Sonographic findings of a large vulvar lipoma.

Lipomas of the vulva are rare benign tumors that consist of mature fat cells often interspersed with strands of fibrous connective tissue. They arise from the vulvar fatty pads and present as soft, multilobulated subcutaneous neoplasms. Histological examination reveals a thin capsule surrounding a lobular proliferation of lipocytes. Liposarcomas of the vulva have been described rarely. We present the sonographic findings of a large lipoma of the vulva, and demonstrate the contribution of topical application of a high-frequency transvaginal transducer in depicting lobular structural features, characteristic of this soft tissue tumor.

Transvaginal sonographic findings of a large intramural uterine hematoma associated with iatrogenic injury sustained at termination of pregnancy.

We report a case in which a patient presented with severe right lower abdominal pain associated with nausea and vomiting 3 days after termination of pregnancy. Transvaginal ultrasonography showed a large intramural mass in the anterior aspect of the lower segment of an acutely retroflexed uterus. Computed tomography and magnetic resonance imaging findings were consistent with an intramural hematoma as a result of iatrogenic injury sustained during the preceding termination of pregnancy. The patient was managed expectantly. Systematic review of the literature confirmed that this is the first report of sonographic findings associated with an intramural uterine hematoma some days after the injury sustained at termination of pregnancy. This case supports utilization of real-time ultrasound guidance during intrauterine surgery of selected cases to decrease procedure-related morbidity.

Transient bilateral ovarian enlargement associated with large retroperitoneal lymphoma.

Bilateral ovarian enlargement may reflect benign or malignant processes of the ovary. Benign causes of ovarian enlargement include luteomas, tumors such as mature cystic teratomas, fibrothecomas, cystadenomas and rare conditions including capillary hemangioma and massive edema of the ovaries. Ovarian malignancies include epithelial, stromal and germ-cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma. We present an unusual case in which a patient presenting with weakness and mild lower abdominal and pelvic pain was noted at sonography to have bilaterally enlarged ovaries with features similar to those of massive ovarian edema as described previously, which has been associated with venous and lymphatic obstruction. Subsequent computerized tomography (CT) imaging depicted a large retroperitoneal tumor, CT-guided biopsy of which revealed diffuse large B cell lymphoma. The patient responded well to chemotherapy with significant shrinkage of the tumor, and reappearance of normal findings on ovarian sonography. This case demonstrates that bilaterally enlarged ovaries may be the first clinical evidence of a large retroperitoneal tumor and that in such cases CT imaging may be warranted.

Nomograms of the axial fetal cerebellar hemisphere circumference and area throughout gestation.

OBJECTIVE: The widely applied transcerebellar diameter (TCD) obtained at axial cranial imaging, measures the distance between the lateral aspects of the cerebellum and incorporates the width of the cerebellar vermis. Our objective was to create reference ranges of axial fetal cerebellar hemisphere circumference (CHC) and area (CHA), independent of the cerebellar vermis, throughout gestation. METHODS: This cross-sectional study involved pregnant patients between 14 and 41 weeks of gestation. Inclusion criteria consisted of well-established dates (confirmed by early ultrasound), non-anomalous singleton fetuses and intact amniotic membranes. Sonographic measurements included biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), humerus length (HL), TCD, and estimated fetal weight (EFW). Values of axial fetal CHC and CHA were each calculated as the mean of three separate measurements. The 5th, 50th and 95th centiles were estimated at each week of gestational age (GA) by least-squares regression for the mean and standard deviation (SD) of the CHC and CHA as functions of GA. r2 and associated P-values for the relationships of CHC and CHA with other sonographic biometric measurements were calculated. RESULTS: The study included 651 consecutive patients. All attempts at obtaining axial fetal CHC and CHA were successful. Mean maternal age was 27.3+/-6.7 years, median gravidity was 1 (range 1-16), and median parity was 1 (range 0-6). Mean CHC (cm) throughout gestation was modeled as -2.091+0.2563xGA (weeks) (SD=-0.075+0.0164xGA), and mean CHA (cm2) was modeled as 0.245-0.0765xGA+0.00506xGA2 (SD=1.167-0.1565xGA+0.006785xGA(2)-0.00008028xGA3). Fetal axial CHC and CHA correlated significantly and strongly with BPD, HC, AC, HL, FL, TCD and EFW (all R2 values were >or=0.95, and all P-values were <0.001). CONCLUSION: Nomograms of axial fetal cerebellar hemisphere circumference and area throughout gestation, independent of the cerebellar vermis, have been provided.

Fetal clavicle length throughout gestation: a nomogram.

OBJECTIVE: To create a nomogram of fetal clavicle length (CL) throughout gestation. METHODS: Cross-sectional study of patients between 14 and 42 weeks' gestation. Inclusion criteria consisted of well-established dates (consistent with early ultrasound), singleton, non-anomalous fetuses, and intact amniotic membranes. Sonographic measurements included biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), humerus length (HL) and sonographically estimated fetal weight (SEFW). For every case, the average of three separate measurements of the CL was used. The 5th, 50th and 95th centiles were obtained by least squares regression. Pearson's correlation coefficient and associated P-values for the relationships between CL and other biometric measurements were calculated. The data were compared to a nomogram of the CL generated in 1985 from the measurement of 85 fetuses. RESULTS: A total of 623 consecutive patients were studied. In all but three cases, CL was successfully measured. Mean maternal age was 27.7 +/- 6.2 years, median gravidity 3 (range, 1-14) and median parity 1 (range, 0-9). Mean CL (mm) = -75.30 + 32.70*ln(GA) and SD = -0.41 + 0.08328*GA, where ln represents the natural logarithm and GA the gestational age in weeks. Fetal CL correlated significantly and strongly with BPD, HC, AC, HL, FL and the logarithm of SEFW, with Pearson correlation values of 0.973, 0.977, 0.976, 0.979, 0.977 and 0.979, respectively (all P < 0.001). Measurements according to comparable 1985 data were consistently substantially below the present data (smaller CL for any given GA except below 17 weeks' gestation). CONCLUSIONS: We propose a new nomogram of CL, which differs significantly from the previously published nomogram. We suggest that the present data reflect the use of high-resolution ultrasound technology and propose that these data, based on a large number of fetuses, replace the previous nomogram. We also suggest that the '1 mm = 1 week' rule of thumb should no longer be used, since it can be erroneous by as much as 6 weeks.

Cord entanglement of monochorionic diamniotic twins following spontaneous antepartum septostomy sonographically simulating a true knot of the umbilical cord.

Spontaneous antepartum septostomy occurring in monochorionic diamniotic twins is extremely rare. We present a case in which prenatal sonography at 26 weeks' gestation depicted a monochorionic diamniotic twin gestation with concordant fetal growth and findings suggestive of a true knot of the umbilical cord. At Cesarean delivery at 34 weeks' gestation, spontaneous antepartum septostomy with entanglement of the two separate umbilical cords was noted. This case suggests that the differential diagnosis of findings considered consistent with a true knot of the umbilical cord in monochorionic diamniotic twin gestations, should include spontaneous antepartum septostomy and umbilical cord entanglement.

Is fetal cerebral vascular resistance affected by the presence of nuchal cord(s) in the third trimester of pregnancy?

OBJECTIVE: To assess whether fetal cerebral vascular resistance is affected by the presence of nuchal cord(s) in the third trimester. METHODS: A set of 115 patients with well-established dates and singleton, appropriate for gestational age (GA), non-anomalous fetuses with nuchal cord(s) diagnosed with prenatal color Doppler imaging, between 28 and 41 weeks and 115 controls matched for GA, were studied. Patients with hypertension, diabetes and autoimmune conditions were excluded. Doppler indices were obtained from the umbilical artery (UA) and the fetal middle cerebral artery (MCA) upon initial diagnosis of the nuchal cord. RESULTS: Of 115 GA-matched pairs of pregnancies, 103 fetuses had a single nuchal cord and 12 a double nuchal cord. No significant differences were noted in patient age, gravidity, parity, sonographically estimated fetal weight (SEFW), and growth centile at ultrasonographic diagnosis. Mean UA systolic/diastolic ratio (S/D) was 2.28 +/- 0.32 and 2.36 +/- 0.33 (P = 0.03) and UA resistance index (RI) 0.55 +/- 0.06 and 0.57 +/- 0.06 (P = 0.02) among study and controls, respectively. Mean fetal MCA S/D and RI did not differ significantly between the two groups (fetal MCA S/D 5.01 +/- 1.28 and 5.04 +/- 1.71 (P = 0.86), and mean fetal MCA RI 0.78 +/- 0.06 and 0.78 +/- 0.05 (P = 0.88)). No significant differences were noted in GA at delivery, incidence of meconium-stained amniotic fluid, birth weight, mode of delivery, neonatal gender, 1 and 5 minute Apgar scores, or UA pH and base excess, between study and control patients. CONCLUSION: Fetal cerebral vascular resistance is not affected by the presence of nuchal cord(s) in the third trimester of pregnancy.