Esophageal atresia and tracheoesophageal fistula: prenatal sonographic manifestation from early to late pregnancy.

OBJECTIVE: Esophageal atresia and/or tracheoesophageal fistula (EA/TEF) remains one of the most frequently missed congenital anomalies prenatally. The aim of our study was to elucidate the sonographic manifestation of EA/TEF throughout pregnancy. METHODS: This was a retrospective study of data obtained from a tertiary center over a 12-year period. The prenatal ultrasound scans of fetuses with EA/TEF were assessed to determine the presence and timing of detection of three principal signs: small/absent stomach and worsening polyhydramnios, both of which were considered as 'suspected' EA/TEF, and esophageal pouch, which was considered as 'detected' EA/TEF. We assessed the yield of the early (14-16 weeks' gestation), routine mid-trimester (19-26 weeks) and third-trimester (≥ 27 weeks) anomaly scans in the prenatal diagnosis of EA/TEF. RESULTS: Seventy-five cases of EA/TEF with available ultrasound images were included in the study. A small/absent stomach was detected on the early anomaly scan in 3.6% of fetuses scanned, without a definitive diagnosis. On the mid-trimester scan, 19.4% of scanned cases were suspected and 4.3% were detected. On the third-trimester anomaly scan, 43.9% of scanned cases were suspected and 33.9% were detected. An additional case with an esophageal pouch was detected on magnetic resonance imaging (MRI) in the mid-trimester and a further two were detected on MRI in the third trimester. In total, 44.0% of cases of EA/TEF in our cohort were suspected, 33.3% were detected and 10.7% were suspected but, eventually, not detected prenatally. CONCLUSIONS: Prenatal diagnosis of EA/TEF on ultrasound is not feasible before the late second trimester. A small/absent stomach may be visualized as early as 15 weeks' gestation. Polyhydramnios does not develop before the mid-trimester. An esophageal pouch can be detected as early as 22 weeks on a targeted scan in suspected cases. The detection rates of all three signs increase with advancing pregnancy, peaking in the third trimester. The early and mid-trimester anomaly scans perform poorly as a screening and diagnostic test for EA/TEF. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Can Ultrasound Performed in Prolonged Second Stage of Labor Predict the Difficulty and Success Rates of Operative Vaginal Delivery?

OBJECTIVE: To evaluate different sonographic methods for the prediction of the difficulty and the success of operative vaginal delivery (OPD). MATERIALS AND METHODS: A prospective study was performed on 45 term singleton uncomplicated pregnancies with prolonged 2nd stage of delivery with cephalic presentation. Measurements of the fetal head, relations between the fetal head and maternal pelvic parameters during rest and during maternal pushing were taken using translabial ultrasound. RESULTS: 29 cases of OPD were successful and 4 cases failed ending in cesarean section. The passage of the biparietal diameter (BPD) of the infrapubic line (IPL) was statistically correlated with the success of OPD. Head station, passage of the BPD of the IPL, percentage of head after the IPL, circumference of head after IPL were all correlated with the difficulty of OPD. When the distance between the widest diameter of the head and the IPL is < 1.2 cm, there is a 90 % probability of success of OPD. When that distance is > 3.3 cm, there is 90 % probability of cesarean section. When the percentage of head beyond the IPL was > 54 %, there was 90 % probability of successful OPD. DISCUSSION: Translabial ultrasound is useful in the prediction of the difficulty and the success of OPD. The higher the extent of head that passed the IPL, the less difficult the OPD and the greater the success rate of the OPD.

3-Dimensional demonstration of fetal anal canal and sphincter.

PURPOSE: To identify the fetal anal canal and sphincter using 3-dimensional (3 D) ultrasound. MATERIALS AND METHODS: 3 D volumes of the fetal pelvis were acquired prospectively in 52 fetuses between 10 and 39 gestational weeks. A standard method for evaluating the fetal anal canal and sphincter was developed. Measurements of mucosal and muscular circumferences and the length of the anal canal were taken. RESULTS: The anal canal was demonstrated in 46 out of 50 patients (92 %). The sonographic characteristics of the anal canal in the axial plane appear like a "target sign" with an echogenic mucosa in the center, the hypoechoic internal sphincter muscle surrounding it and an outer echogenic circle reflecting the external sphincter. Measurements of mucosal and internal sphincter circumferences and the length of the anal canal demonstrated linear growth during pregnancy (p < 0.01). One case of anal atresia was demonstrated. CONCLUSION: The fetal anal canal can be visualized when a systematic analysis is performed using a 3 D volume dataset.

Umbilical vein anomaly in fetuses with Down syndrome.

OBJECTIVE: To describe the prevalence of abnormal umbilical vein (UV) anatomy in fetuses with Down syndrome. METHODS: This was a retrospective survey covering a 24-month period of fetuses with a genetic diagnosis of Down syndrome following a routine early second-trimester (12-16-week) detailed fetal anomaly scan at a single academic tertiary referral center. In our unit this exam includes fetal umbilicoportal venous system evaluation. RESULTS: During the study period, 37 fetuses were diagnosed with Down syndrome and had a detailed early anatomy scan. In four (11%) the detailed early anomaly scan revealed that the UV was connected to the hepatic portion of the inferior vena cava (IVC) at a position lower than its usual site. Their average gestational age at diagnosis was 13 + 6 (range, 11 + 6 to 15 + 2) weeks. Three of the four fetuses had a nuchal translucency thickness of 3-4 mm. In one fetus there was an additional finding of significant tricuspid regurgitation and the one with normal nuchal translucency thickness had an atrioventricular septal defect (atrioventricular canal) and umbilical cord hernia. During the same period three of 2500 (0.12%) fetuses with normal karyotype demonstrated similar anomalous insertion of the UV into the IVC, creating a portocaval shunt which had normal ductus venosus-like Doppler flow in all three cases. The odds ratio for abnormal umbilicoportal venous system in fetuses with Down syndrome compared with the normal population was 107.4 (95% CI, 19.2-637.1). CONCLUSIONS: Fetuses with Down syndrome demonstrate an increased prevalence of abnormal connection of the UV to the IVC.

Does the availability of maternal HbA1c results improve the accuracy of sonographic diagnosis of macrosomia?

OBJECTIVE: To determine whether measuring maternal glycosylated hemoglobin (HbA1c) can improve the accuracy of sonographic estimation of fetal macrosomia. METHODS: Sonographic estimation of fetal weight (EFW) and maternal HbA1c were obtained in term, non-diabetic patients within 1 week before delivery. Neonatal birth weights were recorded at delivery and compared with both sonographic estimations and HbA1c. Macrosomia was defined as birth weight of >or=4000 g. The absolute error of the sonographic EFW was calculated. Receiver-operating characteristics (ROC) curve analysis was used to evaluate sonographic EFW and HbA1c as predictors of birth weight >or=4000 g. Variables were tested using regression analysis and student's t-test. RESULTS: One hundred and sixty two patients were evaluated between July and December 2002. Twenty-eight patients (17.3%) delivered macrosomic infants. Sonographic EFW >or=4000 g predicted macrosomia with sensitivity, specificity and positive and negative predictive values of 66.6%, 88.8%, 54.5% and 93.0%, respectively. Its overall accuracy was 85.5%. The area under the ROC curve of sonographic EFW in the prediction of macrosomia was 0.9 (P < 0.001). HbA1c levels in women delivering macrosomic and non-macrosomic neonates were 5.3 +/- 0.7% and 5.2 +/- 0.5%, respectively (P = 0.27). The area under the ROC curve of HbA1c in the prediction of macrosomia was 0.53 (P = 0.27). CONCLUSIONS: Maternal HbA1c is not a useful test in the prediction of birth weight. It therefore cannot be used to improve the accuracy of sonographic EFW.

Familial Kaposi's sarcoma: a cluster of five Israeli cases.

AIM: Familial cases of Kaposi's sarcoma (KS) are rare, and have all been described in patients with the classical variant of the disease. The predisposition of classical Kaposi's sarcoma among Jews is well known. We herein describe five families, all Jews, in which two members have Kaposi's sarcoma. To our knowledge, this has been the largest reported series of familial Kaposi's sarcoma. PATIENTS AND METHODS: The clinical course, management and response to therapy were described and compared with other published cases. RESULTS: No similarity was found in any of the families in time and age of onset of the disease, or in the severity and course of the disease among the members of the same family. There was a high incidence of second neoplasms among these familial cases. CONCLUSIONS: We discuss the potential implications of second neoplasms based on our understanding of the pathogenesis of the disease, as well as the influence or predisposal of some genetic mechanisms to the development of Kaposi's sarcoma.

Inferior vena cava thrombosis presenting as non-immune hydrops in the fetus of a woman with diabetes.

We present a rare case of non-immune hydrops fetalis (NIHF) caused by a thrombus in the inferior vena cava in a neonate with low levels of anti-thrombin III. The diagnosis of (NIHF) was made in utero in a 43-year-old woman with poorly controlled gestational diabetes who subsequently developed pre-eclampsia. Cesarean section was performed due to fetal compromise and worsening pre-eclampsia. The thrombus resolved after neonatal treatment with heparin.