intact anal sphincter by TPUS. Follow-up questionnaires, 2 months later, revealed 30 symptomatic women: all of them had sonographically recognized tears on the initial TPUS and 27 of them had positive findings on the TPUS performed 2 months after birth. Six months after delivery, 27 women reported symptoms and all of them had sphincteric disruption evidenced on TPUS performed on the day of delivery. All the women with intact sphincter on the initial TPUS were asymptomatic 6 months later. CONCLUSION: TPUS findings on the day of delivery are related to long-term anorectal complaints, supporting a potential role for TPUS as a screening aid for anal sphincter tears.

Renal blood flow alteration after paracentesis in women with ovarian hyperstimulation.

OBJECTIVE: To evaluate renal arterial resistance to flow by Doppler indices concurrently with ascites drainage in women with severe ovarian hyperstimulation syndrome. METHODS: We conducted an interventional clinical study of 19 women with severe ovarian hyperstimulation syndrome, manifested by free peritoneal fluid. The subjects were evaluated before and after therapeutic paracentesis by measuring urine output, blood urea nitrogen, intra-abdominal pressure, and renal artery flow measures by Doppler ultrasonography (systolic/diastolic ratio [S/D] and resistance index). RESULTS: An average of 3,340 mL of ascitic fluid was drained, and the intra-abdominal pressure decreased from 17.5 +/- 1.24 cm H2O to 10 +/- 1.22 cm H2O. Urine output was increased (by 65%, from 925 +/- 248 mL/d before paracentesis to 1,523 +/- 526 mL/d on the day after paracentesis, P <.001). The mean renal arterial S/D decreased from 3 +/- 0.15 to 2.29 +/- 0.13 (P =.001). Most of the decrease in intra-abdominal pressure as well as in renal vasculature resistance was apparent after an initial drainage of 2,000 mL. Additional fluid drainage had only negligible effect on intra-abdominal pressure and renal flow. CONCLUSION: Paracentesis lowered intra-abdominal pressure and decreased renal arterial resistance (lowered S/D and resistance index), ultimately resulting in increased urine production. It is plausible that the beneficial effects of paracentesis on urine output in ovarian hyperstimulation syndrome are due to improved renal blood flow from a direct decompression effect.

Effect of 1 week of oral hydration on the amniotic fluid index.

OBJECTIVE: To evaluate the effect of long-term (1-week) oral hydration on amniotic fluid volume in women with an amniotic fluid index (AFI) < 10th percentile. STUDY DESIGN: This prospective, nonrandomized, interventional study was conducted on 30 women with AFI < 10th percentile. Study inclusion criteria were singleton pregnancy, well-established gestational age, intact membranes, no maternal complications (e.g., hypertension, cardiovascular disease, hyperthyroidism), no evidence of preeclampsia, no fetal structural malformations and no evidence of fetal distress. The women were instructed to drink at least 2L of water daily; their AFI was evaluated before and 1 week after the initiation of oral hydration. The study group was compared to a control group of 30 women matched for age and gestational age, with AFI > 10th and < 90th percentile. RESULTS: AFI increased from 8.1 +/- 0.73 (mean +/- SD) to 11.8 +/- 2.4 1 week later (P < .01) in 25 (83%) of the study subjects. The AFI was similar before and 1 week after oral hydration in all the controls. CONCLUSION: Long-term maternal oral hydration seems to significantly increase the AFI in selected women with reduced fluid and possibly prevents oligohydramnios.

Intrapartum sonographic assessment of labor.

Fetal head progression during labor is difficult to assess. Digital examination has been shown to be an inaccurate method. Utilizing the ultrasound technology in the delivery room can standardize the way we assess head progression. Intrapartum ultrasound is applicable, for the assessment of the progression of labor and assists the obstetrician, in decision making regarding the need for an assisted delivery. This article summarizes the latest studies regarding the usage of ultrasound in the delivery room and the measurements that are used during delivery.

Ultrasonographic evidence of intra-abdominal umbilical vein dilatation: is it a true varix?

Fetal intraabdominal umbilical vein (FIUV) dilatation, or varix, is a rare ultrasonographic (US) finding of focal dilatation of the umbilical vein. This article describes FIUV tortuosity in cases with suspected varix and provides ultrasonographic criteria for its diagnosis. Cases of suspected FIUV varix referred to our unit for final diagnosis and follow-up were studied. Each woman underwent comprehensive US evaluations that included basic grayscale scan and color Doppler scan. In 12 singleton pregnancies, primary grayscale scan confirmed FIUV dilatation. Supplementary color Doppler scans, however, revealed linear bidirectional blood flow and FIUV tortuosity in all cases. Color Doppler scans did not depict true FIUV dilatations or varix but rather a tortuous course of the vein. A normal pregnancy outcome can be expected in these cases.

Embryo transfer using the SureView catheter-beacon in the womb.

OBJECTIVE: To compare the performance of the SureView catheter, a new ultrasonic embryo transfer (ET), with the classic Wallace catheter during ultrasound-guided ET. DESIGN: Prospective, randomized study. SETTING: Private, academically affiliated clinic. PATIENT(S): 175 patients undergoing donor egg in vitro fertilization with ET (IVF-ET). INTERVENTION(S): Ultrasound-guided ET by a single physician with a standardized technique randomly using one of the two catheters. MAIN OUTCOME MEASURE(S): Implantation rate, pregnancy rate, ease of transfer, and visualization of catheter. RESULT(S): The echo-dense tip and the entire length of the SureView catheter were consistently seen with ultrasound guidance. Visualization was statistically significantly better, but there was no statistically significant difference with regard to the ease of transfer. Comparing the SureView with the classic Wallace catheters, the implantation rate (27.76% vs. 23.56%, respectively) and clinical pregnancy rate (41.02% vs. 43.29%, respectively) were similar in both groups. However, the physician using the SureView catheter noted a remarkably superior ease of transfer. CONCLUSION(S): The SureView catheter with its ultrasonic contrast properties simplifies ultrasound-guided ET, but pregnancy rates are similar to those obtained when a classic Wallace catheter is used.

Cervical mucus status can be accurately estimated by transvaginal ultrasound during fertility evaluation.

Examinations of the cervical mucus for determining its quantity and physical characteristics are used to provide a clinical marker for the timing of ovulation. We propose that transvaginal ultrasound, which is routinely used as a tool for monitoring follicular growth in patients undergoing ovulation induction, might also be used simultaneously for estimating cervical mucus measurements. With no additional effort or expense, these data may help to optimize individual patient management.

Estradiol valerate as a possible endocrine reproductive disruptor: evidence from an in vivo rat model.

We used an in vivo rat model to demonstrate that low-dose intradermal exposure to E(2) valerate has an inverse effect on the female's estrus cycle pattern and can significantly reduce litter size. These results suggest that, under certain circumstances, environmental exposure to exogenous estrogens may play a role as an endocrine disruptor and adversely affect reproductive outcome.

Combined clinical and ultrasonographic work-up for the diagnosis of retained products of conception.

Retained products of conception (RPOC) present a major clinical challenge. We assessed the accuracy of an evaluation protocol based on clinical management and transvaginal ultrasonographic evaluation for the detection of retained products of conception. This combined clinical and sonographic evaluation protocol offers a high sensitivity for the accurate diagnosis of RPOC.