Meningeal tuberculoma mimicking a brain tumor.

Meningeal tuberculoma is one of the most serious sites of tuberculosis. Its incidence varies depending on the geographical area, rare in Western countries and frequent in developing countries where it represents 5% to 10% of intracranial masses. We report the case of a 21-year-old male patient with no particular medical history from Africa and living in Europe for more than a year, is hospitalized for an isolated inaugural, generalized, afebrile seizure in whom the scanner and cerebral magnetic resonance imaging (MRI) revealed a meningeal mass with significant glove finger edema suggesting a primary brain tumor. Surgical excision and anatomopathological analysis of the excisional piece allowed the diagnosis of tuberculoma. Meningeal tuberculoma is a source of diagnostic error because its clinical and radiological expression can mimic a brain tumor. This is an etiology that should not be ignored in the face of a meningeal mass in any subject coming from or living in a region with a high endemic tuberculosis.

Predicting birth weight by fetal upper-arm volume with use of three-dimensional ultrasonography.

OBJECTIVE: Our purpose was to determine the usefulness and accuracy of the three-dimensional ultrasonography assessed fetal upper-arm volume in predicting birth weight. STUDY DESIGN: From June 1996 to October 1996, we performed a prospective study of ultrasonography on 105 pregnant women without fetal structural anomaly or aneuploidy. Both the traditional two-dimensional ultrasonographic parameters and three-dimensional ultrasonography for fetal upper arm volume were measured within 48 hours of delivery. RESULTS: The upper arm volume correlated well with birth weight (r = 0.92, n = 105, p < 0.0001). With use of linear and polynomial regression, we obtained a best-fit new formula, Birth weight = 1088.60 + 36.024 x Upper-arm volume. The accuracy of this new formula is compared with that of two Chinese equations predicting fetal weight reported before and other formulas commonly used in the world as well. Our formula is more accurate in predicting birth weight than all the other formulas by traditional two-dimensional ultrasonography, either in error, percentage error, or absolute error. Another group by prospective validation further proved this finding. CONCLUSION: The upper-arm volume assessed by three-dimensional ultrasonography can accurately predict birth weight, and its accuracy is superior to the previous, formulas. Our study has at least validated the application of upper-arm volume by three-dimensional ultrasonography in estimating fetal weight. Further larger series are needed to confirm our findings.

PIP: The capability of fetal upper-arm volume assessed by 3-dimensional ultrasonography to predict birth weight was investigated in a prospective study involving 105 women who delivered live infants at National Cheng Kung University Hospital (Tainan, Taiwan) in 1996. Mean birth weight was 3312 grams (range, 1194-4425 g). Upper-arm volume was measured within 48 hours of delivery by both traditional 2-dimensional ultrasonography and the 3-dimensional technique. 3-dimensional ultrasonography has the advantage of being independent of fetal position and is not influenced by arm shape. Upper-arm volume was highly correlated with birth weight (p 0.0001). Through use of linear and polynomial regression, a best-fit new formula for predicting birth weight was derived: 1088.60 + 36.024 x upper-arm volume. Compared with 4 pre-existing formulas, the new formula (with upper-arm volume measured by 3-dimensional ultrasonography) had the lowest values in terms of error (0.0 g), absolute error (153.7 g), and percentage error (0.53%) in predicting birth weight. A large-scale prospective study is underway at this hospital to further validate the new formula.

Prenatal sonographic diagnosis of single umbilical artery.

PURPOSE: We evaluated the reliability of prenatal sonography and the usefulness of the umbilical vein and artery diameter ratio, transverse umbilical artery diameter, and systolic-diastolic ratio in detecting single umbilical artery (SUA). METHODS: In 24 of 6,970 fetuses, SUA was detected using prenatal sonography and confirmed at birth. These cases were retrospectively reviewed. RESULTS: Four fetuses had major malformations, and 1 had a minor anomaly. Thirteen fetuses with SUA underwent chromosomal analysis, and only 2 had abnormal karyotypes. Most of the SUA fetuses had a normal systolic-diastolic ratio. CONCLUSIONS: Our retrospective study determined that the prognosis of SUA fetuses is good when there is no concurrent anatomic or chromosomal abnormality. Although some reports claim that the transverse umbilical artery diameter or the ratio between umbilical vein and artery diameters can predict SUA, we found no significant improvement in the recognition of SUA using these parameters.

Three-dimensional ultrasound-assessed fetal thigh volumetry in predicting birth weight.

OBJECTIVE: To compare the accuracy of three-dimensional ultrasound-assessed fetal thigh volumetry in predicting birth weight with that of other commonly used formulas composed of biparietal diameter (BPD), abdominal circumference (AC), and femur length (FL) by two-dimensional ultrasound. METHODS: We assessed the thigh volume of 100 fetuses using three-dimensional ultrasound. Meanwhile, their BPD, AC, and FL were measured by two-dimensional ultrasound. All infants were delivered within 48 hours after the ultrasound examinations. From polynomial regression analysis, we generated a best-fit formula for the thigh volume to predict birth weight. The accuracy of this thigh-volume formula was compared with those of three formulas commonly used in the United States. In addition, another group of 50 fetuses was measured for prospective validation. RESULTS: The high volume assessed by three-dimensional ultrasound was highly correlated with birth weight (r = 0.89, n = 100, P < .0001). The best-fit formula for thigh volume to predict birth weight was linear, and it was superior to the other commonly used two-dimensional formulas in predicting birth weight. The predicting error (0 g), percent error (0.7%), absolute error (176.1 g), and absolute percent error (5.8%) of the thigh-volume formula were all smaller than those of the other formulas (n = 100, all P < .05). In addition, the thigh-volume formula predicted birth weight more accurately than the other two-dimensional formulas in the prospective-validation group. The three-dimensional formula had smaller mean values of predicting error (38.6 g), percent error (1.5%), absolute error (160.0 g), and absolute percent error (5.1%) than the two-dimensional formulas (n = 50, all P < or = .001), as well as the smallest variances of the above errors (178.1 g, 5.6%, 84.3 g, and 2.9%, respectively). CONCLUSION: The three-dimensional ultrasound-assessed thigh volume has better accuracy in predicting birth weight than the commonly used formulas by two-dimensional ultrasound, and it may improve fetal weight prediction in clinical practice. However, a large-scale prospective validation study may be needed to confirm our conclusions.

Refined fetal abdominal growth assessment in normal pregnancy: Part I. Abdominal anteroposterior diameter.

BACKGROUND: The assessment of the adequacy of fetal growth by parameters other than the abdominal anteroposterior diameter (AAPD) of the fetus has been studied extensively. However the designs of these studies and the statistical methods used appears to deserve some criticism, based on present knowledge. Noncross-sectional cases selection, uncertainty of the fetal normality and inadequacy in statistical method, mostly ignored the changing property of each standard deviation (SD) of each gestational age (GA) which was proposed by Altman et. al. in 1993, are the three most common flaws in previous publishes. We tried to use AAPD with a strict study design as well as a reasonable statistical method to evaluate the fetal growth. METHODS: This study was performed in the Division of Maternal Fetal Medicine, National Cheng Kung University Hospital, Taiwan. The prenatal sonographic data of the fetuses were collected prospectively based on the following criteria: (1) accurate dating by knowing the maternal last menstration period (LMP) and early ultrasonography of the fetuses, (2) singleton pregnancy, (3) no fetal structural or chromosomal abnormality confirmed by prenatal ultrasonography and postnatal examination, (4) GA at birth was between 37 and 41 weeks' gestation, (5) no birth asphyxia, (6) appropriate birth body weight, and (7) no maternal medical disease or obstetrical complication which might predictably interfere with fetal growth. The collected data were analyzed by polynomial regression test and the best-fit equation for prediction of fetal growth was selected. The standard deviation (SD) of each GA was modeled before constructing the fetal growth centile charts by Altman's method. RESULTS: A total of 2077 cross-sectional sonographic data meeting the above criteria were collected for statistical analysis. The best-fit equation for the prediction of fetal GA by AAPD is GA = 20.8539 - 3.36743 x AAPD + 0.86927 x (AAPD)2 - 0.03789 x (AAPD)3 +/- k x [1.2533 x (0.36772 + 0.10938 x AAPD)], (r = 0.97287, p < 0.0001). The best-fit equation for prediction of fetal AAPD by GA is AAPD = -2.49495 + 0.38247 x GA - 1.07071 x 0.001 x (GA)2 +/- k x [1.2533 x (0.01760 + 0.01372 x GA)], r = 0.97122, p < 0.0001. The SD of AAPD for each complete GA was not the same. The fetal growth centile charts in the study are presented in this article. CONCLUSIONS: The SD of each complete GA changed with each specific GA. The GA of the fetus can be assessed accurately by measuring the AAPD alone. The utilization of these growth centile charts for evaluation of fetal growth is recommended.

Three-dimensional ultrasound assessment of fetal liver volume in normal pregnancy: a comparison of reproducibility with two-dimensional ultrasound and a search for a volume constant.

The purposes of this study are to compare the reproducibility of two-dimensional ultrasound (2DUS) and three-dimensional ultrasound (3DUS) in the assessment of fetal liver volume (LV), and to test whether the fetal LV assessed by the traditional method with 2DUS is equal to that with 3DUS in normal pregnancy. If significantly different, we then try to calculate a new constant of fetal LV for the traditional equation from the LV values obtained with 3DUS. In total, 30 normal singleton fetuses with gestational ages ranging from 20 to 30 weeks were included for the reproducibility test and 55 cases ranging from 20 to 31 weeks gestation were enrolled for finding a new volume constant of LV. The results showed that 3DUS is superior to 2DUS in the reproducibility test of fetal LV assessment. Moreover, the LV assessed with the traditional 2DUS method (identified as LV_42) was significantly smaller than that measured with 3DUS (P < 0.001). If the traditional 2DUS equation is to be used, the multiplying factor in the equation for the calculation of LV should be modified to 0.55 (SE = 0.017, N = 55). With the new volume constant, the new derived LV with 2DUS (identified as LV 55) was not different from that with 3DUS (identified as LV_3D). In conclusion, we recommend that 3DUS, instead of 2DUS, should be used for reaching an accurate assessment of fetal LV. Otherwise, applying our new volume constant may be of help in detecting abnormal fetal liver growth when only 2DUS is available.

Fetal heart volume assessment by three-dimensional ultrasound.

Heart volume may provide important information on the status of fetal hemodynamics. However, traditionally fetal heart volume has been assessed with the erroneous assumption that the fetal heart is spherical or elliptical. With the advent of three-dimensional ultrasound, accurate assessment of organ volume has become feasible. The objectives of this study were to compare the reproducibility of two-dimensional ultrasound and three-dimensional ultrasound in the assessment of heart volume, and to test whether heart volume assessed by the traditional method of two-dimensional ultrasound equates to that assessed by three-dimensional ultrasound. If it proved to be significantly different, we aimed to find a new constant which, if incorporated into the traditional formula used to determine heart volume, would enable us to achieve more accurate volumes with two-dimensional ultrasound. In total, 50 normal singleton fetuses ranging from 20 to 30 weeks' gestation were included in the study. Both the traditional two-dimensional and the new three-dimensional volume measurements were compared. The results showed that three-dimensional ultrasound has a better reproducibility than two-dimensional ultrasound in heart volume assessment and that heart volume assessed by the traditional formula of two-dimensional ultrasound is significantly larger than that measured by three-dimensional ultrasound (p < 0.001). We therefore propose that, if the traditional two-dimensional equation is to be used, the constant for heart volume could be modified to 0.4563 (SE = 0.0153, n = 50) to achieve more accurate results. With this new constant, the heart volume derived by two-dimensional ultrasound was not found to differ from that measured by three-dimensional ultrasound. From our series, we conclude that three-dimensional ultrasound is theoretically the best method for the assessment of heart volume. However, because of the limitations of three-dimensional ultrasound (i.e. it is not routinely available, it is more expensive and more time-consuming) two-dimensional ultrasound in practical terms should be the method of choice. Although we were able to improve the accuracy of the heart volume measurements using a new constant in the traditional two-dimensional formula, the new constant will not improve variability, which can only be reduced by three-dimensional ultrasound.

Refractory fetal supraventricular tachycardia with hydrops: report of one case.

Fetal tachycardia sometimes is quite difficult to treat, especially when the fetus has congestive heart failure. Sustained supraventricular tachycardia and hydrops had been diagnosed in a fetus as early as the 27th week of gestational age. A variety of antiarrhythmic agents, including digoxin, digoxin in combination with quinidine or propranolol or verapamil, have been prescribed for the mother, always in a vain effort of conversion of the tachycardia. A baby was born via vaginal delivery at 35 weeks' gestation because of premature labor. The tachycardia disappeared immediately after birth, but several episodes of tachycardia occurred during the neonatal period, and were converted only by electric cardioversion or intravenous amiodarone. Oral amiodarone was then prescribed for three months to prevent recurrence. The baby has lived well without attacks during a one-and-a-half-year follow-up.

Differentiation between adenomyoma and leiomyoma with transvaginal ultrasonography.

The clinical utility of transvaginal ultrasonography in the differentiation of adenomyoma from leiomyoma was evaluated in 147 patients who had been scheduled for surgery due to symptomatic uterine masses. In all subjects, ultrasonographic images obtained preoperatively were correlated postoperatively with surgicopathological findings. Pathological findings showed that 110 patients proved to have fibroids, while 30 had adenomyomata. For the diagnosis of adenomyoma, transvaginal ultrasonography attained a sensitivity of 80%, a specificity of 94.3%, a positive predictive value of 85.7% and a negative predictive value of 90.9%, compared with a sensitivity of 94.3%, a specificity of 80%, a positive predictive value of 90.9% and a negative predictive value of 85.7% for leiomyoma diagnosis. Further to assess which characteristic used in ultrasonography was useful in the differential diagnosis, five characteristics were analyzed and compared by chi 2 test. These were position, number, margin and echogenicity of the uterine masses and the presence or absence of hypoechoic spaces (lacunae). Margin, echogenicity, mass number and lacunae were significantly different between both conditions. A stepwise logistic regression procedure revealed that margin, lacunae and echogenicity were good parameters for differentiating adenomyoma from leiomyoma. If we selected the features of distinct margin and absence of hypoechoic lacunae within the masses for analysis, leiomyoma could be correctly predicted in 97% of patients.

Acceleration time in normal fetal umbilical artery at term and its relationship to the cord blood hematocrit.

The purpose of this study was to test the hypothesis that the acceleration time (AT) of the fetal umbilical artery remains constant at term for normal pregnancies. In addition, we also examined whether the AT has any correlation with umbilical cord blood hematocrit (Hct). In total, 539 normal-term fetuses with menstrual ages (MA) ranging from 37 weeks to 42 weeks were enrolled in a cross-sectional design. The AT of the fetal umbilical artery was measured prior to delivery using a high-resolution, real-time Doppler scanner. All were delivered within 2 days of the ultrasound examination. At parturition, blood from the umbilical vein was collected and the red cell indices, including the Hct, were determined. The results indicated that the mean values of AT of the umbilical artery remained constant during normal-term pregnancies from 37 weeks to 42 weeks, menstrual age (mean: 0.104 sec, SE: 0.001 sec, n = 539). Although the AT was thought to be affected by the Hct, the AT had no correlation with umbilical venous Hct (n = 539, r = 0.002, p > 0.05). This constant value of the AT may be used as a reference for fetal physiology and perinatal medicine.

Serum level of squamous cell carcinoma antigen and tumor size are useful to identify preoperatively patients at high risk of cervical cancer.

BACKGROUND: The benefit of postoperative adjuvant therapy for patients with cervical cancer is uncertain, and moreover, may increase morbidity. In this study, patient age, clinical stage of the cancer, tumor size, and levels of serum squamous cell carcinoma cell antigen and carcinoembryonic antigen were studied in patients with Stage Ib and IIa squamous cell carcinoma of the uterine cervix to determine if these parameters can be used, before the surgical intervention, to distinguish patients who require postoperative adjuvant therapy from those who do not. METHODS: Ninety-nine patients were studied. After surgery, patients were classified either as high risk or low risk according to the results of histopathologic findings. The age of the patient was noted, and FIGO stage, squamous cell carcinoma antigen, carcinoembryonic antigen, and clinical tumor size were determined. A univariate analysis and then a stepwise logistic regression procedure were performed to select significant clinical predictors from among the five variables mentioned above. Any selected predictors were further analyzed by the receiver operator characteristic curve. RESULTS: Serum squamous cell carcinoma antigen and clinical tumor size measured by colposcopic examination were significant clinical predictors of the treatment strategy postoperatively. From the receiver operator characteristic curve, a sensitivity of 84.2%, a specificity of 91.8%, a positive predictive value of 84.5% were attained. CONCLUSIONS: Serum squamous cell carcinoma antigen assays and clinical tumor size estimated by colposcopic examination are helpful in identifying patients who require postoperative adjunctive therapy.

Color Doppler ultrasonography and serum CA 125 in the differentiation of benign and malignant ovarian tumors.

Color Doppler ultrasonography and serum CA 125 were used to evaluate 114 adnexal tumors prior to surgery. Six patients were excluded from this study because of ovarian cancer, borderline ovarian malignancy, and tubal gestation. A total of 108 patients were eligible: 83 patients with benign and 25 patients with malignant ovarian tumors. Resistance index (RI) was used to determine the peripheral resistance of intratumoral vessels. The cutoff point for the RI was defined as 0.5. The blood flow was considered to be normal when the RI was greater than 0.5 and abnormal when it was less than 0.5. The blood flow was detected in 100% of malignant tumors and 59% of benign tumors. The initial cutoff value for CA 125 was 35 U/mL. Sensitivity, specificity, positive predictive value, and negative predictive value were compared in terms of RI, serum CA 125, and a combination of the two. Our conclusion is that the combination of RI and CA 125 gives a sensitivity of 100% and negative predictive value of 100%. If the cutoff point of CA 125 was raised from 35 to 65 U/mL, then a specificity of 100% and positive predictive value of 100% were also attained with the use of RI and CA 125 without changes in sensitivity or negative predictive value. We conclude that the combination of color Doppler ultrasonography and serum CA 125 is an effective method to differentiate benign from malignant ovarian tumors.

Clinical case-controlled study of small-for-gestational-age babies.

In this series, we compared the prenatal risk factors and perinatal complications of small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA) babies systemically through a case-controlled study. A total of 115 SGA babies were retrospectively compared with 115 AGA matched pairs at the National Cheng Kung University Hospital. We analyzed the prenatal risk factors, signs of fetal distress and perinatal outcome between these two groups. Univariate analysis showed significant differences for the following items: 1) maternal risk factors, 2) fetal risk factors, 3) presence of prenatal risk factors, 4) abnormal fetal heart rate tracings, 5) low one-minute Apgar scores, 6) low five-minute Apgar scores, 7) thick meconium staining, 8) presence of fetal distress, 9) pediatric ICU care, and 10) presence of perinatal complications. Multivariate logistic regression showed that maternal hypertension and fetal anomaly were statistically significant risk factors associated with SGA in this series. In conclusion, SGA babies demonstrate higher frequencies of maternal and fetal risk factors, signs of fetal distress and perinatal complications than AGA babies.

Antithrombin III activity in normal and toxemic pregnancies.

From August 1989 to October 1990, 83 pregnant Chinese women were the subjects for measuring the levels of plasma functional antithrombin III (AT III) activity. The correlations of AT III activity with perinatal outcome and the changes in maternal hepatorenal function were analyzed. The population was divided into four groups: Group I (n = 30), normal pregnancies; Group II (n = 23), mild pre-eclampsia; Group III (n = 26), severe pre-eclampsia; and Group IV (n = 4), eclampsia. The results demonstrated that: 1) AT III activity decreased with the severity of toxemia (p < 0.001), 2) AT III activity correlated with the degree of perinatal outcome and maternal morbidity, and 3) reduction of AT III activity correlated with impairment of maternal hepatorenal function. In conclusion, plasma AT III activity is a valuable parameter in the evaluation of toxemia.

The primary application of three-dimensional ultrasonography in obstetrics.

To date, no report of three-dimensional ultrasonography in obstetrics has been available in the literature. In this study we describe the primary experience with three-dimensional ultrasonography for the prenatal evaluation of nine fetuses between 21 and 33 weeks of gestation. We found that it provides more information for clinical diagnosis than the traditional two-dimensional ultrasonography. The following advantages are notable: (1) the anatomic area of interest can be located first with the conventional real-time two-dimensional mode, then switched to reveal three-dimensional images, instantly; (2) three images are exhibited concurrently; (3) each of the three images can be arrayed separately and scrolled to search for the area of interest within the scanned volume; (4) the three-dimensional ultrasonography can be equipped with Doppler color flow mapping for the study of the fetal cardiovascular system. In conclusion, we believe that three-dimensional ultrasonography can greatly strengthen diagnostic potential, which deserves obstetricians' attention.

Clinical validation of two equations in antenatal prediction of Chinese fetal weight by ultrasonography.

The purpose of this series is to prospectively validate the Chinese equations for predicting fetal weight developed in a previous study. A total of 640 Chinese fetuses were examined antenatally for biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL) by real-time ultrasonography within two days of delivery. The results showed the actual birth weight (BW) to be highly correlated with the estimated body weight for both the equation using BPD and AC (EBW1) (r = 0.888, p less than 0.0001) and the equation using BPD, AC and FL (EBW2) (r = 0.890, p less than 0.0001). Our results demonstrate that the Chinese equations developed by Hsieh et al are a better fit for Chinese fetuses than the foreign equations are. Also, the two Chinese equations predict fetal weight well between 2,000 g and 4,000 g, but further modification is needed in cases where the BW is less than 2,000 g or greater than 4,000 g.

Antenatal ultrasonographic diagnosis of hypotelorism.

Hypotelorism is one of the most important fetal anomalies, which deserves early antenatal detection and management. To date, only a few cases of antenatally diagnosed hypotelorism have been reported. In this series, we report a case of hypotelorism and microphthalmia diagnosed prenatally. A 30-year-old female, G1P0, was admitted to our hospital due to chronic bronchitis and a breech presentation of the fetus at 38 weeks of gestation. Routine ultrasound screening revealed hypotelorism. Associated anomalies detected by ultrasound were alobar holoprosencephaly, microcephaly, microphthalmia and oligohydramnios. After delivery, hypotelorism with holoprosencephaly was confirmed, which corresponded with the antenatal ultrasound findings. In conclusion, systemic routine ultrasound screening of fetal orbits is the best way to prenatally detect hypotelorism and microphthalmia.