A new approach for quantitative assessment of fetal general movements in the early second trimester of pregnancy using four-dimensional ultrasound.

PURPOSE: Complex fetal behavior involving multiple parts of the body, called general movement (GM), has been considered an essential predictor of neurological functional development because it directly reflects the integrity of the brain and central and peripheral nervous systems. We have developed a novel method for quantitative analysis of fetal behavior using four-dimensional ultrasound (4DUS) and conducted a pilot study for quantitative assessment of fetal GM in the early second trimester. METHODS: All subjects underwent 4DUS to depict the whole fetal body, and maximum velocity (MAXV), median velocity (MV), average velocity (AV), and mode velocity (MOV) were calculated by utilizing optical flow analysis. Receiver operating characteristic (ROC) curve analysis was performed to analyze the optimal speed parameters for detecting GM in the fetus. The Mann-Whitney U test was used to validate MAXV, AV, and MV ability to detect fetal GM. RESULTS: The presence of fetal GMs and the absence of fetal GMs were 226 and 107, respectively, based on optical flow analysis. Mann-Whitney U test revealed a significant difference in the presence or absence of fetal GM in MAXV, MV, AV, and MOV. ROC analysis showed that the area under the curve (AUC) of MAXV was 0.959; the threshold was 0.421, the sensitivity was 86%, and the specificity was 93%. In contrast, the AUC/threshold for AV and MV was 0.700/0.110 (sensitivity 71% and specificity 76%) and 0.521/0.119 (sensitivity 21% and specificity 90%), respectively. Spearman's rank correlation analysis also showed a weak negative correlation between GM and MAXV (r = - 0.235, P < 0.01) and AV (r = - 0.28, P < 0.01). CONCLUSION: In this study, we conducted a quantitative analysis of fetal behavior based on optical flow using 4DUS and demonstrated that it was highly accurate for detecting GMs and for evaluating developmental changes in GMs. The implementation of quantitative analysis of fetal GMs in the early second trimester has been very preliminary, and there is much debate on how it will be clinically applied to perinatal assessment.

An incidental finding of low-grade appendiceal mucinous neoplasm during cesarean section: A case report.

Low-grade appendiceal mucinous neoplasms are rare and difficult to diagnose preoperatively because of a lack of characteristic symptoms. A 24-year-old female with no symptoms before pregnancy underwent an elective cesarean section at 38 weeks of gestation because of cephalo-pelvic disproportion. Although no abnormalities were detected in the newborn, uterus, or uterine adnexa, a sausage-like, swollen appendix was noted. The patient underwent appendectomy. Pathology showed the tumor was a low-grade appendiceal mucinous neoplasm.

3D and 4D sonographic imaging of amniotic band syndrome in early pregnancy.

We present a case of amniotic band syndrome diagnosed with two-dimensional (2D), three-dimensional (3D), and four-dimensional (4D) sonography at 14 weeks and 5 days of gestation. Conventional 2D sonography revealed multiple amniotic bands, fetal acrania, deformed hand, gastroschisis, kyphoscoliosis, and club foot. 3D and 4D sonography revealed multiple amniotic bands swinging in the amniotic cavity with 1 of them attached to the fetal head, and the severe deformity of the fetal face.

Three-dimensional sonographic features of a fetus with Wolf-Hirschhorn syndrome.

We present a case of fetal Wolf-Hirschhorn syndrome diagnosed by conventional two-dimensional and three-dimensional ultrasonography. Conventional two-dimensional ultrasonography revealed a diaphragmatic hernia, nuchal edema, and suspected hypospadias. Three-dimensional ultrasonography clearly showed a flattening of the face, a high forehead, a broad nasal bridge continuing to the forehead, exophthalmos, and micrognathia (resembling the appearance of a Greek warrior helmet), but conventional two-dimensional ultrasonography did not depict these findings. Prenatal chromosomal analysis confirmed the diagnosis of Wolf-Hirschhorn syndrome [46XY, del(4)(p15.2)]. Here we demonstrate how three-dimensional ultrasonography provided a novel visual depiction of the facial dysmorphism, which helped substantially in prenatal counseling.

Three-dimensional HDlive imaging of an umbilical cord cyst.

Umbilical cord cysts (UCC) are a rare congenital malformation. Previous reports have suggested that the second- and third-trimester UCC may be associated with other structural anomalies or chromosomal abnormalities. Therefore, high-quality imaging is clinically important for the antenatal diagnosis of UCC and to conduct a precise anatomical survey of intrauterine abnormalities. There have been few reports of antenatal diagnosis of UCC with the conventional two- and three-dimensional ultrasonography. In this report, we demonstrate the novel visual depiction of UCC in utero with three-dimensional HDlive imaging, which helps substantially with prenatal diagnosis. A case with an abnormal placental mass at 16 weeks and 5 days of gestation was observed in detail using HDlive. HDlive revealed very realistic images of the intrauterine abnormality: the oval lesion was smooth with regular contours and a homogenous wall at the site of cord insertion on the placenta. In addition, we confirmed the absent of umbilical cord, placental, and fetal structural anomalies. Here, we report a case wherein HDlive may have provided clinically valuable information for prenatal diagnosis of UCC and offered a potential advantage relative to the conventional US.

Feasibility assessment for successfully visualizing the fetal heart utilizing spatiotemporal image correlation.

PURPOSE: Spatiotemporal image correlation (STIC) is an excellent imaging modality for observing the fetal heart. High-quality STIC volume data are needed for an antenatal anatomic survey to diagnose congenital heart disease. We aimed to clarify the causes of unsuccessful STIC volume data acquisition and describe a more accurate, efficient STIC examination. METHODS: This cross-sectional study of 1124 women with fetuses assessed risk factors for unsuccessful acquisition of STIC volume data. Logistic regression analysis quantified the relation between unsuccessful acquisition and clinical variables, including maternal body mass index (BMI), shadowing artifacts due to unexpected fetal limb movement (SAU), estimated fetal weight (EFW), gestational age (GA), use of volume rendering images in four-dimensional ultrasonography (4D-US), fetal heart rate (FHR), maternal age, anterior placenta, and prior lower abdominal surgery. RESULTS: STIC volume data acquisition was unsuccessful in 210 of 1124 (18.6%) cases. SAU, BMI ≥ 28 kg/m2, not using volume rendering images in 4D-US, EFW ≥ 1300 g, and anterior placenta were independent risk factors for unsuccessful STIC data acquisition. CONCLUSIONS: Avoiding SAU was the most important factor for accurate, efficient STIC evaluations for diagnosing congenital heart disease antenatally. The risk was not explained by lack of sonographer proficiency. Volume rendering images in 4D-US is a promising approach to successful acquisition of STIC volume data.

Three-dimensional sonographic volume measurement of the fetal cerebellum.

PURPOSE: The objective of this longitudinal study was to evaluate the growth of the fetal cerebellum in normal pregnancy by using three-dimensional ultrasound. METHODS: Three-dimensional sonographic examinations were performed for 13 appropriate-for-gestational-age fetuses. Fetal cerebellar volume was measured every 2 to 3 weeks after 20 weeks of gestational age until delivery. The common multiplanar technique was used to calculate the fetal cerebellar volume. RESULTS: A curvilinear relationship was found between gestational age and cerebellar volume (R(2) = 78.6%, P < 0.0001), and normal ranges of cerebellar volume measurements for estimating the growth of the fetal cerebellum during normal pregnancy were generated. The data gathered in this study were fairly comparable with previous data obtained using three-dimensional ultrasound. However, the normal ranges of cerebellar volume that we determined were relatively wide throughout pregnancy. CONCLUSIONS: Our findings suggest that a standard curve for fetal cerebellar volume using three-dimensional ultrasound can play a role in the evaluation of normal cerebellar growth in the fetus. However, we do cast doubt on the reliability and reproducibility of cerebellar volume measurement using three-dimensional ultrasound. Further studies involving a larger sample size and another technique (the rotational method with VOCAL) would be needed to confirm these findings.

Three-dimensional sonographic measurement of fetal renal volume.

OBJECTIVE: The objective of this longitudinal study was to evaluate the growth of the fetal kidney in normal pregnancies using three-dimensional ultrasound. METHODS: Three-dimensional sonographic examinations were performed on 13 appropriate-for-gestational-age fetuses. Fetal renal volume was measured every 2 to 3 weeks after 20 weeks gestational age until delivery. RESULTS: There was a good linear correlation between left and right renal volumes (r = 0.9614, P < 0.0001). Curvilinear relationships were found between gestational age and left and right renal volume (left: R(2) = 79.1%, P < 0.0001; right: R(2) = 74.2%, P < 0.0001), and normal ranges of left and right renal volume measurements for estimating the growth of the fetal kidney during normal pregnancy were generated. There was a difference for each predicted value of the fetal renal volume in the third trimester of pregnancy in our study and in two other previous studies. The left and right fetal renal volume to estimated fetal weight ratios were constant during the pregnancies studied. CONCLUSION: Our findings suggest that fetal renal volume measurement plays a role in assessment of the growth of fetal kidneys. However, we are doubtful about the reproducibility of fetal renal volume measurements made by using three-dimensional ultrasound in utero. Further studies involving larger sample sizes are needed to reevaluate the usefulness and reproducibility of fetal renal volume measurements.

HDlive rendering images of the fetal stomach: a preliminary report.

PURPOSE: This study aimed to show reconstruction of the fetal stomach using the HDlive rendering mode in ultrasound. METHODS: Seventeen healthy singleton fetuses at 18-34 weeks' gestational age were observed using the HDlive rendering mode of ultrasound in utero. RESULTS: In all of the fetuses, we identified specific spatial structures, including macroscopic anatomical features (e.g., the pyrous, cardia, fundus, and great curvature) of the fetal stomach, using the HDlive rendering mode. In particular, HDlive rendering images showed remarkably fine details that appeared as if they were being viewed under an endoscope, with visible rugal folds after 27 weeks' gestational age. CONCLUSION: Our study suggests that the HDlive rendering mode can be used as an additional method for evaluating the fetal stomach. The HDlive rendering mode shows detailed 3D structural images and anatomically realistic images of the fetal stomach. This technique may be effective in prenatal diagnosis for examining detailed information of fetal organs.

Three-dimensional and four-dimensional HDlive-rendered images of thanatophoric dysplasia.

We present herein our first experience with a case of thanatophoric dysplasia (type I) that was diagnosed during the second trimester using three- and four-dimensional HDlive ultrasonography. The HDlive rendering mode clearly showed the anatomical features of thanatophoric dysplasia: external malformations and skeletal abnormalities, including extremely short limbs, flattened vertebral bodies, and short horizontal ribs, among others. HDlive can provide valuable, highly realistic images for the differential diagnosis of skeletal dysplasia. It may also play an important complementary role when conventional two- and three-dimensional ultrasonography does not provide sufficient definition.

Three-dimensional high-definition flow in the diagnosis of placental lakes.

Placental lakes are sonolucent areas often found in the normal placenta. Most of them are asymptomatic. They are sometimes related to placenta accreta or intrauterine fetal growth restriction, among other conditions. Although Doppler sonography is useful for evaluating noxious placental lakes, it is not easy to adapt Doppler studies to conventional two-dimensional color Doppler sonography because of the low-velocity blood flow and high vascularity in the placenta. Here, we demonstrate how three-dimensional high-definition imaging of flow provides a novel visual depiction of placental lakes, which helps substantially with the differential diagnosis. As far as we know, there have been no previous reports of observation of placental lakes using three-dimensional high-definition imaging of flow.

Three-dimensional sonographic volume measurement of the fetal stomach.

The objective of this study was to measure the fetal gastric volume using three-dimensional (3-D) ultrasound during pregnancy. Three-dimensional sonographic examinations were performed involving 35 pregnant women from 12 to 38 weeks of gestation. The fetal gastric volume was monitored every 5 min for a minimum of 40 min (40-60 min) in each woman. The rotational technique with Virtual Organ Computer-aided AnaLysis (VOCAL) was used to calculate the fetal gastric volume. Maximum and minimum gastric volumes were curvilinearly associated with the gestational age, respectively (R(2) = 0.611, p < 0.0001, and R(2) = 0.407, p < 0.0001, respectively). A curvilinear relationship was noted between the functional capacity (maximum volume - minimum volume) of the fetal stomach and gestational age (R(2) = 0.531, p < 0.0001). The maximum volume change [(maximum volume - minimum volume/maximum volume) × 100] did not change during pregnancy (mean and standard deviation, 64.1% ± 16.1%). However, gastric emptying cycles could not be determined in this study because of the short observation period and small number of subjects. Our findings suggest that the fetal gastric volume calculated by conventional two-dimensional ultrasound in previous investigations is approximately one-third of the maximum volume using 3-D ultrasound in the present study and that 3-D ultrasound is a superior means of evaluating the fetal gastric volume in utero. However, the data and their interpretation in the present study should be viewed with some degree of caution because of the small number of subjects. Further studies involving a larger sample size are needed to confirm these findings.

Positron emission tomography with the glucose analog [F]-fluoro-2-deoxy-D-glucose for evaluating pelvic lymph node metastasis in uterine corpus cancer: comparison with CT and MRI findings.

OBJECTIVE: The aims of this study were to investigate the ability of positron emission tomography (PET) with the glucose analog [(18)F]-fluoro-2-deoxy-D-glucose (FDG) to detect pelvic lymph node metastasis of uterine corpus cancer and to perform a retrospective comparison with computed tomography (CT) and magnetic resonance imaging (MRI) findings. METHODS: Forty-six patients with uterine corpus cancer scheduled for surgery, including bilateral pelvic and/or para-aortic lymphadenectomy, were eligible for this study. CT and MRI of the pelvis and abdomen were performed in all patients within 2 weeks preceding whole-body FDG-PET. FDG-PET images were analyzed visually for objective assessment of regional tracer uptake. The sensitivity and specificity of each imaging modality for detecting pelvic lymph node metastasis were determined, respectively. RESULTS: Eleven (7 with myometrial invasion less than 1/2, 4 with myometrial invasion over 1/2) of the 46 patients (23.9%) were revealed to have pelvic lymph node metastasis. The sensitivity and specificity for detecting pelvic lymph node metastasis in patients with uterine corpus cancer by FDG-PET were 31.3% and 96.1% by lymph node region, respectively, and 36.4% and 91.4% by patient, respectively. No significant difference was noted among each imaging modality with sensitivity or specificity. Moreover, the sensitivity and specificity for detecting pelvic lymph node metastasis in 29 patients with endometrioid adenocarcinomas by FDG-PET were 28.6% and 96.1% by lymph node region, respectively, and 50% and 92% by patient, respectively. No significant difference was noted among each imaging modality in terms of sensitivity or specificity. Among 11 patients with pathologically positive pelvic lymph node metastasis, three out of four patients with myometrial invasion over 1/2 were diagnosed as pelvic lymph node metastasis positive by all diagnostic modalities, however, only one of seven patients with myometrial invasion less than 1/2 was diagnosed as pelvic lymph node metastasis positive by PDF-PET and CT. MRI could not detect pelvic lymph node metastasis in patients with myometrial invasion less than 1/2. CONCLUSIONS: We suggest that current imaging modalities including FDG-PET cannot change medical management of patients with uterine corpus cancer before surgery.

Four-dimensional sonography with B-flow imaging and spatiotemporal image correlation for visualization of the fetal heart.

PURPOSE: To use B-flow imaging with 4-dimensional (4D) sonography and spatiotemporal image correlation (STIC) in the evaluation of normal fetal heart and congenital heart disease during pregnancy. METHOD: Volume data sets of the fetal heart were acquired with automated transverse and longitudinal sweeps of the anterior chest wall. We studied 13 normal fetuses and 2 fetuses with congenital heart disease (1 double-outlet right ventricle and 1 hypoplastic left heart syndrome) at gestation ages ranging from 13 to 39 weeks using transabdominal 4D B-flow sonography with STIC (4D BF-STIC). RESULTS: 4D BF-STIC demonstrated dynamic angiographic features in both normal and abnormal fetal hearts. 4D BF-STIC images could not be obtained in 2 normal fetuses at 18.1 and 33.1 weeks because of the high fetal heart rate and inappropriate fetal position. In normal fetal heart, characteristic hemodynamic changes in both atria and ventricles were clearly demonstrated in systole and diastole. 4D BF-STIC also allowed visualization of the relationship, size, and course of the outflow tracts, thus helping the examiner to better understand the relationships between the vessels. In a case of hypoplastic left heart syndrome, dramatic hemodynamic changes including the right atrium, right ventricle, and pulmonary artery were evident. In a case of double-outlet right ventricle with ventricular septal defect, left-to-right shunt flow through a ventricular septal defect was clearly shown, as were great arteries originating in parallel from the right ventricle. CONCLUSION: 4D BF-STIC provides a means of real-time 3-dimensional evaluation of fetal intracardiac and extracardiac hemodynamics in the second and third trimesters. This novel technique assists in the evaluation of fetal cardiac hemodynamics and may play an important role in future fetal cardiac research and in the evaluation of congenital heart disease in the fetus.

Real-time three-dimensional color Doppler fetal echocardiographic features of congenital heart disease.

The purpose of this report is to describe the real-time three-dimensional (3D) color Doppler fetal echocardiographic findings of congenital heart diseases. Two cases of fetal congenital heart disease were diagnosed antenatally by conventional two-dimensional fetal echocardiography and real-time 3D color Doppler fetal echocardiography. Conventional two-dimensional (2D) fetal echocardiography showed a hypoplastic left heart in one case, and a double-outlet right ventricle in the second case. Real-time 3D fetal echocardiography with instantaneous volume-rendered displays showed surgeon's eye views of intracardiac abnormal cardiac structures of the beating heart in both cases. Real-time 3D color Doppler fetal echocardiography depicted a subtle tricuspid regurgitant jet in hypoplastic left heart syndrome, and great arteries, left from the right ventricle, in parallel in a double-outlet right ventricle. Real-time 3D color Doppler fetal echocardiography may assist in the evaluation of fetal cardiac anatomy and hemodynamics, and offer the potential advantages relative to conventional 2D fetal echocardiography and Doppler flow mapping.

Does three-dimensional power Doppler ultrasound improve the diagnostic accuracy for the prediction of adnexal malignancy?

OBJECTIVE: The aim of the present study was to investigate the diagnostic accuracy of three-dimensional power Doppler ultrasound (3DPD) in the differentiation between benign and malignant adnexal masses and evaluate 3DPD for assessing malignancy in comparison with two-dimensional transvaginal gray-scale sonography (2DTVS), magnetic resonance imaging (MRI) and positron emission tomography (PET). SUBJECTS AND METHODS: Thirty-six patients with suspicious adnexal masses were included in this study. 2DTVS and 3DPD were performed preoperatively. MRI and PET examinations were also carried on within two weeks of initial sonography. All the results of diagnostic imaging techniques were evaluated separately. Final diagnosis was confirmed by the postoperative histopathology. The mature cystic teratomas and endometriomas with typical gray-scale sonographic appearance were excluded from the study. RESULTS: Of the 36 patients, 25 had a malignancy, 5 had a borderline tumor, and 6 had a benign mass. Sensitivity of 2DTVS, 3DPD, MRI and PET were 96.7%, 76.7%, 96.7% and 83.3%, respectively. The sensitivity of 2DTVS was as high as that of MRI, and both of them were significantly higher than those of 3DPD and PET, respectively. There were no significant differences both in specificity and accuracy among these 4 techniques. CONCLUSION: 3DPD did not improve the diagnostic accuracy for the prediction of malignancy in adnexal masses. 2DTVS may still remain an important modality for the prediction of adnexal malignancy.

Three-dimensional sonographic volume measurement of the fetal lung.

AIM: The objective of this longitudinal study was to evaluate the growth of the fetal lung in normal pregnancies, using 3-D ultrasound. METHODS: 3-D sonographic examinations were performed on 14 appropriate-for-gestational-age fetuses. Fetal lung volumes (left, right, and total lung volumes) were measured every 2-3 weeks from 20 weeks of gestational age until delivery. The common multiplanar technique was used to calculate fetal lung volume. RESULTS: Curvilinear relationships were found between the gestational age and left (R2 = 86.9%, P < 0.0001), right (R2 = 83.9%, P < 0.0001) and total (R2 = 83.8%, P < 0.0001) lung volumes. The data described in this study were fairly comparable with previous data from autopsy series. However, there were big differences for predicted values of the fetal total lung volumes using 3-D ultrasound among the present study and previous investigations. CONCLUSION: Our findings suggest that the standard curve for fetal lung volume using 3-D ultrasound provides a role for evaluating the normal lung growth in the fetus. However, we do cast doubt on the reliability and reproducibility of fetal lung volume measurements using 3-D ultrasound. Moreover, the data and its interpretation in our study should be taken with some degree of caution because of the small number of subjects studied. Further studies involving a larger sample size would be needed to confirm these findings.

Three-dimensional sonographic volume measurement of the fetal spleen.

AIM: The objective of this longitudinal study was to evaluate the growth of the fetal spleen in normal pregnancies, using three-dimensional ultrasound. METHODS: Three-dimensional sonographic examinations were performed on 14 appropriate-for-gestational-age fetuses. Fetal splenic volume was measured every 2-3 weeks after 20 weeks of gestational age until delivery. RESULTS: Curvilinear relationships were found between the gestational age and splenic volume (R(2) = 80.2%, P < 0.0001), and normal ranges of splenic volume measurements for estimating the growth of the fetal spleen during normal pregnancy were generated. We found that the splenic volume calculation based on the equation for the volume of the ellipsoid by conventional two-dimensional ultrasound in previous investigations is about twice as large as that using three-dimensional ultrasound in our study, whereas the present data described in this study is quite comparable with previous data from an autopsy series. CONCLUSION: Our findings suggest that the standard curve for the fetal splenic volume using three-dimensional ultrasound provides a superior means for evaluating the normal splenic growth in the fetus and for identifying splenic abnormalities in utero. However, the data and its interpretation in our study should be taken with some degree of caution because of the small number of subjects studied. Further studies involving a larger sample size would be needed to confirm these findings.