Perinatal and infant outcome of fetuses with prenatally diagnosed hyperechogenic kidneys.

OBJECTIVE: Hyperechogenic kidneys are a relatively rare antenatal finding, which can generate significant parental anxiety due to uncertain prognosis. We report on the perinatal and infant outcomes of a large cohort of fetuses with antenatally diagnosed hyperechogenic kidneys. METHODS: This was a retrospective analysis of all cases diagnosed prenatally with hyperechogenic kidneys between 2002 and 2017 in a large tertiary fetal medicine unit. Hyperechogenicity was defined as kidney parenchyma with greater echogenicity than that of the liver. Pregnancy, pathological and postnatal outcomes were collected from hospital and general practitioner records up to 1 year of age. Abnormal renal outcome was defined as elevated creatinine beyond 6 months of age, hypertension requiring medication or major kidney surgery, such as nephrectomy. Severe abnormal renal outcome was defined as the need for dialysis or kidney transplant at any stage. RESULTS: Three-hundred and sixteen fetuses with hyperechogenic kidneys were identified at a mean gestational age of 21 (range, 13-37) weeks. The majority of cases (97%) had bilateral hyperechogenic kidneys. In the 265 cases with available follow-up data, other associated renal tract abnormalities were identified prenatally in 36%, concomitant extrarenal structural abnormalities in 39% and abnormal karyotype in 15% of cases. Of the 316 included cases, 139 did not survive, including 105 terminations of pregnancy, five intrauterine deaths and 29 early neonatal deaths. Only 4.3% (6/139) of these fetuses had isolated hyperechogenic kidneys while 28.1% (39/139) had associated multiple renal tract abnormalities alongside hyperechogenic kidneys and over two-thirds (67.6%; 94/139) had concomitant extrarenal abnormalities. Of the 177 cases that survived beyond 1 month of age, outcome data were available in 126. Of these, based on the antenatal findings, 60 (47.6%) cases had isolated hyperechogenic kidneys, 56 (44.4%) had associated renal structural abnormalities and 10 (7.9%) had additional extrarenal abnormalities. Considering renal outcome alone, kidney function was abnormal in 13 (21.7%), 10 (17.9%) and 0 (0%) infants in these three groups, respectively, although concurrent pathology clearly affected global outcome in the more complex cases. Neonatal mortality of 1.6% was observed in the isolated renal hyperechogenicity group. The presence of oligohydramnios or abnormal renal volume was not associated significantly with abnormal renal function (odds ratio (OR), 2.32 (99% CI, 0.54-10.02) and OR, 0.74 (99% CI, 0.21-2.59), respectively) in this group. CONCLUSIONS: Hyperechogenic kidneys are often complicated by associated renal tract and extrarenal abnormalities, aberrant karyotype and genetic disease, and these factors have a greater effect on overall outcome than does kidney echogenicity. The renal outcome of fetuses with isolated hyperechogenic kidneys is good generally, with over 70% of cases having normal renal function postpartum. Importantly, for prognostic counseling, all of the fetuses in this non-selected series with isolated hyperechogenic kidneys and normal amniotic fluid levels had normal renal outcome in infancy. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Crash sign: new first-trimester sonographic marker of spina bifida.

OBJECTIVES: To describe a new first-trimester sonographic sign, the 'crash sign', associated with fetal open spina bifida, and to evaluate its clinical usefulness in the first-trimester diagnosis of spina bifida. METHODS: This was a retrospective review of patients referred to three fetal medicine centers in the first trimester (11 + 0 to 13 + 6 weeks) with suspected spina bifida. Spina bifida was confirmed by direct visualization of the spinal defect on ultrasound by two experts and, when possible, by fetal postmortem examination. Ultrasound images were reviewed for the presence of the crash sign, which is the posterior displacement of the mesencephalon and deformation against the occipital bone in the axial view. The first-trimester ultrasound images of a mixed group of 10 cases and 40 control fetuses without spina bifida were assessed for the presence of the crash sign by two assessors blinded to the diagnosis. RESULTS: The crash sign was present in 48 out of 53 confirmed cases of spina bifida. Of these, 27 had isolated spina bifida and 21 had an associated anomaly. Of the five cases without the crash sign, one had isolated spina bifida and four had an associated anomaly. The crash sign was not reported in any of the control fetuses. CONCLUSIONS: We have described a new first-trimester sonographic marker for the diagnosis of spina bifida. Our results suggest that the crash sign may be a useful tool in the first-trimester detection of spina bifida. Prospective evaluation of the crash sign would be beneficial, ideally in a routine clinical screening ultrasound setting. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Lateral ventricles in fetuses with aneuploidies at 11-13 weeks' gestation.

OBJECTIVE: To examine the possible association between aneuploidies and fetal lateral cerebral ventriculomegaly in the first trimester of pregnancy. METHODS: Three-dimensional brain volumes were acquired by transvaginal ultrasound examination at 11-13 weeks' gestation in 410 euploid fetuses and 63 fetuses with trisomy 21, 34 with trisomy 18 and seven with trisomy 13. Lateral ventricles were assessed in a transverse view, just above the roof of the third ventricle and measurements of the areas of the lateral ventricles and choroid plexuses were obtained. The ratio between choroid plexus and lateral ventricle areas (CLR) was calculated. Measurements in aneuploid fetuses were compared to those in euploid fetuses. RESULTS: In euploid fetuses the lateral ventricle and choroid plexus areas increased, whereas the CLR decreased with fetal biparietal diameter. In fetuses with trisomy 21, lateral ventricle and choroid plexus areas were smaller but CLR was not significantly different from that in euploid fetuses. In trisomy 18 and 13 fetuses, CLR was significantly smaller than in euploid fetuses. The CLR was below the 5(th) centile of normal range in 11 (32.4%) fetuses with trisomy 18 and in six (85.7%) with trisomy 13. CONCLUSION: There is evidence of ventriculomegaly at 11-13 weeks' gestation in most fetuses with trisomy 13 and one third of fetuses with trisomy 18.

Cerebral ventricular system in fetuses with open spina bifida at 11-13 weeks' gestation.

OBJECTIVE: To determine if in fetuses with open spina bifida at 11-13 weeks' gestation there are alterations in the cerebral ventricular system. METHODS: In this study we selected 10 cases of open spina bifida and 410 normal singleton pregnancies which subsequently resulted in the delivery of phenotypically normal neonates. In all cases transvaginal sonography was carried out at 11-13 weeks' gestation and three-dimensional (3D) brain volumes were acquired. The fetal head was systematically assessed in a series of transverse views and measurements were obtained of the area of the lateral ventricles, the diameter of the roof of the third ventricle, the diameter of the aqueduct of Sylvius and the diameter of the fourth ventricle. The measurements obtained on the normal and affected fetuses were compared. RESULTS: In normal fetuses the area of the lateral ventricles and the diameter of the roof of the third ventricle increased, the diameter of the aqueduct of Sylvius decreased and the diameter of the fourth ventricle did not change significantly with biparietal diameter (BPD). In fetuses with open spina bifida, compared with normal fetuses, the measurements of the lateral ventricle area, the diameter of the roof of the third ventricle, the diameter of the aqueduct of Sylvius and the diameter of the fourth ventricle were significantly decreased (P < 0.01). CONCLUSION: In fetuses with open spina bifida at 11-13 weeks' gestation the intracranial collection of cerebrospinal fluid is substantially reduced.

Recurrent heterotopic pregnancy after bilateral salpingectomy in an IVF patient: case report.

PURPOSE: To report a rare clinical case of recurrent heterotopic pregnancy in the same patient following bilateral salpingectomy and in-vitro fertilization (IVF) treatments. METHODS: A 35 year-old woman, suffering from mechanical infertility, was treated by IVF, resulting in two episodes of heterotopic pregnancies within 2 years. The first episode ended in bilateral salpingectomy due to unilateral tubal pregnancy and contralateral severely damaged tube. The intrauterine pregnancy ended in early missed abortion. The second heterotopic pregnancy presented as bleeding cornual pregnancy, managed by laparoscopic resection of the tubal stump, and ended in a term singleton delivery. CONCLUSION: The possibility of cornual heterotopic pregnancy following bilateral salpingectomy, though very rare, should be considered by every gynecologist treating IVF patient.

A model for second-trimester Down syndrome sonographic screening based on facial landmarks and digit length measurement.

OBJECTIVE: To determine whether Down syndrome can be detected by combining measurements of fetal nasal bone (NB) length, prenasal thickness (PT) and digits 2 and 3 of the hand. METHODS: Two hundred and fifty-four normal and 25 Down-syndrome fetuses were scanned between 15 and 33 weeks' gestation. Physicians performing the scans were not blinded to the fetal karyotype. Both PT and NB were measured in a mid-sagittal plane. For PT measurement calipers were placed between the frontonasal angle and the outer skin edge. Digits 2 and 3 of one hand were also measured. The results (except for PT/NB ratio) were expressed in multiples of the normal gestation-specific median (MoM). A logistic regression model was used to estimate the odds of the fetus having Down syndrome given different combinations of NB, PT, PT/NB ratio, and digits 2 and 3 measurements. The odds were used to calculate the risk of Down syndrome for each pregnant woman from her age and measurements. RESULTS: The median PT MoM for unaffected fetuses and Down-syndrome fetuses was 1.12 vs. 1.35 (P < 0.0001). The median NB MoM for unaffected and Down-syndrome fetuses was 1.03 vs. 0.81 (P < 0.001) and the PT/NB ratio MoM for unaffected and Down-syndrome fetuses was 0.63 vs. 0.96 (P < 0.001). The respective median MoM values for digits 2 and 3 of the Down-syndrome fetuses were significantly smaller (0.81 vs. 0.93 and 0.89 vs. 0.95, respectively, P = 0.003). Only the PT/NB ratio and digit 2 were finally included in the logistic regression equation. Using a 1 in 200 risk cut-off, the observed sensitivity and false-positive rate were 76% and 6.7%, respectively. CONCLUSION: Combining the PT/NB ratio and digit 2 measurements yielded a promising screening detection rate. Confirmation of our findings in a prospective study is needed before the method can be used clinically.

Application of free-hand three-dimensional echocardiography in the evaluation of fetal cardiac ejection fraction: a preliminary study.

OBJECTIVE: To investigate the feasibility of using free-hand three-dimensional (3D) echocardiography to evaluate fetal cardiac function. METHODS: 3D cardiac data were collected during screening examinations for 37 normal fetuses with gestational ages of between 16 and 26 weeks. Processing of the 3D volumes included separation of the end-diastolic and end-systolic slices, segmentation of right and left ventricles, measurement of end-diastolic and end-systolic volumes, and calculation of the ejection fraction (EF) for each ventricle. In 21 fetuses at 21-24 weeks, right and left ventricle volumes and EF were compared. RESULTS: Twenty-five cases were appropriate for final statistical analysis. The volume of the ventricles increased with gestational age and estimated fetal weight. There was no significant trend in the difference between the volumes and EF of the right and left ventricles in the 21-24-week subgroup. The mean right and left ventricular EF were 54 +/- 11.2% and 57.5 +/- 14.6%, respectively. The mean combined EF of ventricles during gestation was 55.1 +/- 10.7% and seemed to remain constant during the gestational ages studied. CONCLUSIONS: 3D echocardiography can provide estimates of ventricular volume and function and may in future be used for evaluation of fetuses with congenital heart disease and cardiac dysfunction.

Parasitic ovarian dermoid tumor of the omentum-A review of the literature and report of two new cases.

Two cases of a parasitic omental teratoma which originated from an ovarian dermoid that underwent torsion, autoamputation and omental reimplantation are presented. A review of the literature revealed 23 additional cases of omental teratoma which occurred mostly in females. In some cases, the mature teratoma of the omentum showed histological evidence of ovarian stroma, and was associated with a dermoid tumor of the remaining contralateral ovary. It is generally believed that autoamputation and reimplantation of an ovarian dermoid cyst is the most common etiology of omental teratomas. Abdominal pain is the main presenting symptom of these tumors, and on physical examination a mobile abdominal or pelvic mass is often found. Both ultrasonography with colour flow Doppler and CT-scan are helpful in the diagnosis of dermoid tumors, but the correct diagnosis of omental localisation is extremely difficult. Mature omental teratomas may be treated by simple resection. The immature teratomas of the greater omentum, however, are potentially malignant tumors requiring postoperative chemotherapy and radiotherapy.

Cervical pregnancy: past and future.

Cervical pregnancy (CP) is a rare life-threatening form of ectopic pregnancy occurring in 1 of 8628 deliveries. We reviewed 117 cases of CP in the English language literature from 1978 and added three cases from our department. Etiology of CP is still unknown, but there is evidence for its association with cervicouterine instrumentation. The possible role of embryo chromosomal abnormality in the CP etiology is considered. Sonography improved pretreatment diagnosis up to 81.8 percent. Obligatory sonographic criteria of CP include endocervical localization of the gestational sac and trophoblastic invasion. About 60 percent of cervical pregnancies are with a viable fetus. The majority of patients with a cervical pregnancy are women with low parity, thus, the current treatment trend is to preserve their reproductive function. The main problem of conservative treatment is life-threatening hemorrhage after pregnancy evacuation. The use of cervical canal tamponade with a Foley catheter balloon led to reliable hemostasis in 92.3 percent of cases in which this method was used. Early diagnosis of CP allowed for treatment by chemotherapy in 32 cases, with an 81.3 percent success rate. Serial beta-human chorionic gonadotropin levels and transvaginal ultrasound with color Doppler are used to monitor therapy. Another conservative treatment modality is local intrasac KCI injections. Hysterectomy is recommended mostly for second and third trimester cervical pregnancy, or for uncontrolled bleeding.

[Endometrial measurement by transvaginal sonography in postmenopausal bleeding].

We evaluated the role of transvaginal sonography (TVS) in the investigation of postmenopausal bleeding (PMB) in 50 women with PMB and 25 asymptomatic postmenopausal women presenting for periodic check-up, who served as controls. All those with PMB had a diagnostic curettage or hysterectomy within a week of TVS examination. Measurement of endometrial thickness was compared with the histopathological diagnosis of the endometrium. Of the 32 patients whose endometrial thickness was more than 5 mm, 22 had pathological changes in the endometrium. These included 6 cases of endometrial cancer and 16 with benign changes. All 18 patients of the PMB group with endometrial thickness less than 5 mm had normal endometrial histology. Endometrial thickness in all asymptomatic controls was less than 5 mm. Our results showed endometrial thickness greater than 5 mm to be 100% sensitive and 64% specific in identifying endometrial pathology. TVS follow-up without curettage may be considered for PMB patients with uniform endometrium less than 5 mm thick.