Frequency and prediction of persistent urinary tract dilation in third trimester and postnatal urinary tract dilation in infants following diagnosis in second trimester.

OBJECTIVE: To determine the frequency, associated characteristics and prognostic value of the current risk stratification system for prenatal urinary tract dilation (UTD) for predicting persistent UTD in the third trimester and subsequent postnatal UTD in the infant, following diagnosis in the second trimester. METHODS: This was a single-institution retrospective cohort study of singleton pregnancies diagnosed with unilateral or bilateral UTD in the second trimester (before 28 weeks' gestation) with follow-up in the third trimester (at or after 28 weeks) between January 2017 and May 2019. In all cases, the prenatal diagnosis and stratification to low-risk (Grade A1) or increased-risk (Grade A2-3) UTD was made using the 2014 UTD consensus classification system. The primary outcomes included persistent prenatal UTD in the third trimester and postnatal UTD up to 6 months of age. We performed multivariable analysis to assess whether patient and second- and third-trimester sonographic characteristics (such as UTD laterality, other renal abnormality (calyceal dilation, abnormal parenchymal appearance, abnormal ureter or bladder) and anteroposterior renal pelvic diameter (AP-RPD)) were associated with the study outcomes. We assessed the predictive value of the current risk stratification system (Grade A1 vs Grade A2-3) in the second and third trimesters for persistent prenatal UTD and postnatal UTD using the area under the receiver-operating-characteristics curve (AUC). RESULTS: Of 26 620 second-trimester ultrasound assessments in the study period, 347 patients were diagnosed with UTD in the second trimester and had third-trimester follow-up, of whom 150/347 (43% (95% CI, 38-49%)) had persistent UTD in the third trimester. Among the 282/347 (81%) patients with postnatal follow-up available, the frequency of postnatal UTD was 49/282 (17% (95% CI, 13-22%)), and among the subset with persistent UTD in the third trimester, the frequency of postnatal UTD was 46/102 (45% (95% CI, 35-55%)). The most frequent postnatal diagnosis was transient UTD (76%), followed by duplicated collecting system (10%). Of infants originally diagnosed with UTD in the second trimester, 2% (7/347) required surgery; stated differently, of the 49 infants with postnatal UTD, 14% (7/49) required surgery. At second-trimester diagnosis, sonographic predictors of both persistent prenatal UTD and postnatal UTD included the presence of other renal abnormality and UTD Grade A2-3. At third-trimester follow-up, predictors of postnatal UTD were larger mean AP-RPD and UTD Grade A2-3, while all cases had other renal abnormality. Second-trimester diagnosis of UTD Grade A2-3 had satisfactory discrimination for predicting persistent prenatal UTD (AUC, 0.64 (95% CI, 0.58-0.70)) and postnatal UTD (AUC, 0.72 (95% CI, 0.63-0.81)), as did third-trimester UTD Grade A2-3 for predicting postnatal UTD (AUC, 0.66 (95% CI, 0.56-0.76)). CONCLUSIONS: The majority of cases of prenatal UTD did not result in postnatal UTD, and of those that did, very few required surgery. Follow-up third-trimester assessment after a second-trimester diagnosis of UTD is warranted. The current risk stratification system by UTD grade, based on the 2014 UTD consensus classification, can be used to predict postnatal UTD with fair accuracy. Further research is needed to determine whether the predictive performance of this system can be improved by incorporating additional risk factors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

United States' experience in nuchal translucency measurement: variation according to provider characteristics in over five million ultrasound examinations.

OBJECTIVE: The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception. METHODS: We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log10 NT MoM and slope of NT with respect to crown-rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders. RESULTS: Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% had NT median MoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway. CONCLUSIONS: Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Nuchal Translucency Quality Review (NTQR) program: first one and half million results.

OBJECTIVE: To evaluate the performance of first-trimester nuchal translucency (NT) measurement by providers (physician-sonologists and sonographers) within the Nuchal Translucency Quality Review (NTQR) program. METHODS: After training and credentialing providers, the NTQR monitored performance of NT measurement by the extent to which an individual's median multiple of the normal median (MoM) for crown-rump length (CRL) was within the range 0.9-1.1 MoM of a published normal median curve. The SD of log10 MoM and regression slope of NT on CRL were also evaluated. We report the distribution between providers of these performance indicators and evaluate potential sources of variation. RESULTS: Among the first 1.5 million scans in the NTQR program, performed between 2005 and 2011, there were 1 485 944 with CRL in the range 41-84 mm, from 4710 providers at 2150 ultrasound units. Among the 3463 providers with at least 30 scans in total, the median of the providers' median NT-MoMs was 0.913. Only 1901 (55%) had a median NT-MoM within the expected range; there were 89 above 1.1 MoM, 1046 at 0.8-0.9 MoM, 344 at 0.7-0.8 MoM and 83 below 0.7 MoM. There was a small increase in the median NT-MoM according to providers' length of time in the NTQR program and number of scans entered annually. On average, physician-sonologists had a higher median NT-MoM than did sonographers, as did those already credentialed before joining the program. The median provider SD was 0.093 and the median slope was 13.5%. SD correlated negatively with the median NT-MoM (r = -0.34) and positively with the slope (r = 0.22). CONCLUSION: Even with extensive training, credentialing and monitoring, there remains considerable variability between NT providers. There was a general tendency towards under-measurement of NT compared with expected values, although more experienced providers had performance closer to that expected.

Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding.

OBJECTIVE: To determine whether intrauterine contraceptive devices (IUDs) that are located abnormally within the myometrium or cervix cause a higher incidence of pelvic pain and abnormal bleeding compared with normally positioned devices. METHODS: Over a period of 9 months, all patients with an IUD presenting at our unit for two-dimensional pelvic ultrasound underwent a three-dimensional (3D) volume reconstruction of the coronal view, to visualize the entire IUD within the cavity. The IUD was deemed malpositioned if any part extended past the cavity, into the myometrium or cervix. The indications for ultrasound were recorded at presentation for the exam. The presenting symptoms of patients with an abnormally located IUD were compared with those with normally positioned ones. RESULTS: Among 167 consecutive patients with an IUD evaluated using the 3D reconstructed coronal view, 28 (16.8%) had an IUD with side arms abnormally located within the myometrium. The abnormal positioning of the IUD arms was only detected using the 3D coronal view. A higher proportion of patients with an abnormally located IUD presented with bleeding (35.7%) or pain (39.3%) compared with those with normally positioned IUDs (15.1% with bleeding and 19.4% with pain) (P = 0.02 and 0.03, respectively). Seventy-five percent of patients with an abnormally located IUD presented with bleeding or pain compared with 34.5% of those whose IUD was normally placed (P = 0.0001). Twenty of 21 patients with an abnormally located IUD presenting with pelvic pain or bleeding reported improvement in their symptoms after IUD removal. CONCLUSION: A 3D coronal view of the uterus is useful in the visualization of IUDs. The coronal view showing the entire device and its position within the uterus may help in identifying the cause of pelvic pain and bleeding in patients with an embedded IUD.

Nuchal thickening or cystic hygromas in first- and early second-trimester fetuses: prognosis and outcome.

OBJECTIVE: To elucidate the relationship between nuchal abnormality, karyotype, and prognosis in fetuses with nuchal thickening or cystic hygroma observed between 10-15 weeks' gestation. METHODS: We reviewed all cases of fetal nuchal thickening (4 mm or greater) in 10-15-week fetuses over a 5-year period. Generalized hydrops and the presence of other anomalies were noted prospectively. We retrospectively measured the nuchal area and determined whether septations were present. Data consisted of karyotype, pathologic studies, and clinical follow-up of live-born infants. RESULTS: Of 100 consecutive fetuses, 29 were excluded because of pregnancy termination without karyotype or pathologic information. Of the remaining 71 fetuses, 63 had karyotyping. Abnormal karyotypes were found in 31 of 37 hydropic fetuses but in only 12 of 26 nonhydropic fetuses (P < .05). Fetuses with Turner syndrome had larger cystic hygromas than those with trisomy 18, trisomy 21, or normal karyotype (P < .05). There were ten normal live-born infants, none of whom was hydropic at the time of initial diagnosis and all of whom demonstrated spontaneous resolution of the nuchal thickening on subsequent sonograms. CONCLUSIONS: Fetuses with nuchal thickening or cystic hygromas demonstrated by ultrasound should have their karyotype determined. If the karyotype is normal and there are no hydrops or septations, the prognosis is good.

Comparison between sonographic morphology and Doppler waveform for the diagnosis of ovarian malignancy.

OBJECTIVE: To assess the accuracy of pelvic sonography in distinguishing benign from malignant lesions in postmenopausal women, using morphologic criteria and Doppler flow characteristics. METHODS: All postmenopausal patients scanned from March 1992 to April 1993 with sonographically identified and pathologically confirmed adnexal masses formed the study group. The adnexal lesions were morphologically categorized prospectively as benign or malignant, and pulsed Doppler flow studies were measured using the lowest resistance index obtained from each mass. The sensitivity and specificity were determined for morphologic and Doppler flow assessments, as well as for a combination of these methods, for predicting the presence of malignancy. RESULTS: Thirty-three postmenopausal patients formed the study group; 12 lesions were malignant and 21 were benign pathologically. Using morphologic criteria alone, the sensitivity in detecting malignancy was 91% and specificity was 52%. Using pulsed Doppler alone with a resistance index limit of 0.6, the sensitivity in predicting malignancy was 66%, with a specificity of 81%. If a resistance index limit of 0.8 were used, the sensitivity and specificity would be the same as those for morphology alone. Combining morphology and resistance index, a single malignancy would still have been missed (sensitivity 91%). CONCLUSION: In our experience, Doppler flow studies did not add substantially to the prediction of malignancy using morphologic assessment alone.

Amnion-chorion separation after 17 weeks' gestation.

OBJECTIVE: To evaluate the cause of and perinatal outcomes of amnion-chorion separation that is apparent sonographically after 17 weeks' gestation. METHODS: We searched our ultrasound database over 7 years for information on pregnant women who had live fetuses and complete separation between amnion and chorion that persisted beyond 17 weeks' gestation. For inclusion in the study, the women had to have amnion separated from chorion on at least three sides of the gestational sac. Medical records were reviewed for whether women had amniocenteses, results of the amniocenteses, and outcomes of the pregnancies. RESULTS: Of 15 pregnant women with live fetuses, ten had amniocenteses before identification of amnion-chorion separation and five did not. Three had fetuses with Down syndrome, two of whom had amnion-chorion separation evident before amniocentesis, and all three had other sonographic findings suggestive of aneuploidy. Three fetuses died. The other pregnancies were complicated by one or more adverse events, including two fetuses with growth restriction, five preterm deliveries, two with oligohydramnios, and one with abruptio placentae. Five infants were delivered at term and are alive and well. Overall, ten of 15 pregnancies resulted in live newborns, one of whom had Down syndrome. CONCLUSION: Complete amnion-chorion separation that persisted after 17 weeks' gestation is associated with a variety of adverse perinatal outcomes, including aneuploidy.

Echogenic intracardiac focus: a sonographic sign for fetal Down syndrome.

OBJECTIVE: To determine whether an echogenic intracardiac focus identified in the second-trimester fetus is related to an increased risk of Down syndrome. METHODS: During a 10-month period, all women with singleton gestations who underwent second-trimester genetic amniocentesis for non-imaging indications were evaluated prospectively by prenatal sonography. The presence or absence of an echogenic intracardiac focus was noted. Karyotypic information was obtained on each fetus. RESULTS: Among the 1334 patients in the study group, 66 fetuses (4.9%) had an echogenic intracardiac focus. Four of 22 fetuses (18%) with trisomy 21 had an echogenic intracardiac focus, compared with 62 (4.7%) of 1312 fetuses without Down syndrome who also had an echogenic intracardiac focus (P = .004). Sonographic identification of an echogenic intracardiac focus was associated with a fourfold increased risk of Down syndrome (risk ratio 4.3, 95% confidence interval 1.5-12.3). The overall prevalence of Down syndrome in our study population was 1.6%. The sensitivity, specificity, and positive predictive value for using the presence of an echogenic intracardiac focus to identify a fetus with Down syndrome was 18.2, 95.3, and 6.1%, respectively. Extrapolating to a lower risk population, the positive predictive value of an echogenic intracardiac focus for detecting Down syndrome in patients at an age-based risk of one in 250, one in 500, and one in 1000 was calculated to be 1.53, 0.77, and 0.39% respectively. CONCLUSION: Fetuses with an echogenic intracardiac focus have a significantly increased risk of Down syndrome. Although most fetuses with this finding are normal, patients carrying fetuses with an echogenic intracardiac focus should be counseled about the increased risk of trisomy 21.

The iliac angle as a sonographic marker for Down syndrome in second-trimester fetuses.

OBJECTIVE: To determine whether measurements of the iliac wing angle on sonograms of the second-trimester fetus can be used to detect fetuses at increased risk for Down syndrome. METHODS: All second-trimester Down syndrome fetuses karyotyped by amniocentesis over 5 years for whom adequate views of the iliac bones were available were reviewed retrospectively. The control group consisted of consecutive, normal second-trimester fetuses undergoing karyotyping during the same period. The angles between the iliac bones of the fetal pelves were measured on transverse sonograms, and the two groups were compared. A separate prospective evaluation of the ideal level for measurement of the iliac angle was made in two fetuses, one with and one without Down syndrome. RESULTS: We evaluated 38 Down syndrome and 46 control fetuses. The mean iliac-angle measurements differed significantly for the Down syndrome fetuses as compared with normal control fetuses: 78.8 degrees +/- standard deviation (SD) 18.5 and 66.9 degrees +/- SD 13.9, respectively. An iliac angle of at least 90 degrees was measured in 14 (36.8%) Down syndrome fetuses and in two (4.3%) control fetuses, also a significant difference. In a prospective pilot evaluation of two fetuses, we measured the largest iliac angle at the most cephalad level of the iliac bones, and the smallest angle was measured at the most caudad level. The iliac angle measurements for the fetus with Down syndrome ranged from 55 degrees to 100 degrees; for the normal fetus, the range was 52 degrees to 80 degrees. CONCLUSION: Although there is considerable overlap, the average iliac angle for fetuses with Down syndrome is significantly larger than that of normal fetuses. The angle measurement varies widely in any given fetus and is dependent on the level of the image. A prospective study is needed to evaluate the best level of angle measurement for the detection of fetuses with Down syndrome.

Levorotation of the fetal cardiac axis: a clue for the presence of congenital heart disease.

OBJECTIVE: To evaluate the use of the cardiac axis within the chest for the prenatal detection of congenital heart defects. METHODS: We reviewed retrospectively the sonographic findings of all fetuses scanned between 17 and 40 weeks' gestation and diagnosed prenatally as having heart defects. The cardiac diagnoses were confirmed postnatally. The control group consisted of 75 consecutive fetuses with normal fetal surveys and newborn follow-up examinations. The cardiac axes were measured retrospectively using an image of the four-chamber view of the heart and measuring the angle between the interventricular septum and a line bisecting the chest. Mean and standard deviations (SDs) of the axis measurements in normal and abnormal fetuses were compared by Student t test. RESULTS: The 75 fetuses with heart defects diagnosed by prenatal sonogram had a mean cardiac axis of 56 +/- 13 degrees, compared with 43 +/- 7 degrees in normal fetuses (P < .001). Using 57 degrees (two SDs above the mean for normal fetuses) as the upper limit of normal, 33 of 75 (44%) abnormal fetuses versus none of 75 normal fetuses were identified. The frequency of cardiac rotation was greater in fetuses with truncus arteriosus, Ebstein's anomaly, pulmonic stenosis, coarctation of the aorta, and tetralogy of Fallot. CONCLUSION: The presence of a cardiac axis exceeding 57 degrees in the fetal chest is associated with a substantial risk of congenital heart defects. The finding of an abnormal axis should prompt further evaluation of the fetal heart.

Is fetal hyperechoic bowel on second-trimester sonogram an indication for amniocentesis?

OBJECTIVE: To determine the clinical significance of hyperechoic bowel seen sonographically in second-trimester fetuses. METHODS: Fifty fetuses (0.6%) with echogenic bowel were identified sonographically from a population of 8680 consecutive second-trimester fetuses over 21 months. The fetal bowel was considered hyperechoic if its echogenicity was similar to that of surrounding bone. Follow-up was obtained through medical record review. RESULTS: Twenty-nine of 50 fetuses (58%) were normal; eight (16%) were aneuploid, including six Down syndrome, one trisomy 13, and one Turner syndrome. All eight fetuses with aneuploidy had sonographic anomalies in addition to the echogenic bowel. Eight of 50 fetuses (16%) were growth-retarded, and five others (10%) had normal karyotypes but are still undelivered. Among the eight growth-retarded fetuses, there were five intrauterine or neonatal deaths, one elective abortion, and two survivors. In addition, the six fetuses with Down syndrome and echogenic bowel represented 12.5% of all second-trimester Down syndrome fetuses karyotyped in our laboratory during the study period. Combining results from the present study (six Down syndrome fetuses) with three studies from the literature (21 additional Down syndrome fetuses), a total of 27 fetuses with echogenic bowel and Down syndrome were identified, 11 (40.7%) of whom had no other sonographic findings. We calculate that if 1,000,000 second-trimester fetuses were scanned, 5105 would have hyperechoic bowel as the only finding, of whom 71 would have Down syndrome and 5034 would not. The risk of Down syndrome in fetuses with isolated hyperechoic bowel is, therefore, 71 in 5105 or 1.4%. CONCLUSION: The finding of isolated hyperechoic bowel in the second trimester should prompt genetic counseling and consideration of karyotypic analysis.

Sexually dimorphic effects of forced exercise on food intake and body weight in the rat.

The food intake (FI), body weight (BWt) and water intake (WI) of adult male and female rats were compared during a seven day period of forced exercise in a treadmill. Work loads for the exercised groups were gradually increased across the seven-day test period, whereas work loads for the sedentary controls were maintained at the same level used during a previous three-day training period. Relative to their respective control groups, male rats showed a decrease in FI and BWt in response to the exercise challenge, but female rats showed an increase in FI sufficient to maintain their BWt at control levels. Both male and female rats showed a reliable increase in WI during the period of forced exercise. These sexually dimorphic changes in FI and BWt in response to forced exercise indicate that female rats are capable of demonstrating a more vigorous defense of BWt than are male rats and suggest that there is a sex difference in the long-term control of feeding behavior in the rat.

New onset ventricular tachycardia during pregnancy.

A previously healthy young woman who developed the new onset of symptomatic sustained ventricular tachycardia during pregnancy is described. Evaluation revealed mitral valve prolapse with minimal mitral regurgitation, and normal left ventricular size and function. The arrhythmia resolved after delivery, but recurred nine months later in a nonsustained form. Electrophysiologic study revealed only nonsustained ventricular tachycardia, and she was treated with propafenone. It is suggested that the pregnant state may have been important in the pathogenesis of her arrhythmia.

Factors delaying out-of-home placement of children with severe handicaps.

Sixty-three parents of children with severe handicaps who were placed out of the home were interviewed regarding why they did not place their child sooner. Results suggested that parents' reported feelings of attachment and guilt were strong delayers of placement; the availability of formal supportive services also helped to delay the placement decision. Factor analysis of the Factors Preventing Placement Scale utilized in the study indicated three main factors that delay placement. Guilt Feelings, Social Support, and Family Relationships. Implications of these findings were discussed in terms of the relative influences of parental cognitions and support services in delaying the placement decision.

Acute reversal of oligohydramnios-polyhydramnios sequence in monochorionic twins.

Two cases of monochorionic diamniotic twin gestation with severe oligohydramnios-polyhydramnios sequence ('stuck' twin) are described. In each of these cases there was a marked fluctuation in amniotic fluid volume and reversal of which twin was 'stuck'. The definitive identification of the twins was evident due to a discordant fetal malformations in each twin pair.

Sonographically detected abnormalities of the umbilical cord.

OBJECTIVES: This study was undertaken as a retrospective chart review to evaluate the range of umbilical cord abnormalities detected by prenatal sonography, as well as the outcome and pathologic correlation. METHODS: We identified 13 cases of umbilical cord abnormalities detected sonographically over a 46-month period. We evaluated the ultrasound appearance, size, location, and color Doppler characteristic in each case. RESULTS: There were 4 instances of clear cysts on the umbilical cord, 8 with complex masses, and 1 with complete, cystic encasement of the cord throughout its length. The pathology included vascular abnormalities (hemangioma, hematoma, varicosity), edema of the umbilical cord with pseudocysts, and syncytial knots. There was 1 known karyotypic abnormality (trisomy 13). Twelve of the 13 newborns survived; the neonatal death occurred in the fetus with trisomy 13. CONCLUSION: The presence of umbilical cord abnormalities may represent a variety of pathologic entities. Clinical outcome is usually favorable.

Second trimester sonographically diagnosed placenta previa: prediction of persistent previa at birth.

OBJECTIVES: We sought to determine the natural history of second trimester sonographically diagnosed placenta previa, and to ascertain whether the position of the placenta with respect to the cervical os at second trimester sonography can accurately predict persistence of the placenta previa at term. METHODS: The study population included all women consecutively diagnosed by ultrasound with placenta previa between 14 and 20 weeks' gestation. Medical records of the patients requiring cesarean section were reviewed to determine the presence of placenta previa. We reviewed the second trimester sonogram of patients who underwent abdominal delivery for placental and nonplacental indications to determine whether the central (symmetrical) versus the partial (asymmetrial) position of the placenta with respect to the internal os predicted the presence of placenta previa at delivery. RESULTS: A total of 925 second trimester- patients were sonographically identified as having placenta previa. Two hundred and sixty seven patients underwent cesarean delivery, 43 of which had placenta previa (43/925 or 4.6%). Twenty-two of the 43 were asymptomatic without antepartum bleeding. Analysis of the second trimester position of the placenta revealed that symmetry of the placenta with respect to the internal os at second trimester scan had a sensitivity of 49% for prediction of placenta previa at birth. CONCLUSIONS: The degree of placental symmetry with respect to the internal os during the second trimester successfully predicted the previas most likely to persist at delivery with a sensitivity of 49% (95% CI 34-64) and specificity of 93%.

Sonographic appearance of uterine scar dehiscence.

We describe the sonographic appearance of two cases of uterine scar separation in patients with prior cesarean deliveries. In the first case, the anteriorly located placenta appeared to be a placenta previa with accreta and in the second case the placenta was also located directly beneath the uterine scar thus masking a separation until the third stage of labor was complete. These two cases demonstrate an unusual sonographic and clinical presentation of uterine scar separation involving anteriorly located placentas.