Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study.

OBJECTIVE: It has been suggested that the use of Doppler ultrasound in term pregnancies with normal-sized fetuses is able to identify those at high risk of subclinical placental function impairment. The objective of this study was to evaluate the relationship between cerebroplacental ratio (CPR) measured in early labor and perinatal and delivery outcomes in a cohort of uncomplicated singleton term pregnancies. METHODS: This was a prospective multicenter observational study conducted at three tertiary centers between January 2016 and July 2017. Low-risk term pregnancies, defined by the absence of maternal morbidity or pregnancy complication, accompanied by normal ultrasound and clinical screening of fetal growth in the third trimester, with spontaneous onset of labor were included. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler was assessed on admission for early labor. All measurements were performed in between uterine contractions and according to international standards. CPR was computed by dividing MCA pulsatility index by UA pulsatility index and converted into multiples of the median (MoM) in order to adjust for gestational age. Doctors and midwives involved in the clinical management of the women were blinded to the results of the Doppler evaluation. Mode of delivery and perinatal outcome were compared between pregnancies with reduced CPR MoM, defined as CPR MoM within the lowest decile of the study population, and those with normal CPR MoM. Receiver-operating characteristics curve analysis was used to assess the predictive performance of CPR for obstetric intervention due to fetal distress and composite adverse perinatal outcome. RESULTS: Overall, 562 women were included. The rate of obstetric intervention for suspected fetal distress in labor was more than three times higher among cases with reduced CPR MoM compared to those with normal CPR MoM (9/54 (16.7%) vs 28/508 (5.5%); P = 0.004). Furthermore, a significantly higher rate of composite adverse perinatal outcome was found in fetuses with CPR MoM < 10th percentile compared to those with CPR MoM ≥ 10th percentile (6/54 (11.1%) vs 19/508 (3.7%); P = 0.012). CPR had low sensitivity and low positive predictive value for prediction of obstetric intervention due to fetal distress (24.3% and 18.0%, respectively) and composite adverse perinatal outcome (24.0% and 11.1%, respectively). CONCLUSIONS: Data on a wide cohort of low-risk term pregnancies in early labor showed that, while reduced CPR is associated with a higher risk of obstetric intervention due to fetal distress and composite adverse perinatal outcome, it is a poor predictor of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Narrow subpubic arch angle is associated with higher risk of persistent occiput posterior position at delivery.

OBJECTIVE: To determine whether the subpubic arch angle (SPA) measured by three-dimensional ultrasound is associated with the fetal occiput position at delivery and the mode of delivery. METHODS: Nulliparous women with an uncomplicated singleton pregnancy at ≥ 37 weeks' gestation were recruited from two tertiary centers between September 2013 and August 2015. All women underwent a three-dimensional transperineal ultrasound examination and the SPA was measured using the previously validated Oblique View Extended Imaging software. Data on the outcome of labor were obtained prospectively in all cases and the correlations between SPA and the fetal occiput position at delivery and the incidence of operative delivery were investigated. RESULTS: Overall, 368 women were included in the study. Fetal position at delivery was occiput anterior in 339 (92.1%) cases and occiput posterior (OP) in 29 (7.9%) cases. A significantly narrower SPA was found in the OP group compared with the occiput anterior group (104.4 ± 16.8° vs 116.4 ± 11.9°; P < 0.0001). The SPA was significantly narrower in women requiring obstetric intervention compared with in women with a spontaneous vaginal delivery. From multivariable logistic regression analysis, SPA and maternal height appeared to be significant predictors of both the fetal occiput position at delivery and the risk of operative delivery. The best cut-off value of SPA for predicting an OP position at delivery was 90.5°. CONCLUSION: A narrow SPA is associated with a higher risk of persistent OP position at delivery and of operative delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Placental volume and uterine artery Doppler evaluation at 11 + 0 to 13 + 6 weeks' gestation in pregnancies conceived with in-vitro fertilization: comparison between autologous and donor oocyte recipients.

OBJECTIVE: To compare first-trimester uterine artery pulsatility index (UtA-PI) and three-dimensional (3D) placental volume in pregnancies conceived through in-vitro fertilization (IVF) using autologous or donor oocytes and pregnancies conceived naturally, and to relate these measurements to the development of pre-eclampsia (PE). METHODS: UtA-PI and placental volume were measured at 11 + 0 to 13 + 6 weeks of gestation in 416 IVF pregnancies (307 with autologous and 109 with donor oocytes) and in 498 spontaneously conceived pregnancies. We recruited nulliparous women with singleton pregnancy. The measured mean UtA-PI and placental volume values were converted to multiples of the expected normal median (MoM), adjusted for gestational age. MoM values of IVF pregnancies were compared with MoM values of the naturally conceived pregnancies and related to PE development. RESULTS: Placental volume was significantly reduced in IVF pregnancies (K = 169.3; P < 0.0001) compared with natural pregnancies. No difference was found in UtA-PI MoM between the two groups. Among IVF pregnancies, significantly lower placental volumes were seen in those that received donor oocytes when compared with those with autologous oocytes (z = 3.89; P < 0.001). In IVF pregnancies that developed PE, lower values of placental volume were demonstrated with respect to normotensive pregnancies (donor: U = 6.8; P = 0.009; autologous: U = 5.1; P = 0.023), whereas no difference was found in UtA-PI. Multivariate logistic regression analysis demonstrated that placental volume (odds ratio (OR), 1.97 (95% CI, 1.33-2.27)) and donor oocytes in IVF pregnancy (OR, 2.24 (95% CI, 1.5-2.83)) were independent predictors of PE, whereas autologous oocytes in IVF pregnancy were not found to be significant in the model. CONCLUSIONS: First-trimester placental volume, as assessed by 3D ultrasound, is reduced in IVF pregnancies and this reduction is more marked in those involving donor oocyte recipients. The relative decrease in placental volume in IVF pregnancies that developed PE suggests an etiological mechanism different from uterine perfusion in such patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Uterine artery Doppler evaluation in twin pregnancies at 11 + 0 to 13 + 6 weeks of gestation.

OBJECTIVES: To compare uterine artery pulsatility index (PI) obtained at 11 + 0 to 13 + 6 weeks of gestation in singleton and twin pregnancies and to evaluate changes in PI values of twin pregnancies developing pre-eclampsia (PE) or small-for-gestational age (SGA) of either one or both fetuses. METHODS: Uterine artery PI was measured in 421 twin pregnancies (384 dichorionic and 37 monochorionic) and in 500 singleton pregnancies. The measured mean and lowest uterine artery PI values were converted to multiples of the expected normal median (MoM) after correction for maternal body mass index, ethnicity and gestational age. The median PI-MoM values of twins were compared with those of singleton pregnancies. In twin pregnancies, PI-MoM values were analyzed according to chorionicity, development of early-onset (< 34 weeks) or late-onset (≥ 34 weeks) PE and SGA of one or both twins. RESULTS: Uterine artery PI-MoM was significantly lower in twin compared with singleton pregnancies (mean K = 174.31, P < 0.0001, lowest K = 139.27, P < 0.0001). However, there were no significant differences in the uterine artery PI-MoM values between monochorionic and dichorionic twins. The uterine artery PI in twin pregnancies that developed early-onset PE (P < 0.001) and SGA of both twins (P < 0.05) was higher than the uterine artery PI in uncomplicated twin pregnancies, whereas no differences were found for late PE or SGA of one twin. CONCLUSIONS: First-trimester placental impedance to flow, as assessed by uterine artery Doppler examination, is reduced in twin pregnancies, with no differences related to chorionicity. The relative increase of uterine artery PI found in twin pregnancies that developed early PE and SGA of both twins suggests that first-trimester uterine artery assessment may be useful in identifying such complications.

Are there any relationships between umbilical artery Pulsatility Index and macrosomia in fetuses of type I diabetic mothers?

OBJECTIVE: To establish whether there are relationships between umbilical artery Pulsatility Index (PI) and fetal macrosomia in pregnancies complicated by type I diabetes. METHODS: In a retrospective observational study, 102 singleton pregnant women with type I diabetes were considered. Umbilical artery PI was measured by Doppler ultrasonography within one week from delivery and related to neonatal weight. Pregnancies were grouped according to birtweight in macrosomic group (≥4000 g) and normal growth group (<4000 g). Relationships between umbilical artery PI and birth weight and birth weight centile were tested by Pearson's correlation analysis. Further umbilical artery PI values were compared between macrosomic and normally grown fetuses. RESULTS: Birth weight was ≥4000 g in 24 pregnancies (23.5%). A significant relationship was found between umbilical artery PI and neonatal weight (r = 0.512; p < 0.01) and neonatal weight centile (r = 0.400; p < 0.01). Umbilical artery PI were significantly lower (t = -6.013; p < 0.001) in the macrosomic group (0.78; 95% confidence interval (CI) 0.73-0.84) than in the normal growth group (1.00; 95% CI 0.97-1.04). CONCLUSIONS: In pregnancies complicated by type I diabetes there is a significant relationship between umbilical artery PI value before delivery and absolute birth weight and birth weight centile. Macrosomic fetuses show a significant reduction in umbilical artery PI when compared with diabetic pregnancies without fetal overgrowth.

Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: feasibility in office tubal patency testing.

OBJECTIVE: To evaluate the feasibility of transvaginal hysterosalpingo-contrast sonography (HyCoSy) with new automated three-dimensional coded contrast imaging (3D-CCI) software in the evaluation of tubal patency and visualization of tubal course. METHODS: Patients undergoing HyCoSy with automated 3D-CCI software were evaluated prospectively. First, to evaluate the feasibility of 3D visualization of tubal course, we performed consecutive volume acquisitions while injecting SonoVue contrast agent. We then performed conventional two-dimensional (2D) real-time HyCoSy to confirm tubal patency status by detection of saline and air bubbles moving through the Fallopian tubes and around the ovaries. We also evaluated visualization with CCI of the contrast agent around the ovaries, side effects and pain during and after the procedure, by visual analog scale (VAS) (ranging from 0 to 10, with 0 corresponding to no pain and 10 corresponding to maximum pain). RESULTS: A total of 126 patients (252 tubes) underwent 3D-CCI HyCoSy followed by 2D real-time HyCoSy. According to the final 2D real-time evaluation, bilateral tubal patency was observed in 111 patients, bilateral tubal occlusion in four patients and unilateral tubal patency in 11 patients. The concordance rate for tubal patency status between the first 3D volume acquisition and the final 2D real-time evaluation was 84% and that between the second 3D volume acquisition and the final 2D real-time evaluation was 97%. A pain score >5 on VAS was recorded in 58% of patients during the procedure, but a pain score ≤ 5 was recorded in 85.7% of patients immediately after the procedure. CONCLUSIONS: HyCoSy with automated 3D-CCI technology retains the advantages of conventional 2D HyCoSy while overcoming the disadvantages. 2D HyCoSy is highly observer-dependent and is only accurate in the hands of experienced investigators; by obtaining a volume of the uterus and tubes, automated 3D volume acquisition permits visualization of the tubes in the coronal view and of the tubal course in 3D space, and should allow less experienced operators to evaluate tubal patency status relatively easily.

The role of three-dimensional ultrasound in the diagnosis of fetal congenital anomalies: a review.

The objective of this review was to establish whether three-dimensional (3D) and four dimensional (4D) ultrasonography adds diagnostic information to what is currently provided by two-dimensional (2D) ultrasound in the diagnosis of the most frequent fetal structural defects: congenital heart disease and central nervous system congenital anomalies. There are evidences suggesting that 3D ultrasound allows to reduce the operator dependency in the visualization of standard diagnostic planes, thus reducing the examination time require for the obstetric ultrasound examination, with minimal impact on the visualization quality of the anatomic landmarks. Furthermore, operators with minimal experience may record cardiac or brain volumes that can be successfully analyzed off-line locally or sent by internet to experts for remote review. As a consequence 3D ultrasonography promises to become the method of choice for diagnosis congenital structural defects.

Adenomyosis: three-dimensional sonographic findings of the junctional zone and correlation with histology.

OBJECTIVE: To correlate with histopathological features the adenomyosis-induced morphological alterations of the outer myometrium and the inner myometrium ('junctional zone', JZ) detectable on two- (2D) and three-dimensional (3D) transvaginal ultrasound imaging (TVS), and to evaluate their diagnostic accuracy for adenomyosis. METHODS: Premenopausal patients scheduled for hysterectomy for benign pathology were enrolled in this prospective study. Before hysterectomy all patients underwent detailed 2D-TVS and 3D volume acquisition of the entire uterus. The major sonographic signs of adenomyosis were noted. On the multiplanar coronal and longitudinal views obtained by 3D-TVS we measured the maximum and minimum JZ thickness from the basal endometrium to the internal layer of the outer myometrium (JZmax, JZmin), the difference between them (JZdif = JZmax - JZmin) and the ratio JZmax/total maximum myometrial thickness. Results of these examinations were correlated blindly to the presence of adenomyosis on histological specimens. RESULTS: A total of 72 premenopausal patients underwent 2D- and 3D-TVS before hysterectomy. The histological prevalence of adenomyosis was 44.4% (32/72 patients). In diagnosing adenomyosis, the presence of myometrial cysts was the most specific 2D-TVS feature (specificity, 98%; accuracy, 78%) and heterogeneous myometrium was the most sensitive (sensitivity, 88%; accuracy, 75%). The 3D-TVS markers JZdif ≥ 4 mm and JZ infiltration and distortion had high sensitivity (88%) and the best accuracy (85% and 82%, respectively). For 2D-TVS and 3D-TVS, respectively, the overall accuracy for diagnosis of adenomyosis was 83% and 89%, the sensitivity was 75% and 91%, the specificity was 90% and 88%, the positive predictive value was 86% and 85% and the negative predictive value was 82% and 92%. CONCLUSIONS: The coronal section of the uterus obtained by 3D-TVS permits accurate evaluation and measurement of the JZ, and its alteration has good diagnostic accuracy for adenomyosis.

An algorithm based on OmniView technology to reconstruct sagittal and coronal planes of the fetal brain from volume datasets acquired by three-dimensional ultrasound.

OBJECTIVE: To describe a novel algorithm, based on the new display technology 'OmniView', developed to visualize diagnostic sagittal and coronal planes of the fetal brain from volumes obtained by three-dimensional (3D) ultrasonography. METHODS: We developed an algorithm to image standard neurosonographic planes by drawing dissecting lines through the axial transventricular view of 3D volume datasets acquired transabdominally. The algorithm was tested on 106 normal fetuses at 18-24 weeks of gestation and the visualization rates of brain diagnostic planes were evaluated by two independent reviewers. The algorithm was also applied to nine cases with proven brain defects. RESULTS: The two reviewers, using the algorithm on normal fetuses, found satisfactory images with visualization rates ranging between 71.7% and 96.2% for sagittal planes and between 76.4% and 90.6% for coronal planes. The agreement rate between the two reviewers, as expressed by Cohen's kappa coefficient, was > 0.93 for sagittal planes and > 0.89 for coronal planes. All nine abnormal volumes were identified by a single observer from among a series including normal brains, and eight of these nine cases were diagnosed correctly. CONCLUSIONS: This novel algorithm can be used to visualize standard sagittal and coronal planes in the fetal brain. This approach may simplify the examination of the fetal brain and reduce dependency of success on operator skill.

Controlled trial of active tuberculosis case finding in a Brazilian favela.

SETTING: A large, impoverished squatters' settlement (favela), Rio de Janeiro, Brazil. OBJECTIVE: To assess the community impact of active case finding for tuberculosis (TB) compared to an enhanced case-finding strategy. DESIGN: A pair-matched, cluster-randomized trial comparing household symptom screening and spot sputum collection (Arm 1) vs. distribution of an educational pamphlet (Arm 2) was performed in a large Brazilian favela. We compared TB case-notification rates, time from symptom onset to treatment start and treatment completion proportions between arms. Fourteen neighborhoods (estimated population 58,587) were pair-matched by prior TB case rates and randomly allocated to one of two interventions. TB was diagnosed using acid-fast bacilli smears. New TB cases were interviewed and clinic records were reviewed. RESULTS: A total of 193 TB cases were identified in the 14 study neighborhoods (incidence proportion 329 per 100,000 population). The case identification rate in Arm 1 was 934/100,000 person-years (py) vs. 604/100,000 py in Arm 2 (RR 1.55, 95%CI 1.10-1.99). No significant differences were found in time from cough onset to treatment start or proportion completing treatment. CONCLUSIONS: A door-to-door case-finding campaign was more effective (while ongoing) at detecting prevalent cases and influencing people to come for care than leafleting, but no differences were seen in time to treatment start or treatment completion.

First-trimester umbilical vein blood flow in pregnancies with low serum pregnancy-associated plasma protein-A levels: an early predictor of fetal growth restriction.

OBJECTIVE: To investigate umbilical vein blood flow (UVBF) during the first trimester in pregnancies with low serum pregnancy-associated plasma protein-A (PAPP-A) levels and to relate umbilical vein (UV) diameter, time-averaged maximum velocity (TAMXV) and UVBF values to the subsequent development of fetal intrauterine growth restriction (IUGR). METHODS: UVBF assessment was performed at 11 + 0 to 13 + 6 weeks' gestation in 102 singleton pregnancies with PAPP-A concentrations of < 0.3 multiples of the median. UV diameter, UV-TAMXV and UVBF were calculated and analyzed in relation to pregnancy outcome. RESULTS: Pregnancy outcomes were: 51 pregnancies with birth weight ≥ 10(th) centile (Group A), 30 pregnancies with birth weight < 10(th) centile with normal Doppler in the umbilical artery throughout gestation (Group B) and 21 pregnancies with birth weight < 10(th) centile and abnormal umbilical artery Doppler later in gestation (Group C). No differences were found in PAPP-A levels between groups. Group C fetuses exhibited significantly lower values of UV-TAMXV (z-score - 1.99 SDs, t = 8.527, P ≤ 0.0001) and UVBF (z-score - 0.97 SDs, t = 7.420, P ≤ 0.0001) in comparison with normal reference ranges, while no differences were found in Groups A or B. CONCLUSIONS: Decreased UV-TAMXV and UVBF at 11 + 0 to 13 + 6 weeks' gestation identify fetuses at risk of developing IUGR among pregnancies with low levels of PAPP-A.

Intrauterine growth restriction: diagnosis and management. A review.

Intrauterine growth restriction (IUGR) is the failure to achieve the genetically predetermined growth potential and may be caused by maternal, fetal, placental, and external factors. IUGR is associated not only with a marked increased risk in perinatal mortality and morbidity but also with long-term outcome risks. IUGR is clinically suspected when ultrasonographic estimates of fetal size, simmetry or weight result abnormal. Exclusion of structural and/or chromosomal anomalies and Doppler studies of maternal and fetal circulations is the most effective method to differentiate IUGR fetuses secondary to placental dysfunction from those secondary to aneuploidy, genetic syndromes, and intrauterine infections. This review summarizes the current knowledge about fetal hemodynamics in IUGR pregnancies and its relationship with the severity of the disease. A better understanding of fetal hemodynamic changes occurring in IUGR will likely lead to targeted monitoring intervals in such fetuses leading to an appropriate timing of delivery only when fetal risks exceed neonatal risks.

Low cardiac output to the placenta: an early hemodynamic adaptive mechanism in intrauterine growth restriction.

OBJECTIVE: A low combined cardiac output (CCO) to the placenta (placenta/CCO fraction) has been reported in growth-restricted (IUGR) fetuses, but the temporal sequence of these modifications in relation to other changes in the fetal circulation is unknown. The aim of this study was to evaluate the placenta/CCO fraction in relation to other hemodynamic changes in fetuses at risk of developing IUGR. METHODS: We studied 340 singleton nulliparous pregnancies characterized at 20-24 weeks by abnormal uterine artery pulsatility index (PI) values (> 95(th) centile). At this gestational age we measured fetal biometry and Doppler waveforms from the umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV), umbilical vein (UV) and outflow tracts of both ventricles. The diameters of the semilunar valves and UV were measured and CCO (left cardiac + right cardiac outputs) and UV blood flow were calculated. The placenta/CCO fraction was calculated as UV flow as a percentage of CCO. RESULTS: There were 283 pregnancies with birth weight >or= 10(th) centile and normal UA-PI throughout gestation (Group A), 34 with birth weight < 10(th) centile and normal UA-PI throughout gestation (Group B) and 23 with birth weight < 10(th) centile and abnormal UA-PI developing later in gestation (Group C). At 20-24 weeks there were no differences among the three groups in fetal biometric parameters, PI values from the UA, MCA and DV, and CCO. UV flow and placenta/CCO fraction were significantly lower in Group C compared with Group A (UV flow delta value = - 1.439, P < 0.0001; placenta/CCO fraction delta value = - 1.74, P < 0.0001) but not in Group B. CONCLUSIONS: Our data suggest that, in fetuses developing IUGR secondary to placental compromise, UV flow and placental/CCO fraction are already reduced by 20-24 weeks, and that this reduction occurs earlier than do modifications in fetal size and arterial and venous PI values.

Maternal and fetal hemodynamic effects induced by nitric oxide donors and plasma volume expansion in pregnancies with gestational hypertension complicated by intrauterine growth restriction with absent end-diastolic flow in the umbilical artery.

OBJECTIVE: To evaluate the effect of plasma volume expansion (PVE) and nitric oxide (NO) donors, in addition to antihypertensive therapy for gestational hypertensive pregnancies complicated by intrauterine growth restriction (IUGR) with absent end-diastolic flow (AEDF) in the umbilical artery (UA). METHODS: This was a case-control study into which 32 gestational hypertensive pregnancies with IUGR and AEDF were enrolled. Sixteen of these were treated with antihypertensive drugs, NO donors and PVE (Group A), and 16, matched for maternal age, gestational age and fetal conditions, were treated with antihypertensive drugs only (Group B). All patients underwent fetal and uteroplacental assessment and maternal echocardiography to evaluate total vascular resistance (TVR) and cardiac output before and 5-14 days after initiation of treatment. RESULTS: After 5-14 days of treatment, the maternal TVR in Group A fell from 2170 +/- 248 to 1377 +/- 110 dynes.s.cm(-5) (P < 0.01), and that in Group B fell from 2090 +/- 260 to 1824 +/- 126 dynes.s.cm(-5) (P < 0.01), with the reduction being greater in Group A than in Group B (P < 0.01). There was a significant increase in cardiac output in Group A after 5-14 days of treatment vs. baseline (6.19 +/- 0.77 vs. 4.32 +/- 0.66, P < 0.001), and, after treatment, cardiac output was significantly greater in Group A than it was in Group B (6.19 +/- 0.77 vs. 4.70 +/- 0.44, P < 0.001). Reappearance of end-diastolic flow in the UA occurred in 14/16 patients in Group A but in no patients in Group B (87.5% vs. 0%, P < 0.05). The interval between detection of UA-AEDF and delivery was 28 +/- 16 days in Group A and 11 +/- 6 days in Group B (P < 0.05). CONCLUSION: Administration of NO donors and PVE in gestational hypertensive pregnancies affected by IUGR and UA-AEDF appears to improve both maternal and fetal hemodynamics, inducing prolongation of gestation.

Placental vascularization measured by three-dimensional power Doppler ultrasound at 11 to 13 + 6 weeks' gestation in normal and aneuploid fetuses.

OBJECTIVE: To establish the potential role of three-dimensional (3D) power Doppler evaluation of the placental circulation in aneuploidy screening at 11 to 13 + 6 weeks of gestation. METHODS: 3D power Doppler ultrasound examination of the placenta was performed in 25 pregnancies with fetuses with abnormal karyotype and in 100 control pregnancies at 11 to 13 + 6 weeks of gestation. Using the same pre-established settings for all cases, the vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated for the whole placenta. RESULTS: In the chromosomally normal group all the vascular indices increased significantly with advancing gestation between 11 and 13 + 6 weeks (VI: r = 0.482, P < 0.001; FI: r = 0.295, P = 0.0029; VFI, r = 0.484, P < 0.001). In the chromosomally abnormal group, the flow indices were not significantly different from normal in cases with trisomy 21 (13 cases), but they were significantly reduced compared with normal in cases with trisomies 13 and 18 (VI: t = 8.321, P < 0.0001: FI: t = 12.934, P < 0.0001; VFI: t = 7.608, P < 0.0001). CONCLUSIONS: 3D power Doppler evaluation of the placental circulation is not useful in screening for trisomy 21, and unlikely to further increase the already high detection rate for trisomies 13 and 18. However, we provide normal ranges of placental vascular indices between 11 + 0 and 13 + 6 weeks of gestation, which may be useful in future research on placental vascularity in certain at-risk pregnancies.

The role of CnTI-SonoVue in the diagnosis of ovarian masses with papillary projections: a preliminary study.

OBJECTIVES: To describe sonographically the distribution patterns of a second-generation contrast agent in the microcirculation of unilocular and multilocular ovarian masses with papillary projections, and to investigate whether qualitative evaluation of the passage of the contrast agent can improve the performance of sonography in distinguishing between benign and malignant masses with papillary projections. METHODS: Thirty-three patients with unilocular or multilocular ovarian masses with papillary projections were enrolled into the study in three clinical centers. The contrast-enhanced transvaginal examination was performed using 'Contrast Tuned Imaging' (CnTI) technology and SonoVue ultrasound contrast agent. RESULTS: Twenty-four (73%) lesions were benign, eight (24%) were borderline ovarian tumors, and one patient presented with an endometrioid ovarian adenocarcinoma. On color and power Doppler examinations the presence of vessels was demonstrated in 17 papillary projections, while on CnTI-SonoVue examination, the presence of vessels was shown in these 17 and in six additional cases. In all cases with absent papillary perfusion after SonoVue intravenous injection, the cyst wall appeared unequivocally regular. The sensitivity and specificity of conventional color Doppler examination with regard to malignancy were 100% and 67% and the positive and negative likelihood ratios were 3.03 and 0.16, respectively. For the contrast-enhanced examination the corresponding values were 100%, 42%, 1.7 and 0.26. The difference in specificity was statistically significant (P<0.05) because 14 cases, in which papillary perfusion was detected after SonoVue injection, proved to be benign on pathological examination. CONCLUSION: Qualitative evaluation of blood circulation in papillary projections using CnTI-SonoVue examination does not improve the discrimination of benign from borderline/malignant ovarian masses with papillary projections.

Maternal total vascular resistance and concentric geometry: a key to identify uncomplicated gestational hypertension.

OBJECTIVE: To evaluate the prognostic impact of elevated total vascular resistance (TVR) on the outcome of pregnancy in early mild gestational hypertension (EMGH). DESIGN: Prospective observational study. SETTING: Data collected from women with EMGH referred to the obstetrics outpatient clinic of Tor Vergata University from June 2003 to June 2005. POPULATION: A total of 268 women with EMGH (systolic and diastolic blood pressure [BP] 140-150 mmHg and 90-99 mmHg, respectively, without significant proteinuria). METHODS: Women had a maternal echocardiographic examination and BP examination within 24 hours of diagnosis. From this, the TVR was calculated and the geometric pattern of the left ventricle assessed. MAIN OUTCOME MEASURES: Fetal/maternal adverse outcomes (pre-eclampsia, preterm delivery, placental abruption, other maternal medical problems, fetal distress, neonatal low birthweight, admittance to neonatal intensive care unit and perinatal death). RESULTS: Ninety-two out of the 268 pregnancies showed adverse outcomes (34.3%). The best independent predictor for the composite of maternal and fetal complications was TVR (OR 64.4, 95% CI 25.9-160.1). The cutoff value was 1340 dyn seconds/cm(5) with a sensitivity and a specificity of 90 and 91%, respectively. Concentric geometry of the left ventricle was also an independent predictor (OR 4.72, 95% CI 1.85-12.04). CONCLUSIONS: Echocardiography could help in identifying women with EMGH who subsequently develop maternal and fetal complications, allowing a classification in high-risk (TVR > 1340 dyn seconds/cm(5), concentric geometry of the left ventricle) and low-risk women (TVR < 1340 dyn seconds/cm(5), nonconcentric geometry of the left ventricle) for adverse outcomes of pregnancy.