Self-made transvaginal ultrasound simulator: new training equipment in ultrasound evaluation of controlled ovarian stimulation and oocyte retrieval.

Aim: We sought to create and describe a self-made simulator designed and created for teaching purposes: a high-fidelity ultrasound phantom for demonstrating antral follicle count, ultrasound supervision of controlled of ovarian stimulation, and ultrasound-guided oocyte retrieval. Materials and methods: The uterus and ovaries of the ultrasound phantom were made from beef tongue, a male condom, latex gloves, cotton suture threads, bi-distilled water, and ultrasound gel. The components were placed in a pelvis created using three-dimensional (3D) printing. The phantom was presented to and evaluated by a group of 14 physicians pursuing a postgraduate course in reproductive medicine. Two training stations were structured: one to simulate antral follicle count and controlled ovarian stimulation and the other to simulate ultrasound-guided oocyte retrieval. Future specialists were requested to complete a feedback questionnaire evaluating the self-made simulator and the two practice stations. Results: The transvaginal ultrasound phantom was successfully created, making it possible to simulate antral follicle count, ultrasound control of ovarian hyperstimulation, and oocyte retrieval, and to capture ultrasound images. A review of the answers provided in the feedback questionnaire showed that the phantom had a good appearance and design, was realistic, helped to improve motor coordination, and could be a useful tool in the training of specialists in assisted reproduction. Conclusion: This phantom was designed to enable instruction and practice in the evaluation of ovarian follicles and ultrasound-guided oocyte retrieval in a supervised training environment. This self-made simulator is proposed as a training tool that could be included in the curricular structure of residency and postgraduate programs in reproductive medicine.

Aicardi syndrome: Neonatal diagnosis by means of transfontanellar ultrasound.

Aicardi syndrome is a rare genetic disease characterized by a characteristic classical trio of neurological clinical abnormalities (spasms), agenesis of the corpus callosum and ophthalmological abnormalities (chorioretinal lacunae). The diagnosis can be suspected by prenatal ultrasound with color Doppler identifying the agenesis of the corpus callosum. Usually, the diagnosis is confirmed in the neonate period by transfontanellar ultrasound and ophthalmological examination. We present a case of newborn with Aicardi syndrome, being the transfontanellar identified partial dysgenesis of the corpus callosum and a cyst in the inter-hemispheric fissure. Ophthalmological examination showed bilateral chorioretinal lacunae.

Reference charts for fetal biometric parameters in twin pregnancies according to chorionicity.

OBJECTIVE: The objective of this article is to determine reference values for fetal biometric parameters in twin pregnancies and to compare these values between monochorionic and dichorionic pregnancies. METHODS: A retrospective cross-sectional study was conducted among 157 monochorionic and 176 dichorionic twin pregnancies between 14 and 38 weeks of gestation. Biometric measurements included the biparietal diameter (BPD), abdominal circumference (AC), femurs length (FL) and estimated fetal weight (EFW). To evaluate the correlation between biometric parameters and gestational age, polynomial regression models were created, with adjustments using the coefficient of determination (R(2) ). Comparison between monochorionic and dichorionic pregnancies was performed using analysis of covariance. RESULTS: The mean BPD, AC, FL and EFW for the dichorionic pregnancies were 56.16 mm, 191.1 mm, 41.08 mm and 816.1 g, respectively. The mean BPD, AC, FL and EFW for the monochorionic pregnancies were 57.14 mm, 184.2 mm, 39.29 mm and 723.4 g, respectively. There was a statistical difference between mono and dichorionic pregnancies for all the biometric parameters (BPD p = 0.012; AC p = 0.047; FL p = 0.007; EFW p = 0.011). CONCLUSION: Reference curves of biometric parameters in twin pregnancies were determined. Biometric parameters were statistically different between monochorionic and dichorionic pregnancies.

Reference intervals of embryos/fetuses heart rate between 6 and 14 weeks of pregnancy.

OBJECTIVE: To determine reference intervals for the embryos/fetuses heart rate (HR) between 6 and 14 weeks of pregnancy. METHODS: A retrospective cross-sectional study was carried in a single center with singleton pregnancies of embryos/fetuses with a crown-rump length (CRL) between 5 and 85 mm. The HR was assessed by real time M-mode or spectrum Doppler ultrasound. To evaluate the correlation between embryo/fetal HR and CRL, polynomial equations were calculated, with adjustment by the determination coefficient (R(2)). RESULTS: A total of 5867 pregnancies were assessed. The mean gestational age was 10.37 ± 2.12 weeks. The mean maternal age was 26.41 ± 6.78 years. The mean embryo/fetal HR (bpm) for the CRL (mm) intervals 5├15; 15├25; 25├35; 35├45; 45├55; 55├65; 65├75; 75├85 was 145.1 ± 18.7; 167.2 ± 10.1; 166.9 ± 8.7; 165.5 ± 6.9; 162.2 ± 6.8; 159.2 ± 6.4; 157.1 ± 6.4; 154.9 ± 7.3; respectively. The following third-order equation best represented the correlation between embryo/fetal HR and CRL: HR = 119.25 + 3.596*CRL-0.07954*CRL(2 )+ 0.00051*CRL(3) (R(2 )= 0.36). CONCLUSION: Reference intervals of HR in embryos/fetuses in a large sample were determined. These reference intervals can be used in high-risk early pregnancy losses.

Reference range of fetal nasal bone length between 18 and 24 weeks of pregnancy in an unselected Brazilian population: experience from a single service.

OBJECTIVE: To determine reference range of fetal nasal bone length (NBL) during the second trimester of pregnancy in a Brazilian population. METHODS: This was a retrospective cross-sectional study with 2681 normal singleton pregnancies between 18 and 24 weeks of gestation. The NBL was obtained in the mid-sagittal plane of the fetal face profile using the following landmarks: nasal bone, overlying skin and the tip of the nose. The NBL was measured by placing the calipers in the out-to-out position. To assess the correlation between NBL and gestational age (GA), polynomial equations were calculated, with adjustments by coefficient of determination (R(2)). RESULTS: The mean of NBL ranged from 5.72 ± 0.87 mm at 18-18 + 6 weeks to 7.45 ± 1.23 mm at 24-24+6 weeks of pregnancy. We observed a good correlation between NBL and GA, best represented by a linear equation: NBL = 0.080+0.276*GA (R(2 )= 0.16). CONCLUSION: We established a reference range of fetal NBL in the second trimester of pregnancy in a Brazilian population.

Normative data for fetal cisterna magna length measurement between 18 and 24 weeks of pregnancy.

PURPOSE: The aim of this study was to determine normative data for fetal cisterna magna length (CML) measurement in a Brazilian population. METHODS: This was a retrospective cross-sectional study on 3,862 normal singleton pregnancies between the 18th and 24th weeks of pregnancy. Fetal CML was measured in the axial plane of the fetal head, at lateral ventricle level, including the cavum septum pellucidum, thalamus, third ventricle, and transverse cerebellar diameter. The anteroposterior measurement was made between the posterior border of the cerebellar vermis and the internal face of the occipital bone. To assess the correlation between CML and gestational age (GA), polynomial equations were calculated, with adjustments using determination coefficient (R2). RESULTS: The mean CML ranged from 4.29±0.93 mm at 18 to 18+6 weeks to 5.58±1.23 mm at 24 to 24+6 weeks of pregnancy. There was a good correlation between CML and GA, best represented by a linear equation: CML=0.535+0.208*GA (R2=0.084). CONCLUSION: We established normative data for fetal CML in the second trimester of pregnancy, in a large Brazilian population.

Occult spinal dysraphism in the presence of rare cutaneous stigma in a neonate: importance of ultrasound and magnetic resonance imaging.

Occult spinal dysraphism is defined as a group of dystrophic conditions below an intact cover of dermis and epidermis. Ultrasonography using linear transducers is a fast, inexpensive, and effective method that makes it possible to view the content of the vertebral canal and bone structures. Magnetic resonance imaging (MRI) is reserved for elucidating the type of dysraphism and for planning corrective surgery. We present a case of a five-day-old female neonate who presented cutaneous stigmas (in the lumbar region, hands, and feet), in whom ultrasonography demonstrated dysraphism in the lumbar region. MRI confirmed the type of dysraphism and enabled surgical planning.

Diagnosis of Intra-Abdominal Extralobar Pulmonary Sequestration by means of Ultrasound in a Neonate.

Pulmonary sequestration is a congenital abnormality consisting of a mass of pulmonary tissue that presents an abnormal connection with the tracheobronchial tree, with a blood supply coming from an anomalous artery derived from the systemic circulation. Extralobar pulmonary sequestration is characterized by having pleural coverings that are independent of the normal lungs, with vascular supply usually coming from the aorta or from one of its branches. This diagnosis can be suspected prenatally if an abdominal mass, generally below the diaphragm, is seen. Here, we present a case of a neonate on the second day of life, with ultrasonography showing extralobar pulmonary sequestration located above the left adrenal gland that prenatally simulated a neuroblastoma.

Nódulos mamários malignos: análise à ultra-sonografia tridimensional / Malignant breast lesions: three-dimensional ultrasonography analysis

Os avanços recentes em técnicas de informática prometem tornar os dados médicos de imagem cada vez mais acessíveis e úteis clinicamente. A ultra-sonografia tridimensional encontra-se em estágio adiantado como objeto de estudo, movendo-se gradualmente para fora dos laboratórios de pesquisa e tornando-se cada vez mais comercialmente disponível para o uso clínico rotineiro. Em mastologia, a ultra-sonografia tridimensional tem demonstrado capacidade de avaliar mais claramente as margens de uma lesão e sua topografia. Estas informações podem ser importantes na diferenciação entre lesões benignas e malignas. A análise pelo modo multiplanar da lesão mamária tem permitido uma nova forma de avaliação do grau de acometimento, que é a retração dos ligamentos de Cooper observada na aquisição do plano frontal. De fato, o aspecto do tecido mamário perilesional, conhecido como zona infiltrativa, analisado a partir do plano de corte coronal obtido por meio da ultra-sonografia tridimensional, possibilita a obtenção de informações adicionais em até 75 porcento dos casos em relação à ultra-sonografia bidimensional.

Sonoembryology by three-dimensional ultrasonography: pictorial essay.

CONTEXT: Three-dimensional ultrasonography in obstetrics has evolved in the last years, and nowadays it is a methodology that greatly helps prenatal diagnosis. Through its rendering mode it allows the careful evaluation of fetal face and limbs, and in multiplanar mode it allows the assessment of the anatomy through the many possible planes. In the first trimester of gestation, three-dimensional ultrasonography permits the detailed evaluation of embryonic development. Its main advantages over two-dimensional ultrasonography are shorter examination time and the possibility of storage of the volumes for later processing and analysis. AIM: We present a pictorial essay with normal embryo development in the first trimester of pregnancy by three-dimensional ultrasonography, from the fifth to ninth week.

Postnatal evaluation of schizencephaly by transfontanellar three-dimensional sonography.

Schizencephaly is a rare anomaly of neuronal migration characterized by the presence of brain clefts that communicate with the lateral ventricles. Type I is characterized by clefts with fused lips or margins, not communicating with the subarachnoid space. Type II is characterized by longer clefts that communicate with the subarachnoid space. Neonatal diagnosis of schizencephaly on transfontanellar two-dimensional (2D) sonography is rare, with only 1 report in the medical literature. The major limitation of 2D sonography is its inability to assess neonatal prognosis. There are no reports on MEDLINE about the use of transfontanellar three-dimensional (3D) sonography in the assessment of schizencephaly. We present a case of type II schizencephaly diagnosed on the 29th week of gestation with 2D sonography and describe the main findings with 3D sonography in surface and transparency modes performed in the neonatal period via the fontanel.

Comparison of two- and three-dimensional ultrasonography in the evaluation of fetal heart: image quality and time spent in the exam.

OBJECTIVES: To compare fetal heart evaluation done through two-dimensional (2DUS) and three-dimensional ultrasonography (3DUS) as to optimal plane imaging, image quality, and time needed to perform the examination. METHODS: Prospective study involving 12 normal pregnant women, with gestational ages ranging from 22 to 26 weeks, scanned with a VOLUSON 730 with a convex 4.0-7.0 MHz transducer, in both two- and three-dimensional modes. In each case, three basic view planes were obtained: four-chambers view, right, and left ventricular outflow tracts. Each view was subjectively evaluated by three different examiners as to image quality, and graded from 0 (minimum) to 4 (maximum) cross-marks (+). The sum of all grades obtained for each case was used to classify the quality of the exam as unsatisfactory (0 to 1+), poor (2 to 4+), regular (5 to 7+), and good (8 to 12+). The time taken to obtain the views was recorded for each case, starting with the acquisition of the first view on the 2D exam and with the identification and opening of the volume blocks on the three-dimensional software. RESULTS: The number of three-dimensional blocks with good, regular, poor, and unsatisfactory grades were, respectively, 6, 15, 9, and 10. The average in cross-marks of the cases graded good in each group without the worst result for each plane was 8. 2DUS was superior to 3DUS regarding the quality of the images obtained by the three pattern view planes and the average time to obtain high quality view planes was longer for 3DUS when compared to 2DUS. 2DUS offered better quality images and in less time than 3DUS. CONCLUSIONS: Three-dimensional ultrasound is an advancement in fetal heart evaluation; however two-dimensional ultrasound remains the best screening method in diagnosing cardiac malformations, due to the good quality of its images and the lesser time needed to perform the exam.

Detecção pré-natal de feto com trissomia do cromossomo 18 por meio de ultra-som bidimensional e tridimensional: relato de caso / Prenatal detection of fetal trisomy 18 by two-dimensional and three-dimensional ultrasound: a case report

A trissomia do cromossomo 18, ou síndrome de Edwards, é a segunda anomalia cromossômica mais freqüente. Apresenta prognóstico extremamente desfavorável, sendo que a maioria dos recémnascidos sobrevive menos de uma semana. Habitualmente, é acompanhada de diversas anomalias estruturais denominadas marcadores, que em sua maioria são detectadas pela ultra-sonografia bidimensional O diagnóstico ultra-sonográfico pré-natal das anomalias estruturais com confirmaçãodo cariótipo fetal são de grande importância ao permitir adequado aconselhamento ao casal. A ultra-sonografia tridimensional no modo de superfície permite avaliação mais acurada da superfície fetal, constituindo-se em método complementar à ultra-sonografia bidimensional em fetossuspeitos de anomalias cromossômicas. Apresentamos um caso de feto com trissomia do cromossomo 18 com provável diagnóstico pelo ultra-som na 13ª semana de gestação e destacamos os principais achados à ultra-sonografia convencional e a importância da ultra-sonografia tridimensional no auxílio diagnóstico de algumas anomalias estruturais.

Trisomy 18, Edwards's syndrome, is the second most frequent chromosomal anomaly. Prognosis is dismal and most infants die within one week of birth. Several structural anomalies are usuallypresent on two-dimensional ultrasound. Antenatal diagnosis of structural anomalies is suspected through ultrasound and confirmed with fetal karyotype, this is important for it allows adequate parental counseling. Three-dimensional ultrasound, through itssurface mode, allows better visualization of fetal surfaces and maycomplement two-dimensional views in fetuses with chromosomal anomalies. We present a case of trisomy 18 diagnosed in the 13th week of gestation through ultrasound. The main findings on twodimensional ultrasound are emphasized, as well as the role ofthree-dimensional ultrasound in the evaluation of some structural anomalies.

Diagnosis of uteroperitoneal fistula through color Doppler hysterosonography.

INTRODUCTION: Uterine fistulas are infrequent pathologic entities characterized by abnormal communication of the uterus with any other organ or structure through a perforation formed due to traumatic and infectious conditions among others. The use of hysterosonography as method of diagnosis for that pathologic entity has few descriptions in medical literature. MEDLINE search resulted in only two cases reporting the use of HS in the diagnosis of uterine fistula. OBJECTIVE: Our objective is to report a case of uteroperitoneal fistula caused by uterine trauma during curettage, diagnosed by color Doppler hysterosonogrphy. The importance of our report lies on HS as a simple, safe and low cost method, which can be used for the diagnosis of fistulous processes involving the uterus.

Three-dimensional transvaginal sonographic diagnosis of early and asymptomatic interstitial pregnancy.

CONTEXT: The interstitial gestation is a rare form of tubal pregnancy which is associated with high morbidity. The diagnosis of an interstitial gestation can be reached through a bidimensional transvaginal ultrasonography (2D-TVUS), however, sometimes when making use of this technique it is not possible to appropriately evaluate the position of the gestational sac in relation to the uterine cavity. The three-dimensional transvaginal ultrasonography (3D-TVUS) allows accessibility to plans that the bidimensional does not, thus it makes it possible to reach a more accurate diagnosis and it also allows for an appropriate therapeutic planning. CASE REPORT: We present a case of interstitial gestation diagnosed in the sixth week in an asymptomatic woman, who had a previous diagnosis of primary infertility. The 2D-TVUS revealed the presence of a gestational sac outside of the uterine cavity; moreover the colored Doppler and the power Doppler indicated a thriving vascular ring. The 3D-TVUS in the surface and transparency mode demonstrated that the gestational sac was located in the interstitial region of the uterine tube, and the niche mode accurately evaluated the relationship between the gestational sac and the uterine cavity. The patient was successfully treated with a local injection of methotrexate guided by a transvaginal ultrasonography. The 3D-TVUS was of great importance to confirm the diagnosis, to allow appropriate therapeutic choices and to decrease the morbidity.

Prenatal diagnosis of trisomy 18 as true mosaicism by three-dimensional ultrasonography: a case report.

Trisomy of chromosome 18 is the second most common autosomal trisomy, occurring in approximately 1:7,000 live births. Its prenatal diagnosis through abnormal findings in ultrasound with later analysis of fetal karyotype is important for a definition of the prognosis and counseling of the patients. We describe a case of trisomy 18 as true mosaicism diagnosed through amniocentesis in the second trimester of pregnancy, associated to the presence of multiple fetal phenotypic alterations. We focus on the importance of fetal morphological study through three-dimensional ultrasonography, which was highly important for clearly showing the fetus' structural alterations, helping parents to understand better the pathology and allowing them to reason about the continuity of the gestation.

Spatio-temporal image correlation (STIC): nova técnica para avaliação do coração fetal / Spatio-temporal image correlation (STIC): a new technique for fetal heart evaluation

As malformações cardíacas são as mais freqüentes anomalias congênitas ao nascimento, entretanto, a sua detecção pré-natal pela ultra-sonografia convencional permanece baixa. As ultra-sonografias de terceira e quarta dimensões surgiram no início da década de 90, apresentando grandes aplicações em obstetrícia, principalmente nos casos de diagnósticos duvidosos à ultra-sonografia bidimensional. O spatio-temporal image correlation (STIC) representa grande avanço na área de ultra-som de quarta dimensão; constitui-se em um software acoplado ao aparelho Voluson 730 Expert, que permite a aquisição volumétrica do coração fetal e suas conexões vasculares. As análises volumétricas são realizadas nos modos multiplanar e de renderização, podendo-se também utilizar o Doppler. Apresenta, como grandes vantagens, a aquisição rápida e a possibilidade de análise posterior por especialistas em ecocardiografia fetal. Pode ser aplicada para a pesquisa de quaisquer cardiopatias congênitas, pois permite a aquisição de qualquer plano, diferentemente do ultra-som bidimensional. Sua principal desvantagem está relacionada aos movimentos fetais. A maior difusão do método pode permitir um aumento na detecção de malformações cardíacas, pois possibilita ao ultra-sonografista geral encaminhar, via Internet, os volumes para a análise por especialistas em ecocardiografia fetal.

Although congenital heart defect is the most frequent anomaly in newborns, its antenatal detection rate through conventional ultrasound remains low. 3D and 4D ultrasound technology was developed early in the nineties, bringing great benefits in obstetrics, especially in cases of dubious diagnosis at 2D ultrasound. The spatio-temporal image correlation (STIC) is a significant development in the field of 4D ultrasound. A software coupled with a Voluson 730 Expert equipment allows a volumetric acquisition of the fetal heart and its vascular connections. Volumetric analyses are performed in multiplanar and surface rendering modes or, alternatively in association with color Doppler. Major advantages are fast images acquisition and the possibility of a later analysis by fetal echocardiography specialists. Differently from 2D ultrasound, this technique may be applied for evaluating any congenital cardiopathy because of the increased number of frames acquired from a specific anatomical region. Main disadvantage is related to the necessity of fetal immobility. The higher diffusion of this method may improve prenatal detection of heart malformations since volumes data captured by a sonographer may be sent through the Internet for analysis by fetal echocardiography specialists.

Diagnosis of Pentalogy of Cantrell by three-dimensional ultrasound in third trimester of pregnancy. A case report.

The Pentalogy of Cantrell is a rare congenital anomaly characterized by defects in the closing of the supraumbilical abdominal wall, in the anterior portion of the diaphragm, in the diaphragmatic pericardium, ectopia cordis, and intracardiac defects. It may be associated to other anomalies determining the variants of this syndrome. The prenatal ultrasound diagnosis is extremely important for detecting structural malformations and for postnatal surgical planning, when possible. We present a case of Pentalogy of Cantrell diagnosed in the 34th week of gestation, showing the main findings by two-dimensional ultrasound and emphasizing the importance of three-dimensional ultrasound on the assessment of structural malformations and on the better understanding of the origins of the pathology.