Placenta acrreta spectrum-first trimester, 2D and 3D ultrasound, and magnetic resonance imaging findings.

BACKGROUND: The term placenta accreta spectrum (PAS) is commonly used to describe abnormal trophoblastic invasion of the myometrium, serosa, or organs adjacent to the uterus. It is of great obstetric importance because of its high morbidity, risk of hemorrhage, admission to the intensive care unit, risk of hysterectomy, and high risk of iatrogenic pelvic lesions and even death. These risks are minimized when prenatal diagnosis is performed. Prenatal diagnosis of PAS is based on imaging findings suggestive of abnormal and pathologically adherent placentation, including placental lacunae (intraplacental sonolucent spaces), disruption of the bladder-uterine serosa interface, turbulent flow on color Doppler, and bridging vessels. OBJECTIVE: In this article, we review the major prenatal imaging features of PAS using diagnostic modalities (first trimester, two-dimensional ultrasound, three-dimensional ultrasound, and magnetic resonance imaging) for the diagnosis of PAS.

Transperineal three-dimensional ultrasound for analyzing the effects of perineal stretching with EPI-NO® in women with multiple pregnancies: a pilot study.

OBJECTIVE: To compare the changes in the pelvic floor of women with twin pregnancies who practiced muscle stretching with the EPI-NO® vaginal dilator, as assessed using transperineal three-dimensional ultrasound (3DUS). METHOD: This prospective cross-sectional case-control study included nulliparous women in the third trimester of their multiple pregnancies and divided them into the control group (CG, n = 9) and EPI-NO® group (EpiG, n = 9). During pretreatment, the women underwent transperineal 3DUS to establish the morphometric measurements of the pelvic floor. The CG received guidance regarding pelvic floor muscles, whereas the EpiG underwent weekly physical therapy sessions with the EPI-NO® dilator for 20 min/day. Following this treatment, all women were reassessed using transperineal 3DUS, and the diameter of the EPI-NO® balloons of the women in the EpiG was measured (epinometry). Paired samples t-test was used for comparative analysis. RESULTS: The EpiG showed improved perineal distensibility, which was evidenced by the increase in sagittal diameter at rest (p < .01). Transperineal 3DUS among women in the EpiG showed a significant increase in the sagittal measurement (p = .02), hiatal circumference at rest (p = .03), and epinometry values (diameter of the EPI-NO® balloon; p < .01). The increase in epinometry values was directly correlated (p = .02) with the number of physical therapy sessions. CONCLUSION: EPI-NO® increased pelvic floor distensibility in women with twin pregnancies, as confirmed using transperineal 3DUS and epinometry. This device promoted an increase in perineal distensibility with a single use; however, better results would be obtained with additional sessions.

Prediction of Lung Maturity in Fetuses with Growth Restriction through Quantitative Ultrasound Analysis.

The present study aimed to evaluate the performance of QuantusFLM software, which performs quantitative analysis of lung tissue texture through ultrasound images, in predicting lung maturity in fetal growth restriction (FGR). We included patients with singleton gestations between 34 and 38 6/7 wk and divided them into two groups: FGR and control (appropriate for gestational age [AGA]). The images were captured by ultrasound according to a specific protocol up to 48 h before delivery and analyzed with QuantusFLM software. The main clinical outcome evaluated was lung maturity (i.e., the absence of neonatal respiratory morbidity). We included 111 patients; one was excluded because of low image quality, leaving 55 patients in each group. The FGR group had a lower birth weight (2207 g vs. 2891 g, p < 0.001) and a longer stay in the neonatal intensive care unit (NICU) (10 d vs. 5 d, p = 0.043). QuantusFLM software was able to predict lung maturity in FGR with accuracy, sensitivity, specificity and positive and negative predictive values of 94.5%, 96.2%, 50%, 98.1% and 33.3%, respectively. QuantusFLM had good accuracy in predicting lung maturity in FGR with reliability in identifying pulmonary maturity.

Uterine Rescue in High-Risk Gestational Trophoblastic Neoplasia Treated with EMA-CO by Uterine Arteries Embolization due to Arteriovenous Malformations.

Complete hydatidiform mole (CHM) is a rare type of pregnancy, in which 15 to 20% of the cases may develop into gestational trophoblastic neoplasia (GTN). The diagnostic of GTN must be done as early as possible through weekly surveillance of serum hCG after uterine evacuation. We report the case of 23-year-old primigravida, with CHM but without surveillance of hCG after uterine evacuation. Two months later, the patient presented to the emergency with vaginal bleeding and was referred to the Centro de Doenças Trofoblásticas do Hospital São Paulo. She was diagnosed with high risk GTN stage/score III:7 as per The International Federation of Gynecology and Obstetrics/World Health Organization (FIGO/WHO). The sonographic examination revealed enlarged uterus with a heterogeneous mass constituted of multiple large vessels invading and causing disarrangement of the myometrium. The patient evolved with progressive worsening of vaginal bleeding after chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen. She underwent blood transfusion and embolization of uterine arteries due to severe vaginal hemorrhage episodes, with complete control of bleeding. The hCG reached a negative value after the third cycle, and there was a complete regression of the anomalous vascularization of the uterus as well as full recovery of the uterine anatomy. The treatment in a reference center was essential for the appropriate management, especially regarding the uterine arteries embolization trough percutaneous femoral artery puncture, which was crucial to avoid the hysterectomy and allow GTN cure and maintenance of reproductive life.

Mola hidatiforme completa (MHC) é um tipo raro de gravidez, na qual 15 a 20% dos casos podem desenvolver neoplasia trofoblástica gestacional (NTG). O diagnóstico de NTG deve ser feito o mais cedo possível, pelo monitoramento semanal do hCG sérico após esvaziamento uterino. Relatamos o caso de uma paciente primigesta, de 23 anos de idade, com MHC, sem vigilância de hCG após esvaziamento uterino. Dois meses depois, a paciente compareceu na emergência com sangramento vaginal, sendo encaminhada ao Centro de Doenças Trofoblásticas do Hospital São Paulo, onde foi diagnosticada com NTG de alto risco, estádio e score de risco III:7 de acordo com a The International Federation of Gynecology and Obstetrics/Organização Mundial de Saúde (FIGO/OMS). O exame ultrassonográfico revelou útero aumentado com uma massa heterogênea constituída por múltiplos vasos volumosos invadindo e desestruturando o miométrio. A paciente evoluiu com piora progressiva do sangramento vaginal após quimioterapia com o regime etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO). Ela foi submetida a transfusão de sangue e embolização das artérias uterinas devido aos episódios graves de hemorragia vaginal, com completo controle do sangramento. O hCG atingiu valor negativo após o terceiro ciclo, havendo regressão completa da vascularização uterina anômala, assim como recuperação da anatomia uterina. O tratamento em um centro de referência permitiu o manejo adequado, principalmente no que se refere à embolização das artérias uterinas através da punção percutânea da artéria femoral, que foi crucial para evitar a histerectomia, permitindo a cura da NTG e a manutenção da vida reprodutiva.

Physiotherapeutic Treatment for Levator Ani Avulsion after Delivery: A Transperineal Three-dimensional Ultrasound Assessment.

BACKGROUND: Levator ani avulsion is defined as the interruption of the insertion of this muscle on the pubic bone. It is currently recognized as an important triggering factor for genital prolapse. Although surgical interventions are available, there are no conservative strategies for this muscular injury. DESCRIPTION: A 40-year-old female presented with urinary incontinence and levator ani avulsion, which was confirmed on transperineal three-dimensional ultrasound (3DUS). Upon referral for physiotherapy, she presented with incorrect and weak contractions of the pelvic floor. Her treatment comprised 13 sessions of intravaginal electrotherapy followed by pelvic floor muscle (PFM) exercises in different positions. At the end of the sessions, another transperineal 3DUS was performed, and it revealed rapprochement of the levator ani muscle. The avulsed levator ani muscle can be reinserted using physiotherapeutic interventions, especially a combination of electrotherapy and PFM exercises. CONCLUSION: Transperineal 3DUS is an important approach for the follow-up of conservative treatment until full recovery.

Prenatal diagnosis of gastric and small bowel atresia: a case series and review of the literature.

OBJECTIVE: To describe seven cases of gastrointestinal tract (GIT) obstructions and to report a skewed review of the literature. METHODS: We performed a search of our permanent perinatal database about cases with prenatal ultrasound and MRI diagnosis of gastrointestinal tract obstructions between 2006 and 2013. All cases were followed until hospital discharge and pre-natal diagnosis were confirmed by fetal MRI, postnatal imaging and/or intra-operative findings. Maternal age, parity, gestational age at diagnosis, ultrasound findings, gestational age at delivery, Apgar scores at 1 and 5 min and postnatal outcome have been recorded. RESULTS: We identified seven cases of gastric and small bowel atresia. Karyotype was normal in six cases and abnormal in one co-twin [46,XY dup (20) (qq13.1q13.3)dn] of a dichorionic-diamniotic pregnancy. The mean ± SD for maternal age, gestational age at diagnosis, gestational at delivery, birth weight and Apgar scores at 1 and 5 min were 30.8 ± 4.8 years, 29.8 ± 3.7 weeks, 2507.5 ± 727.5 g and 5.6 ± 2.1, 7.6 ± 1.6, respectively. All fetuses' undergone surgical procedures in the postnatal period and all of them were discharged live from the hospital. CONCLUSION: Prompted antenatal detection of gastrointestinal tract obstruction using ultrasound proved to be diagnostic in all cases. Fetal MRI aid was a useful complementary diagnostic investigation. Correct pre-natal diagnosis allows adequate counseling, delivery planning and management care by a multidisciplinary team.

Agnathia-otocephaly: prenatal diagnosis by two- and three-dimensional ultrasound and magnetic resonance imaging. Case report.

A case of prenatally diagnosed otocephaly is reported. Otocephaly is an extremely rare malformation characterized by absence or hypoplasia of the mandible and abnormal horizontal position of the ears. 2D ultrasound performed at 25 weeks of gestation revealed agnathia, proboscis and hypotelorism. 3D ultrasound (rendering mode) and magnetic resonance imaging were used to evaluate the facial features, and were essential for characterization of facial malformations in otocephaly and for the demonstration and correct prenatal counseling of the couple.

Assessing the impact of twin pregnancies on the pelvic floor using 3-dimensional sonography: a pilot study.

OBJECTIVES: The purpose of this study was to compare the morphologic characteristics of the pelvic floor musculature between women with twin and singleton pregnancies. METHODS: We conducted a cross-sectional case-control study of 40 nulliparous women aged 20 to 38 years to compare women with singleton pregnancies (n = 23) to women with twin pregnancies (n = 17). Biometric measurements of the levator hiatus and the sagittal and coronal diameters were made by transperineal 3-dimensional sonography between the 28th and 38th gestational weeks. Comparisons were statistically assessed by the unpaired Student t test and Mann-Whitney U test. RESULTS: For the women with singleton pregnancies, the mean sagittal diameters at rest, during the Valsalva maneuver, and during pelvic floor contraction were 5.3, 5.7, and 4.5 cm, respectively, and the mean coronal diameters under these conditions were 3.8, 4.1, and 3.6 cm. For the women with twin pregnancies, the corresponding values were as follows: mean sagittal diameters, 5.3, 5.8, and 4.6 cm; and mean coronal diameters, 4.3, 4.3, and 3.8 cm. The differences in coronal diameters were statistically significant at rest (P < .01) and during contraction (P = .04). The mean levator hiatal areas for the women with singleton pregnancies were 14.6, 16.9, and 11.7 cm(2) at rest, during Valsalva, and during contraction, respectively; for the women with twin pregnancies, these values were 16.0, 18.6, and 12.6 cm(2). CONCLUSIONS: Hiatal measurements were higher in twin than in singleton pregnancies, with coronal diameters reaching significance at rest and during contraction, suggesting that pelvic support undergoes greater changes during twin pregnancy.

Espinha bífida aberta: achados ultra-sonográficos e presença de contrações uterinas na predição da evolução motora neonatal / Open spina bifida: antenatal ultrasound findings and uterine contractions as predictors of the neonatal neuromotor outcome

OBJETIVO: avaliar a influência das alteraçöes ultra-sonográficas pré-natais e das contraçöes uterinas de trabalho de parto na evoluçäo motora neonatal em fetos portadores de espinha bífida aberta. MÉTODOS: foram analisados fetos portadores de espinha bífida aberta. Estes fetos foram acompanhados nos serviços de Medicina Fetal do Hospital Säo Paulo (Universidade Federal de Säo Paulo) e do Hospital e Maternidade Santa Joana. Todos os partos foram realizados nestes serviços e a avaliaçäo neonatal foi realizada pela equipe de Neurocirurgia comum a ambas as instituiçöes Foi observada a influência das alteraçöes ultra-sonográficas (macrocrania, microcrania, nível da falha de fechamento da coluna, pé torto e tipo de apresentaçäo fetal) na força muscular de membros inferiores no período neonatal. Foi analisada, também, a influência das contraçöes uterinas sobre a movimentaçäo dos membros inferiores. Todos os partos foram realizados por cesárea. Foram utilizados os testes de c² e Fisher para comparaçöes categóricas, com p<0,05 para estabelecer associaçäo significante. RESULTADOS: foram estudados cinqüenta e três casos de espinha bífida isolada. As alteraçöes da circunferência craniana e o nível da lesäo näo interferiram na parte neuromotora neonatal. Entretanto, a presença de pé torto e a apresentaçäo pélvica mostraram prognóstico neurológico neonatal desfavorável (p<0,05). O pé torto foi encontrado em 23 fetos (43 por cento). Dezoito recém-nascidos (78,3 por cento) portadores de pé torto apresentaram alteraçöes motoras. Nenhum neonato em apresentaçäo pélvica (n=10) mostrou funçäo motora normal. A diminuiçäo da força motora nos membros inferiores também foi observada em 13 fetos (87 por cento) expostos às contraçöes uterinas de trabalho de parto e à rotura prematura de membranas (p<0,05). CONCLUSÄO: a presença de pé torto e a apresentaçäo pélvica säo parâmetros úteis para a prediçäo da evoluçäo neurológica neonatal. Contraçöes uterinas de trabalho de parto e a rotura prematura de membrana säo fatores de pior prognóstico neuromotor neonatal

Gravidez ectópica tubárea pós-fivete: relato de 2 casos / Tubal pregnancy post in vitro fertilization: report of 2 cases

Os autores relatam 2 casos de gravidez ectópica após tratamento com técnica de fertilizaçäo in vitro e transferência de embrioes (FIVETE). Este tipo de problema näo é incomum. O último senso sobre os dados de 180 clínicas na América do Norte mostrou uma incidência de 5 por cento de gravidez ectópica após FIVETE. De uma casuística de 382 ciclos e 82 gestaçöes em nosso serviço, 2 casos significam apenas 2,44 por cento de incidência, o que nos parece um índice bastante razoável. Em ambos os casos, a gravidez foi detectada precocemente através da ultrasonografia vaginal, sendo que em um caso foi suspeitada devido a sintomas como dor pélvica e sangramento e, no outro, devido a pequeno sangramento 28 dias após a transferência. Além disso, os autores discutem os prováveis mecanismos que levariam à gravidez ectópica após FIVETE, sob os pontos de vista fisiológico e fisiopatológico