Normal cavum veli interpositi at 14-17 gestational weeks: three-dimensional and Doppler transvaginal neurosonographic study.

OBJECTIVES: To provide evidence to support the hypothesis that the midline cyst-like fluid collection that is frequently observed on fetal brain ultrasound (US) imaging during the early second trimester represents a normal transient cavum veli interpositi (CVI). METHODS: This was a retrospective analysis of 89 three-dimensional normal fetal brain volumes, acquired by transvaginal US imaging in 87 pregnant women between 14 and 17 gestational weeks. The midsagittal view was studied using multiplanar imaging, and the maximum length of the fluid collection located over (dorsal to) the tela choroidea of the third ventricle was measured. We calculated the correlation of the transverse cerebellar diameter (TCD) and of the maximum length of the fluid collection with gestational age according to last menstrual period. Color Doppler images were analyzed to determine the location of the internal cerebral veins with respect to the location of the fluid collection. Reports of the second-trimester anatomy scan at 22-24 weeks were also reviewed. RESULTS: Interhemispheric fluid collections of various sizes were found in 55% (49/89) of the volumes (mean length, 5 (range, 3.0-7.8) mm). There was a strong correlation between TCD and gestational age (Pearson's correlation, 0.862; P < 0.001). There was no correlation between maximum fluid length and gestational age (Pearson's correlation, -0.442; P = 0.773). Color Doppler images were retrieved in 32 of the 49 fetuses; in 100% of these, the internal cerebral veins coursed within the echogenic roof of the third ventricle. The midline structures were normal at the 22-24-week scan in all cases. CONCLUSIONS: In approximately half of normal fetuses, during the evolution of the midline structures of the brain, various degrees of fluid accumulate transiently in the velum interpositum, giving rise to a physiologic CVI. Patients should be reassured that this is a normal phenomenon in the early second trimester that, if an isolated finding, has no influence on fetal brain development. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Feto-feto-fetal transfusion syndrome in monozygotic monochorionic triamniotic triplets: vascular evaluation by a cast model.

A unique cast model of the placenta in a rare case of feto-feto-fetal triplet transfusion syndrome (FFFTTS) allowed the demonstration of why the transfusion syndrome developed in one fetus and not in the other two in that single placenta. The vasculature anatomy of a monochorionic triamniotic triplet placenta with FFFTTS of three healthy infants (one donor, two recipients) born in the 35th week of gestation was cast by means of dental casting materials. After the cast hardened, the tissue was corroded, revealing the cast blood vessels. The diameters and lengths of the chorionic blood and intraplacental vessels of the cast placenta were measured with a digital caliper. The cast revealed two artery-artery (A-A) anastomoses on the chorionic plate between the two recipients and the donor. Seven artery-vein (A-V) deep anastomoses connected only the arteries of the donor and the veins of the two recipients. The blood vessel connections among the fetuses allowed the evaluation of a pathologic case with its own control in a single placenta. From the vascular appearance, we speculate that the A-A anastomoses between the two fetuses protected them from developing blood transfusions, but that the A-V anastomoses contributed to their development.

Prediction of fetal weight by ultrasound: the contribution of additional examiners.

OBJECTIVES: To assess the contribution of additional examiners to: the average discrepancy between estimated and actual fetal weights; the correlation between estimated and actual fetal weights; the reduction in major (> 10%) discrepancies between estimated and actual fetal weights. DESIGN: Three experienced sonographers independently measured fetal biparietal diameter, head circumference, abdominal circumference and femur length in 39 fetuses at term. The estimated fetal weights were calculated for each examiner. Fetal biometric measurements were analyzed to obtain the source of differences in estimations among the examiners. Discrepancy, correlation and number of major (> 10%) discrepancies between the estimated and actual fetal weights were calculated for each examiner, and the contribution of additional examiners was analyzed. RESULTS: The differences in measurements of the biparietal diameter and femur length were lower than those of the head and abdominal circumferences. For each of the three examiners, the average discrepancy between the estimated and actual fetal weights was 6.1%, 5.9% and 6.3%. When the estimation was based on two examiners, the discrepancy decreased to 4.8-5.6%. The contribution of a third examiner was nil. Major (> 10%) discrepancies between estimated fetal weight and actual birth weight were found in seven, eight and nine estimations of the examiners. Estimation by two examiners decreased the number of major discrepancies, and estimation by all three examiners further decreased by approximately 50% the number of major discrepancies between the estimated and actual fetal weights. CONCLUSION: Measurements by multiple examiners changes only slightly the average number of discrepancies between estimated and actual fetal weights. However, the reduction in major (> 10%) discrepancies is statistically and clinically significant.

Persistent right umbilical vein: incidence and significance.

OBJECTIVES: To conduct a prospective evaluation of the incidence and neonatal outcome of fetuses with persistent right umbilical vein. This condition had traditionally been considered to be extremely rare and to be associated with a very poor neonatal prognosis, but later evidence has raised some doubts about the veracity of these contentions. METHODS: Between August 1995 and November 1998, 8950 low-risk patients were prospectively evaluated at two medical centers. The sonographic diagnosis of a persistent right umbilical vein was made in a transverse section of the fetal abdomen when the portal vein was curved toward the stomach, and the fetal gall bladder was located medially to the umbilical vein. RESULTS: Persistent right umbilical vein was detected in 17 fetuses during the study. Four of them had additional malformations, of which three had been detected antenatally. CONCLUSIONS: We established that the incidence of persistent right umbilical vein in a low-risk population is 1 : 526. We believe that the sonographic finding of this anomaly is an indication for conducting targeted fetal sonography and echocardiography. When the persistent right umbilical vein is connected to the portal system and other anomalies are ruled out, the prognosis can generally be expected to be favorable.

Effect of the supine position on uterine and umbilical blood flow during the third trimester of uncomplicated pregnancies in multiparous patients.

We established the effects of the supine position on umbilical blood flow when measured during the third trimester in 30 multiparous, normotensive patients. Blood flow in the umbilical and uterine arteries and blood pressure in the brachial and popliteal arteries were blindly taken by two different observers: first in the lateral and 5 min later in the supine position. There was a significant difference in mean blood pressure between the two postures. However, there was no statistical difference in the pulse pressure or in systolic/diastolic ratio in the umbilical and uterine arteries between the two positions. Postural changes in normotensive multiparous patients do not affect uterine and umbilical blood flow during the third trimester of uncomplicated pregnancies.

The mechanism of hydrosalpinx in embryo implantation.

BACKGROUND: Hydrosalpinx adversely affects embryo implantation and contributes to poor implantation rates post embryo transfer. Embryo transport depends on concomitant intrauterine fluid motion induced by uterine wall motility, the result of spontaneous myometrial contractions towards the fundus. METHODS AND RESULTS: The uterine dynamics of five patients with hydrosalpinx were recorded and analysed by image-processing techniques: the frequency was higher while the amplitudes and passive widths were lower compared with healthy volunteers. The existing peristaltic activity should have induced intrauterine fluid flow; however, the recordings failed to show the expected transport of fluid bolus. This observation was supported by mathematical simulations based on the hypothesis that fluid accumulation in the Fallopian tube of a patient with hydrosalpinx increases tubal pressure and thereby induces a pressure gradient between the fundus and the cervix. This pressure gradient acts adversely to the cervix-to-fundus intrauterine peristalsis and generates reflux currents that may thrust embryos away from the implantation site. CONCLUSIONS: The reflux phenomenon could explain the reduced implantation rate associated with hydrosalpinx. Resolution of the issue of whether the removal of a Fallopian tube with hydrosalpinx should be undertaken for improving IVF pregnancy rates should be accompanied by prospective randomized clinical trials.

Effect of fetal gender on first trimester markers and on Down syndrome screening.

OBJECTIVES: The purpose of the present study was to evaluate whether a gender-related difference exists in first trimester markers used for Down syndrome screening, namely nuchal translucency (NT), maternal serum pregnancy-associated plasma protein-A (PAPP-A), and free beta-human chorionic gonadotrophin (beta-hCG), and whether this has an influence on screening performance. METHODS: A total of 1325 patients with a singleton pregnancy underwent combined first trimester screening at 10-13 weeks' gestation. Maternal serum PAPP-A and free beta-hCG were analyzed by fluoroimmunoassay, nuchal translucency (NT) was measured by transvaginal sonography. Only patients with normal outcomes and known fetal gender were included in the study. Data were categorized by gestational age and by fetal gender. RESULTS: There were no significant gender-related differences in NT and PAPP-A levels. However, free beta-hCG was significantly higher (p=0.00004) in the presence of a female fetus than in the presence of a male fetus. Women with female fetuses had a higher median calculated Down syndrome risk (1:5490) compared to those having males (1:6451). This difference was not, however, statistically significant. CONCLUSION: First trimester free beta-hCG is significantly higher in pregnancies with a female fetus.

Second-trimester maternal serum alpha-fetoprotein (MSAFP) is elevated in women with adverse pregnancy outcome associated with inherited thrombophilias.

Obstetric complications, such as severe pre-eclampsia, fetal growth restriction, abruptio placentae, or stillbirth are associated with abnormally elevated second-trimester maternal serum alpha-fetoprotein (MSAFP) and beta subunit of human chorionic gonadotrophin (betahCG). This has been attributed to placental abnormalities. Women with thrombophilias have been shown to have abnormalities of the placenta resulting in adverse pregnancy outcome in these patients. The purpose of the present study was to evaluate whether women with pregnancy complications and inherited thrombophilias have abnormally elevated second-trimester MSAFP or betahCG. Sixty-two women with pregnancy complications were tested for inherited thrombophilias several months after delivery. The thrombophilia group included 29 women with pregnancy complications and an inherited thrombophilia and the control group included 33 other patients without thrombophilia. Patients in the thrombophilia group had a higher median MoM MSAFP compared to the controls (1.337 vs. 1.086, p=0.0516). The incidence of abnormally elevated MSAFP (>2.5 MoM) was also significantly higher in the thrombophilia group compared to controls (21% vs. 3%, p=0.04). Neither the median MoM betahCG nor the incidence of abnormally elevated betahCG were significantly different between the groups. We conclude that second trimester MSAFP, but not betahCG, is abnormally elevated in patients with thrombophilia and obstetric complications.

First trimester PAPP-A in the detection of non-Down syndrome aneuploidy.

Combined first trimester screening using pregnancy associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotrophin, and nuchal translucency (NT), is currently accepted as probably the best combination for the detection of Down syndrome (DS). Current first trimester algorithms provide computed risks only for DS. However, low PAPP-A is also associated with other chromosome anomalies such as trisomy 13, 18, and sex chromosome aneuploidy. Thus, using currently available algorithms, some chromosome anomalies may not be detected. The purpose of the present study was to establish a low-end cut-off value for PAPP-A that would increase the detection rates for non-DS chromosome anomalies. The study included 1408 patients who underwent combined first trimester screening. To determine a low-end cut-off value for PAPP-A, a Receiver-Operator Characteristic (ROC) curve analysis was performed. In the entire study group there were 18 cases of chromosome anomalies (trisomy 21, 13, 18, sex chromosome anomalies), 14 of which were among screen-positive patients, a detection rate of 77.7% for all chromosome anomalies (95% CI: 55.7-99.7%). ROC curve analysis detected a statistically significant cut-off for PAPP-A at 0.25 MoM. If the definition of screen-positive were to also include patients with PAPP-A<0.25 MoM, the detection rate would increase to 88.8% for all chromosome anomalies (95% CI: 71.6-106%). This low cut-off value may be used until specific algorithms are implemented for non-Down syndrome aneuploidy.

Characteristics of uterine peristalsis in spontaneous and induced cycles.

OBJECTIVE: To characterize the dynamics of the intrauterine fluid-wall interface (IUFWI) from in vivo transvaginal ultrasound images by new techniques of image processing of sagittal cross-sections of the uterus, in healthy women with normal cycles and patients treated with clomiphen citrate (CC). DESIGN: Clinical study. SETTING: An ultrasound unit in a large university-affiliated municipal hospital. PATIENT(S): Twenty-five patients with normal spontaneous cycles (group A) and nine patients treated by CC (group B). INTERVENTION(S): Transvaginal ultrasound examinations. MAIN OUTCOME MEASURE(S): Transvaginal ultrasound images were processed to carry out a computational analysis of the resultant IUFWI. RESULT(S): The amplitude and the width of the IUFWI were higher in group B, but the ratio of these measurements was similar in both groups. The frequency of wall motility of group A was lower and its pattern was more symmetrical than that of group B. CONCLUSION(S): The differences in the dynamic characteristics of spontaneous and CC-induced cycles may constitute an additional parameter that should be considered in embryo transport.

Persistent postpartum urinary retention in contemporary obstetric practice. Definition, prevalence and clinical implications.

OBJECTIVE: To prospectively evaluate the prevalence, presumed etiologies and clinical implications of persistent postpartum urinary retention in modern obstetric practice. STUDY DESIGN: The study population comprised 8,402 consecutive, unselected parturients delivered in a university-affiliated maternity hospital over a one-year period. If a woman was unable to void spontaneously until the third postpartum day despite intermittent use of a Foley catheter, a diagnosis of persistent postpartum urinary retention was established. Patients were treated by insertion of a Foley catheter for up to two weeks and subsequently by a suprapubic catheter. Obstetric data were collected from the hospital records. RESULTS: Four patients (0.05% of the study population), aged 29-37 years, developed persistent postpartum urinary retention. Risk factors included vaginal delivery after cesarean section, prolonged second stage of labor, epidural analgesia, and delayed diagnosis and intervention. Urodynamic evaluation, performed on two patients one month after removal of the suprapubic catheter, revealed genuine stress incontinence in one and detrusor instability in another. None had had any lower urinary tract symptoms before pregnancy and delivery. CONCLUSION: Persistent postpartum urinary retention in contemporary obstetric practice is rare but may be associated with long-term bladder dysfunction. Early diagnosis and intervention are required to prevent irreversible bladder damage.

The use of prophylactic Stamey bladder neck suspension to prevent post-operative stress urinary incontinence in clinically continent women undergoing genitourinary prolapse repair.

The present study was undertaken to evaluate the efficacy of Stamey bladder neck suspension in preventing post-perative stress urinary incontinence in clinically continent women undergoing surgery for genitourinary prolapse. Thirty clinically continent women with severe genitourinary prolapse were found to have a positive stress test with re-positioning of the prolapse. They all had significant urethrovesical junction hypermobility. In addition to the genitourinary prolapse repair, these patients underwent a prophylactic Stamey procedure to prevent the possible development of post-operative stress urinary incontinence. The mean duration of follow-up was 8+/-4.5 months (range, 3-19 months). Seven (23.30%) patients developed overt post-operative stress urinary incontinence that was confirmed urodynamically. Eleven (36.7%) other patients denied stress incontinence; however, post-operative urodynamics demonstrated sphincteric incontinence. Post-operative complications were uncommon and minor. In conclusion, continent patients with a positive stress test demonstrated on re-positioning of the prolapse during pre-operative urodynamic evaluation are considered to be at high risk of developing post-operative stress urinary incontinence. In these patients, an additional, effective anti-incontinence procedure should be considered during surgical correction of genitourinary prolapse. The Stamey procedure, although simple and safe, does not appear to be the optimal solution to this clinical problem.

High prevalence of the prothrombin gene mutation in women with intrauterine growth retardation, abruptio placentae and second trimester loss.

BACKGROUND: It has been reported recently that obstetric complications are associated with thrombophilias. Our objective was to investigate the association between pregnancy complications and the guanine 20210 adenine (G20210A) mutation in prothrombin gene. METHODS: Two hundred and twenty-two women (study group) with obstetric complications were tested for the prothrombin mutation. Indications for testing were: severe preeclampsia, mild preeclampsia, intrauterine growth retardation, severe abruptio placentae, unexplained stillbirth, second trimester loss, and three or more consecutive spontaneous abortions. We also tested 156 healthy women who had at least one normal pregnancy and comprised the control group. RESULTS: Demographic data of the study and control groups were similar. Twenty-eight women of the study group (13%) were found to be heterozygous carriers of the 20210 variant of the prothrombin gene compared to five (3.2%) of the control group, p=0.001, odds ratio (OR) 2.9; 95% confidence interval (CI) 1.3-6.5. Compared to the control women, the prothrombin gene mutation was significantly more prevalent in women with IUGR, abruptio placentae, and second trimester loss but not in women with mild or severe preeclampsia, stillbirth and habitual abortion. CONCLUSIONS: Our data demonstrate that the mutation in the prothrombin gene is associated with specific pregnancy complications.

Is amniotic fluid volume influenced by a 24-hour fast?

OBJECTIVE: To assess the influence of fasting for 24 hours on the amniotic fluid index (AFI). STUDY DESIGN: The AFI of 22 parturients in the second trimester of uncomplicated pregnancy was evaluated on the morning after a 24-hour fast. Patients were prospectively matched to another group of 25 patients who did not fast. Both groups were reevaluated after one week. Two different observers, blind to each other's results, performed the examinations. RESULTS: A statistically significant difference was found in the AFI between the two groups on the day after fasting (11.73 +/- 2.12 versus 15.4 +/- 1.2, respectively; P < .01). After one week there was no difference in AFI between the two groups (15.35 +/- 1.2 and 15.42 +/- 1.2, respectively; P > .01). CONCLUSION: Fasting may reduce the amniotic fluid volume as shown by the AFI, and fluid intake may restore the normal amount of amniotic fluid volume.

Transvaginal sonohysterography for the evaluation and treatment of retained products of conception.

Diagnosing retained products of conception in a woman presenting with postpartum or postabortion bleeding presents a clinical challenge. Although ultrasonographic examination may be potentially useful in detecting retained products of conception, its accuracy has not yet been established. Saline infusion sonohysterography is a simple ultrasonographic technique for enhanced transvaginal sonographic imaging of the endometrial cavity by the instillation of saline into the uterine cavity during ultrasonographic evaluation. This technique enhanced our ability to diagnose retained products of conception, and we describe our experience in evacuating them under sonographic guidance while performing saline infusion sonohysterography.

Intracardiac echogenic focus: no apparent association with structural cardiac abnormality.

OBJECTIVE: The aim of our study was to evaluate whether intracardiac echogenic foci (ICEFs) may be associated with increased risk for structural cardiac anomalies in the low-risk population. METHODS: During a 24-month period, 3,744 low-risk patients were prospectively screened for ICEFs by prenatal sonography. The study group was composed of 138 fetuses (3.7%) with ICEF. The control group was composed of 167 fetuses without ICEF. In all fetuses a complete echocardiographic evaluation was performed. RESULTS: Among the 138 fetuses in the study group, 108 (78%) ICEFs were found in the left ventricle, 25 (18%) were found in the right ventricle, and 5 (4%) were found to be bilateral. No statistically significant difference was found between the study and the control group regarding the presence of cardiac anomalies. Only 1 case (0.7%) of pulmonic stenosis was found in the study group, compared to 1 case (0.6%) of bicuspid aortic valve in the control group. CONCLUSIONS: We conclude that ICEFs found in low-risk patients are not associated with a significant increase in the risk of cardiac anomalies.

Anaerobic glycolysis. The metabolism of the preovulatory human oocyte.

OBJECTIVES: The aim of the study was to investigate the process of glycolysis in gonadotropic, hyperstimulated, human ovarian follicles. STUDY DESIGN: Follicular fluid (FF) lactate and glucose concentrations were measured in 26 patients with tubal factor infertility undergoing in vitro fertilization treatment. RESULTS: The mean FF lactate and glucose concentrations were 3.17+/-0.90 mM with positive, and 3.39+/-0.91 mM with negative correlations to follicular size. FF lactate concentration correlated negatively to glucose levels. CONCLUSIONS: Our study confirms in vivo the anaerobic glycolysis in gonadotropic, hyperstimulated human ovarian follicles.

Timing of sonohysterography in menstruating women.

A prospective, blind study was carried out on 44 patients to evaluate the most suitable time to perform transvaginal sonohysterography. On the day of arrival at our unit, regardless of their cycle day, the women underwent sonohysterographic evaluation, which was repeated during the first 10 days of the next cycle. Patients with sonohysterographic findings underwent hysteroscopy. According to the timing of the first examination, they were divided into two groups, i.e. group 1 for the first 10 days of the cycle, and group 2 for days 16 through 28. At the end of the study the groups were compared. The results showed a false-positive rate of 27% in group 2, while no false-positive was found in group 1. We concluded that the best time for sonohysterography in patients who still have their menstrual period is during the first 10 days of the cycle.