Accuracy of ultrasound in antenatal diagnosis of placental attachment disorders.

OBJECTIVES: To evaluate the accuracy of ultrasound in the diagnosis of placenta accreta and its variants, and to assess the impact of prenatal diagnosis in our population. METHODS: A total of 314 women with placenta previa were enrolled prospectively and underwent transabdominal and transvaginal ultrasound examinations. An ultrasound diagnosis (grayscale and color/power Doppler) of placental attachment disorder (PAD) was based on the detection of at least two of the following ('two-criteria system'): loss/irregularity of the retroplacental clear zone, thinning/interruption of the uterine serosa-bladder wall interface, turbulent placental lacunae with high velocity flow, myometrial thickness < 1 mm, increased vascularity of the uterine serosa-bladder wall interface, loss of vascular arch parallel to the basal plate and/or irregular intraplacental vascularization. Definitive diagnosis was made at delivery by Cesarean section. Maternal outcome in cases diagnosed antenatally was compared with that in cases diagnosed at delivery. RESULTS: There were 37/314 cases of PAD (29 anterior and eight posterior). The two-criteria system identified 30 cases of placenta accreta, providing a sensitivity of 81.1% and specificity of 98.9%. When anterior and posterior placentae were considered separately, the detection rates of PAD were 89.7 and 50.0%, respectIvely. Maternal outcome was better in women with prenatal diagnosis of PAD, as seen by less blood loss and shorter hospitalization. CONCLUSIONS: Our data confirmed that grayscale and color Doppler ultrasound have good performance in the diagnosis of PAD and that prenatal diagnosis improves maternal outcome. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Review: Feto-placental vascularization: a multifaceted approach.

Doppler Ultrasound allows the in vivo study of feto-placental hemodynamics. Doppler flow velocity waveforms (FVW's) obtained from the umbilical arteries reflect downstream blood flow impedance, thus giving indirect evidence of vascular villous tree characteristics. Pulsatility Index, which quantifies FVW's, decreases throughout normal pregnancy, indicating decreasing impedance and is often higher in cases of fetal growth restriction (FGR). Different approaches (morphometrical, morphological, mathematical, immunohistochemical and molecular) have contributed to elucidation of which anomalies of the vascular villous tree underlie Doppler findings. 3D ultrasound may be useful in the study of feto-placental perfusion. However, the unsolved question is why developmental villous tree anomalies occur. Crucial to the success of future research is definition of the population studied based on the uniform and correct definition of FGR.

Is three-dimensional power Doppler ultrasound useful in the assessment of placental perfusion in normal and growth-restricted pregnancies?

OBJECTIVES: To investigate three-dimensional (3D) power Doppler ultrasound indices in the assessment of placental perfusion and their relationship to gestational age (GA), placental position and umbilical artery Doppler flow velocity waveform (FVW) patterns in normal and intrauterine growth-restricted (IUGR) pregnancies. METHODS: Forty-five pregnant women at 23-37 weeks' gestation were studied, of whom 30 had IUGR and 15 were controls. Nine of the IUGR group had normal umbilical FVWs (NED), nine had abnormal patterns but positive end-diastolic velocities (PED) and 12 had absent or reversed end-diastolic velocities (AED). Placental position was assessed as being posterior, anterior or lateral. 3D power Doppler indices related to placental perfusion (vascularization index (VI), vascularization flow index (VFI) and flow index (FI)) were obtained from five different sampling sites in each placenta. RESULTS: VI, VFI and FI were not significantly dependent on GA or placental position. VI and VFI were significantly lower in PED and AED cases compared with controls, while FI was reduced in the AED group only. VI and VFI showed high variability between different sampling sites within each placenta, while the variability of FI was much lower. CONCLUSIONS: 3D power Doppler sonography can provide new insights into placental pathophysiology. FI, which identifies the most severe cases of placental impairment, appears to be the most reliable index because of its low intraplacental variability. Further studies are needed to verify its accuracy when applied in clinical practice as a substitute for or an adjunct to umbilical artery Doppler studies.

Prenatal screening for congenital heart disease with four-chamber and outflow-tract views: a multicenter study.

OBJECTIVE: Congenital heart diseases (CHD) are the most common congenital anomalies, and most cases occur in the low-risk population. Prenatal ultrasound screening based on visualization of the four-chamber view has had disappointing results in detecting these anomalies thus far. The aim of this study was to evaluate the diagnostic accuracy of ultrasound screening based on the combination of the four-chamber and outflow-tract views. METHODS: We conducted a multicenter prospective observational study in 15 obstetric units in the Piedmont Region, Italy. All operators received specific training. Data were recorded regarding visualization of the four-chamber view and the outflow tracts at each routine scan in pregnancies without any risk factor. When an anomaly was suspected, the patient was sent to the referral center. We obtained the follow-up data of the newborns until discharge from hospital and calculated the diagnostic accuracy of the test. RESULTS: 9074 ultrasound scans were performed on 7041 women and complete follow-up information was available for 6368 of them. Fifty-eight cases of CHD were observed at birth or postmortem (prevalence 9.1 per thousand); 38 of them were diagnosed in utero. The sensitivity of the test was 65.5%, the specificity 99.7%, the positive predictive value 70.4% and the negative predictive value 99.7%. The sensitivity of the four-chamber view alone was 60.3%. CONCLUSIONS: The sensitivity was significantly higher than that in a similar study performed in 1997 in the same setting. This improvement can be attributed in part to extension of the examination to the outflow-tract view, but also to technological developments and better training of the operators.

Fetal cerebral ventriculomegaly: outcome in 176 cases.

OBJECTIVE: To evaluate the outcome of fetuses affected by different degrees of ventriculomegaly. METHODS: We studied 176 fetuses with ventriculomegaly and evaluated the pregnancy outcome and the neurodevelopmental outcome at age > or = 24 months. The population was divided into three groups according to ventricular width: A (mild ventriculomegaly, 10 to 12 mm); B (moderate, 12.1 to 14.9 mm) and C (severe, > or = 15 mm). RESULTS: Ventriculomegaly was more often an isolated finding in Group A (44/75; 58.7%) than in Group B (10/41; 24.4%) and Group C (24/60; 40%). When the ventriculomegaly was an isolated finding, 97.7% of fetuses with mild, 80% with moderate and 33.3% of those with severe dilatation were alive at > or = 24 months. The neurodevelopmental outcome was normal in 93% of Group A, 75% of Group B and 62.5% of Group C. CONCLUSIONS: Our results suggest that the definition of borderline ventriculomegaly should be limited to ventricular width below 12 mm. Cases with measurements above this value are more often associated with malformations and have a normal neurodevelopmental outcome less frequently.

Economic evaluation of ultrasound screening options for structural fetal malformations.

OBJECTIVE: To perform a cost-effectiveness analysis comparing the current Italian situation of no organized screening program for structural fetal malformations with an organized screening model involving a scan at 19-21 weeks of gestation. METHODS: Assumptions were made about the number of pregnant women examined per year, the number of ultrasound examinations (screening and diagnostic) and amniocenteses, the prevalence of fetal anomalies, ultrasound sensitivity and specificity and the rates of termination of pregnancy and of fetal death. The costs included procedures performed during and after the diagnosis of malformations, and the resources required to organize the program. Data sources were a literature review, estimates and national tariffs. A sensitivity analysis considered variations in screening test sensitivity, number of private scans and costs of ultrasound, fetal echocardiography, amniocentesis, care for malformed infants and organization. RESULTS: An organized program would increase the number of diagnosed malformations (+10.7%) and decrease the number of malformed infants (-19.9%). It would also decrease the total cost of screening, from 505 billion to 400 billion euros (-20.7%), decrease the cost per woman examined from 971 to 770 euros (-20.7%) and decrease the cost per malformed fetus diagnosed from 79,085 to 56,637 euros (-28.4%). CONCLUSIONS: In all scenarios considered, an organized program would lead to increased detection of malformations at lower cost. Further cost analyses should provide a better representation of resources used, especially those related to the care of malformed infants, while cost-benefit assessments should include all the consequences of prenatal diagnosis, such as those deriving from false results and those for both the woman and society, including ethical issues.

Temperature monitoring using ultrasound contrast agents: in vitro investigation on thermal stability.

Invasiveness of temperature monitoring devices is presently one of the most serious limitations to the application of oncological hyperthermia (HT). A promising approach aims at detecting temperature variations by monitoring the mean grey level (MGL) of the ultrasonographic image of the tissue. Gaseous ultrasound contrast agents (UCA), enhancing Ultrasonic (US) imaging, are expected to be sensitive to temperature, and are therefore a good candidate as temperature monitoring medium. The present study evaluates the 'in vitro' temporal and thermal stability and the correlation between temperature and MGL using a gaseous UCA (SonoVue) as phantom. No statistical differences were detected between the MGL value of the phantom kept at 43.5 degrees C before (215.2+/-3.5) and after 1 h (214.8+/-2.5), showing good stability at HT temperatures. Data of MGL image vs. temperature were obtained during both heating and cooling experiments in the HT range (30-43 degrees C). A good linearity of MGL vs. temperature (R2=0.976) was found with a good accuracy (2.5%) and a sensitivity of about 6.6 MGL/degrees C.

Fetal short femur length in the second trimester and the outcome of pregnancy.

We reviewed 86 consecutive cases with fetal femur length (FL) below the 10th centile of our reference ranges at midtrimester ultrasonography. Three groups were identified based on perinatal outcome: normal infants (n= 28), newborns with structural and/or chromosomal anomalies (n= 40), small-for-gestational age (SGA) newborns (n= 18). Fetuses with skeletal dysplasias (n= 13) had significantly shorter FL. Aneuploidies were only found in fetuses with malformations other than skeletal dysplasias. The diagnosis of SGA, based on ultrasound abdominal circumference measurement <10th centile, was made 9 weeks (range 5-14) after the finding of a short FL. Half of these cases also developed pre-eclampsia.

Pulmonary stenosis and atresia with intact ventricular septum during prenatal life.

AIM: To identify fetal echocardiographic characteristics predictive of perinatal outcome in cases with a prenatal diagnosis of pulmonary stenosis or pulmonary atresia. PATIENTS AND METHODS: We retrospectively reviewed the records and the videotapes of all the cases of pulmonary stenosis and pulmonary atresia diagnosed at our institutions between 1990 and 1999. The following measurements were obtained: diameters of right and left atria and ventricles and ventricular wall thickness; main pulmonary artery and aortic root diameter; direction of flow through the atrioventricular, aortic and pulmonary valves and through the ductus arteriosus. Perinatal outcome and follow-up of the survivors were available in each case. RESULTS: There were 21 cases of pulmonary atresia. Eleven were diagnosed before 24 weeks and nine of them (82%) underwent termination of pregnancy. The survival rate was 50% among the 12 fetuses born at term. None of the fetuses that survived had a large right ventricle, while this was a finding in 50% of those that died. Among the fetuses that died, 83% had a hypertrophic right ventricular wall compared to 33% of the survivors. There were 12 cases of pulmonary stenosis. Three cases were diagnosed before 24 weeks but none underwent termination of pregnancy. All the fetuses with pulmonary stenosis were born at term and four died in the perinatal period. The survival rate was thus 66.6% (8/12). Three (75%) of the fetuses that died had reversed flow in the ductus arteriosus compared with one of the fetuses that survived. CONCLUSION: Our data suggest that a grossly enlarged right ventricle and/or a hypertrophied right ventricular wall in cases of pulmonary atresia and reversed flow in the arterial duct in cases of pulmonary stenosis are likely indicators of a poor prognosis.

Prenatal diagnosis of congenital anomalies.

Up till the early 1970s, prenatal diagnosis of congenital anomalies was primarily aimed at detecting chromosomal abnormalities by amniocentesis.1. Over the last two decades, prenatal diagnosis has greatly benefited from advances in ultrasound technology and in our ability to detect microscopic and submicroscopic chromosome abnormalities as well as single gene disorders, leading to substantive improvements in detection of such congenital anomalies.2 At present, invasive prenatal diagnosis continues to be the gold standard for pregnancies at increased risk for chromosomal anomaly or other genetic disease, with chorionic villus sampling being the procedure of choice for the first trimester,3 whereas mid-trimester amniocentesis continues to be the most common form of invasive procedure for prenatal diagnosis.4 Still, invasive techniques are restricted to subgroups at risk for anomalies, for whom such time-consuming procedures are believed to be cost-effective, also accounting for procedure-related abortive risks. In the low-risk population prenatal diagnosis generally consists of screening procedures by means of ultrasound and maternal serum biochemistry.

Ultrasound evaluation of uterine wound healing following laparoscopic myomectomy: preliminary results.

The purpose of our work was to study the evolution of the uterine scar following laparoscopic myomectomy, as imaged by ultrasonography and Doppler velocimetry of the uterine arteries. We prospectively studied 30 patients. In the first phase, 15 patients were submitted to two-dimensional (2D) endovaginal ultrasound on day -1, 1, 7, 30 and 60 (surgery = day 0). In the second phase an additional 15 patients were studied by both 2D ultrasound and by Doppler velocimetry. The resistance index (RI) was calculated from the flow velocity waveform of the uterine arteries, at the origin of their ascending branch. Only one ultrasonic pattern was found, which was a dense echogenic area having an ill-defined, heterogeneous texture. In one case a small anechoic area (1 cm) was detected in the scar, possibly due to a haematoma. The evolution of uterine healing showed a progressive reduction in the size of the scar. On day 1 its mean diameter was 37.04% less than the myoma diameter and on day 30 71.7% less. The difference was significant at P < 0.001. A further significant (P < 0.001) reduction was found at day 60 in the 15 patients studied in phase I. On both day 1 and day 30 following surgery, there was no correlation between the sizes of the myoma and the scar. There was a statistically significant increase (P < 0.01) in the RI value of the ipsilateral uterine artery from 0.64 on day -1 to 0.79 on day 1. On day 30, 12/15 (80%) cases had RI values ranging between 0.80 and 0.98, while in three cases there was absence of end diastolic flow. The RI values of the contralateral uterine artery were high (0.90) before surgery and did not change afterwards. There was no correlation between the size of the myoma and the increase in the uterine artery RI value following surgery. Considering the velocimetric findings, 30 days are a reference point for assessing the healing process. Ultrasound imaging and Doppler velocimetry can be used for studying the evolution of the uterine scar following myomectomy.

Spontaneous ovarian hyperstimulation syndrome and deep vein thrombosis in pregnancy: case report.

This report describes a case of spontaneous ovarian hyperstimulation syndrome (OHSS) occurring in a pregnant woman carrying the factor V Leiden mutation. Even though prophylactic treatment for thrombo-embolism was adopted by administering low molecular weight heparin, the pregnancy was complicated by thromboses of the left subclavian, axillary, humeral and internal jugular veins during the second trimester of gestation. The pregnancy was managed conservatively and a healthy newborn was delivered at term. In order to avoid unnecessary laparotomy, we emphasize the importance of careful diagnosis in order to differentiate spontaneous OHSS from ovarian carcinoma, as well as the necessity to look for the presence of coagulation disorders in women affected by OHSS.

Accuracy of routine ultrasonography in screening heart disease prenatally. Gruppo Piemontese for Prenatal Screening of Congenital Heart Disease.

The aim of the present study was to assess the accuracy of the four-chamber view as a screening test for detection of congenital heart disease (CHD) prenatally in a low-risk population. A prospective observational study was conducted in 17 ultrasound units of the Piemonte Region, Italy, in pregnancies with no risk factors for CHD. At each routine scan, from 18 weeks of gestational age, the four-chamber view of the heart was looked for. When an anomaly was suspected, the patients were referred to a specialized unit. Follow-up of the babies until discharge from the hospital was obtained. 11,232 sonograms were performed on 8299 pregnancies. Cardiac malformations were diagnosed in 40 newborns (4.8/1000). Six of them (15 per cent) had been recognized in utero. The sensitivity, specificity, and positive and negative predictive values were 15, 99.9, 50, and 99.6 per cent, respectively. When malformations that are not associated with an abnormal four-chamber view were excluded from the analysis, the sensitivity increased to 35.3 per cent. The sensitivity found in this study is low, but it is probably realistic since it is comparable to that reported in other multicentric studies. This type of study should reflect the state of the art of the method applied in the field. Although the sensitivity is low, it would be nil if the test were not performed. Moreover, it will probably increase with better training of the operators and by extending the examination to the ventriculo-arterial connections.

Conotruncal anomalies in prenatal life.

This retrospective multicenter study represents an analysis of the intrauterine determinants of the prognosis for conotruncal anomalies. Data regarding reason for referral, presence of chromosomal or extracardiac anomalies, pregnancy and surgical outcome were recorded in 67 cases of conotruncal anomalies from three Italian referral units. Chromosomal aberrations effected 11 of the 60 (18.3%) fetuses in which a karyotype was available. Extra-cardiac malformations were present in 25/67 cases (37.3%). No chromosomal anomalies were present in fetuses with complete or corrected transposition of the great arteries. However, tetralogy of Fallot and double-outlet right ventricle were associated with chromosomal anomalies in 22% and 38% of cases, respectively, and with extracardiac anomalies in 45% and 46% of cases, respectively. Only 20 of the 67 (31%) cardiac malformations were associated with an abnormal four-chamber view. There were 28 (41.7%) terminations of pregnancy, six (8.9%) intrauterine deaths and 16 (23.8%) neonatal deaths. Seventeen neonates (25.3%) are currently alive, and 15 of these have undergone reparative surgery. The prognosis of conotruncal anomalies is poorer when the conditions is diagnosed in utero. This is mainly due to the frequent association with chromosomal and/or extracardiac anomalies, often leading to intrauterine or early neonatal death.

Rudimentary pulmonary valve and ventricular septal defect associated with patent ductus arteriosus.

This report describes a rare case of patency of the ductus arteriosus in the setting of ventricular septal defect and rudimentary pulmonary valve. We comment on the fetal, neonatal, and postmortem findings and speculate about the role of the ductus arteriosus in the development of dilatation of the pulmonary arteries in this malformation.

Conservative management of fetal bigeminy arrhythmia leading to persistent bradycardia.

A case of persistent fetal bradycardia first detected at 32 weeks of gestational age is described. The diagnosis of atrial ectopic beats was made by means of M-mode echocardiography. Since the fetus was normally grown and showed no signs of distress, the vaginal route of delivery was allowed, also because continuous M-mode echocardiographic monitoring was possible during labour.

Pulmonary stenosis with intact ventricular septum: documentation of development of the lesion echocardiographically during fetal life.

We describe a case of severe pulmonary stenosis with intact interventricular septum diagnosed during fetal life at 34 weeks gestational age. An echocardiographic examination had been performed on the same fetus at 20 weeks, when no cardiac anomalies were observed. It is concluded that this form of pulmonary stenosis might be a lesion either acquired during fetal life or becoming progressively more severe in the prenatal period.