Reproducibility of renal volume measurement in adults using 3-dimensional sonography.

OBJECTIVES: The purpose of this study was to determine the interobserver reproducibility of renal volume measurement performed by 3-dimensional (3D) sonography. METHODS: We conducted an exploratory, quantitative, observational, and descriptive cross-sectional study. We calculated ranges, means, and standard deviations of the renal volumes obtained with 3D sonography by 2 different examiners from a sample of 30 patients. The interobserver reproducibility was assessed by calculating intraclass correlation coefficients (ICCs) and by construction of Bland-Altman plots. RESULTS: The ICC between the right 3D renal volumes obtained by examiners 1 and 2 was 0.8552 (95% confidence interval, 0.7153-0.9292), showing excellent reproducibility (P < .0001). For the left 3D renal volumes obtained by examiners 1 and 2, the ICC was 0.6411 (95% confidence interval, 0.3652-0.8135), showing average to good reproducibility (P = .0001). The Bland-Altman plots showed mean differences ± SD of -4.8% ± 23.9% between the right renal volumes obtained by examiners 1 and 2 and -2.2% ± 38% between the left renal volumes. The 95% limits of agreement between the right renal volumes obtained by examiners 1 and 2 were -28.7% to 19%, whereas those between the left renal volumes were -40.2% to 35.7%. CONCLUSIONS: Three-dimensional sonography showed good interobserver reproducibility, which was better for the right kidney. It appears necessary to establish standardized techniques for acquisition of sonographic renal volumes.

Short cervix syndrome: current knowledge from etiology to the control.

BACKGROUND: Preterm delivery is one of the most serious public health problems and is the most important factor relating to neonatal morbidity and mortality. The strategies for preventing it include understanding the risk factors, with specific interventions. Recently, uterine cervix measurements using ultrasonography and vaginal administration of progesterone have gained importance in predicting and secondarily preventing spontaneous preterm delivery. OBJECTIVE: To describe the short cervix syndrome, including its etiology, diagnosis, and possible therapies. METHODS: Research in ISI, Pubmed, and Scielo database using the words short cervix, preterm delivery, sludge, cervical funneling, cervical gland area, progesterone, cerclage, and pessary. RESULTS: We found a lot of articles about this topic, including randomized controlled trials. The etiology is multifactorial, being the diagnosis based in a cervix shortening at 20-24 weeks. The history and measurement of cervix length by transvaginal ultrasound have been shown to be effective to select the high risk pregnancies. The progesterone, cervical cerclage, and cervical pessary showed to be effective to reduce the preterm delivery in pregnant women with short cervix. CONCLUSION: The successful management of pregnant women presenting a short cervix depends on the understanding that cervical shortening is the final common path for several causes of preterm delivery. The best approach should be individualized to each patient.

Reproducibility of three-dimensional power Doppler placental vascular indices in pregnancies between 26 and 35 weeks.

PURPOSE: Assess intra and interobserver reproducibility of three-dimensional power Doppler (3DPD) placental vascular indices in normal pregnancies between 26 and 35 weeks. METHODS: Thirty 3D volumes were captured by one observer and stored for analysis. Vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated from the spherical placental tissue samples obtained through the automatic Virtual Organ Computer-aided AnaLysis (VOCAL). Two observers analyzed the stored volumes and calculated the indices and their findings were compared. Intraclass correlation coefficients (ICCs) were used to analyze intra and interobserver correlations. Data were analyzed using confidence intervals, reliability coefficients and Bland-Altman graphs with concordance limits. RESULTS: All three indices had good intra and interobserver reproducibility. Intraobserver ICCs for the three indices were > 0.90. The FI had the highest ICC (0.99), the highest interobserver ICC (0.98) and the best concordance on the Bland-Altman graphs. CONCLUSION: 3DPD placental vascular indices obtained using the automatic sphere mode had a good intra and interobserver reproducibility for pregnancies between 26 and 35 weeks. The FI obtained the highest reproducibility scores.

Ultrasound assessment of the fetal biophysical profile: what does an radiologist need to know?

Proposed by Frank Manning about 26 years ago, fetal biophysical profile has been incorporated to the propaedeutics of non-invasive fetal well being assessment in high-risk gestations. Despite the existence of other methods for assessing fetal vitality, as Doppler flowmetry, the biophysical profile continues to be important in estimating the risk of hypoxia and perinatal morbimortality for those fetuses. In the present article, the authors review the regulatory mechanisms of fetal biophysical activities, as well as physiological and pathological factors that interfere with them. The main objective of the study is to discuss the present and important aspects of the method, and the practical applications and interpretation of its findings, in order to help radiologists improve their knowledge in this specific area of fetal ultrasonography.

[Diagnosis of uterine synechiae in patients with recurrent miscarriages: contribution of transvaginal hysterosonography]. / Diagnóstico de sinéquias uterinas por histerossonografia transvaginal.

BACKGROUND: The aim of this study was to determine the prevalence of uterine synechiae in patients with recurrent miscarriages and to evaluate the diagnostic accuracy of transvaginal ultrasound and of hysterosonography. METHODS: Sixty non-pregnant patients with a history of at least three previous consecutive miscarriages were evaluated by transvaginal ultrasound, hysterosonography and hysteroscopy to detect uterine synechiae. Hysteroscopy was considered the gold standard. Agreement of findings disclosed by transvaginal ultrasound and by the hysterosonography were evaluated according to the Kappa coefficient and their significance was tested. Significance was established at < 0. 05 (Alpha error = 5%). Sensitivity, specificity, positive and negative predictive values were determined for each method. RESULTS: Uterine synechiae were identified in 16 patients (26.7%). The accuracy of the transvaginal ultrasound and of the hysterosonography was 78.9% and 92.7%, respectively. When compared to the transvaginal ultrasound, hysterosonography had a much greater sensitivity (78. % vs. 20.0%) and a higher degree of agreement with hysteroscopy (Kappa = 80% vs. Kappa = 27%). CONCLUSION: For diagnosis of uterine synechiae, hysterosonography had a higher level of agreement with hysteroscopy than the transvaginal ultrasound. In patients with recurrent miscarriages transvaginal ultrasound is not recommended for the investigation of uterine synechiae because of its low sensitivity. Hysterosonography, on the other hand, seems to offer an important contribution especially because it is a simple, low-cost and accurate method for diagnosis of uterine synechiae.

[Discordant nuchal translucency in monochorionic twin pregnancy. A case report]. / Nuca translúcida incongruente con embarazo gemelar monocigótico. Comunicación de un caso.

The twin-to-twin transfusion syndrome is a serious anomaly occurring from vessels anastomosis between the fetal-planetary circulations of monochorionic twin pregnancies with a high perinatal morbidity and mortality. In the first trimester, the presence of discordant increase of the nuchal translucency associated a reverse blood flow in the ductus venosus are marks of twin-to-twin transfusion syndrome. In this report, we related a case of monochorionic twin pregnancy in the first trimester in that the first diagnostic signal this syndrome was an increase of the measurement of nuchal translucency, associated the reverse blood flow in the ductus venosus of receiving fetus.

Radiological findings in patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is characterized by recurrent upper airway obstruction occurring at the level of the pharynx during sleep. Although cephalometric analysis is an important method in the diagnosis of craniofacial deformities, CT and magnetic resonance imaging have been highlighted as the major imaging methods to investigate the possible causes of OSA, which, in most cases, is multifactorial. Magnetic resonance and CT both allow an excellent evaluation of the various anatomical planes of the site of obstruction, which enables better clinical assessment and surgical approach. This pictorial essay aims to describe the aspects that must be evaluated in the diagnostic imaging of patients presenting with the major predisposing factors for OSA.

Assessment of fetal behavior using four-dimensional ultrasonography: current knowledge and perspectives.

In the last decades, the development of real-time ultrasonography has allowed the direct view of the fetus in the uterus, as well as assessing its activity. The advent of three-dimensional ultrasonography (3D) at the end of the 80s initiated a new era in diagnostic imaging for Obstetrics, dramatically increasing the possibility of studying the fetus. Recently, a new technique allowing the 3D image to be transformed into real-time was introduced: the four-dimensional (4D) ultrasonography. It allows the continuous monitoring of fetal face and other surface areas, such as the extremities. Some studies have already assessed this new methodology for fetal behavior observation during different stages of pregnancy, trying to understand better the relationship between fetal central nervous system maturation and the implications for its behavior. In this article, the authors review the current use of 4D ultrasonography in the assessment of fetal behavior, and discuss the possibilities of the technique to show the neurological development of the fetus, by means of watching movement and facial expressions. They also highlight the potential applicability of this new method in this new research area of fetal medicine.

Placental blood flow measured by three-dimensional power Doppler ultrasound at 26 to 35 weeks gestation in normal pregnancies.

OBJECTIVE: To evaluate placental vascular indices, in pregnancies between 26 and 35 weeks, using three-dimensional power Doppler (3DPD) ultrasound and the effect of placental location on these indices. METHODS: This was a cross-sectional study involving 283 patients. The placental vascularization index (VI), flow index (FI) and vascularization and flow index (VFI) was obtained using the VOCAL program. Pearson's linear correlation coefficient was used to assess the relationship between gestational age and these indices. Student's parametric t-test and Levene's test were used to analyse the results between VI, FI and VFI and placental location. RESULTS: There was no linear correlation between gestational age (GA) and VI (p = 0.390) and VFI (p = 0.053). Only the FI presented a significant linear correlation (p = 0.004), with a slow increase according to GA. It was possible to construct a reliable nomogram only for this index. There were no significant differences in the VI, FI and VFI according to placental location (p = 0.323, 0.172 and 0.120, respectively). CONCLUSION: Placental FI assessed by 3DPD increases progressively and significantly between 26 and 35 weeks. Placental location has no influence on the three vascular indices studied. The FI reference values obtained in this study can be used as a parameter for future investigations on placental vascularization using 3DPD.

Embryo vascularization by three-dimensional power Doppler ultrasonography at 7-10 weeks of pregnancy.

AIM: Assess vascular indices of 7-10 week embryos using three-dimensional power Doppler (3DPD) and correlate them with the crown-rump length (CRL). METHODS: This cross-sectional study included 65 healthy pregnancies between 7 and 10 weeks. The three-dimensional volume of the embryo was obtained using an endocavitary volumetric transducer and the VOCAL (Virtual Organ Computer-aided Analysis) method, with a 12 degree rotation angle and 15 sequential planes. The vascularization (VI), flow (FI) and the vascular and flow (VFI) indices were obtained using 3DPD and the mean, median, standard deviation, maximum and minimum values were calculated for each gestational age. Pearson's correlation coefficient (r) was used to evaluate the correlation between vascular indices and CRL. RESULTS: The VI ranged from 0.77 to 41.67, mean 14.68 (+/-8.60), the FI went from 25.71 to 139.50, mean 90.61 (+/-21.51) and the VFI from 0.20 to 81.57, mean 15.69 (+/-12.42). The correlation between CRL and all 3D power Doppler vascular indices was low (VI - r=-0.073, P=0.566; FI - r=0.173, P=0.168 and VFI - r=-0.004, P=0.974). CONCLUSION: 3D power Doppler vascular indices in 7-10 week embryos do not correlate with CRL.

[Prediction of birth weight by three-dimensional ultrasonography using fetal upper arm volume: preliminary results]. / Predição de peso ao nascimento pela ultra-sonografia tridimensional usando o volume do braço fetal: resultados preliminares.

PURPOSE: to evaluate the accuracy of fetal upper arm volume, using three-dimensional ultrasound (3DUS), in the prediction of birth weight. METHODS: this prospective cross-sectional study involved 25 pregnancies without structural or chromosomal anomalies. Bidimensional parameters (biparietal diameter, abdominal circumference and femur length) and the 3DUS fetal upper arm volume were obtained in the last 48 hours before delivery. The multiplanar method, using multiple sequential planes with 5.0-mm intervals, was used to calculate fetal upper arm volume. Polynomial regressions were used to determine the best equation in the prediction of fetal weight. The accuracy of this new formula was compared with Shepard's and Hadlock's formulas. RESULTS: fetal upper arm volume was strongly correlated to birth weight (r=0.83; p<0.005). Linear regression was the best equation [birth weight=681.59 + 43.23 x fetal upper arm volume]. The fetal upper arm volume mean error (0 g), mean absolute error (196.6 g) and mean percent absolute error (6.5%) were lower than using Shepard's formula; however, the difference did not reach significance (p>0.05). Birth weight predicted by fetal upper arm volume had a mean error lower than Hadlock's formula, but this difference was not statistically significant (p>0.05). CONCLUSIONS: the accuracy of fetal upper arm volume obtained through 3DUS is similar to the accuracy of bidimensional ultrasound in the prediction of birth weight. These findings need to be confirmed by larger studies.

Nomogram of fetal middle cerebral artery peak systolic velocity at 23-35 weeks of gestation in a Brazilian population: pilot study.

OBJECTIVE: To establish normative data for the peak systolic velocity of the middle cerebral artery (MCA-PSV) of fetuses in the second half of pregnancy using multiples of the median and percentile reference range. METHODS: A cross-sectional study was performed in 90 healthy fetuses at between 23 and 35 weeks of gestation. A bi-dimensional axial scan of the brain, including the thalami and cavitas septi pellucidi was obtained. The circle of Willis was visualized using color flow mapping. Pulsed-wave Doppler velocimetry of the MCA was performed close to the artery's origin, with a beam-vessel angle below 20 degrees . A table with the multiples of the median (MoM) of the MCA-PSV for each gestational age was generated and Pearson's correlation coefficient (r) was calculated. Regression modeling across gestational age was performed to obtain the reference values. RESULTS: There was a strong correlation between the MCA-PVS and gestational age (r = 0.70; p < 0.001). Values for the MCA-PSV for the following MoM were calculated: 1.0, 1.29, 1.50, and 1.55. The MCA-PSV 2.5(th) and 97.5(th) centiles ranged from 24.33 cm(2)/s to 78.36 cm(2)/s, respectively, between weeks 23 and 35. CONCLUSIONS: A nomogram for the fetal MCA-PSV during the second half of pregnancy was generated.

Avaliação do comportamento fetal por meio da ultrassonografia de quarta dimensão: conhecimento atual e perspectivas futuras / Assessment of fetal behavior using four-dimensional ultrasonography: current knowledge and perspectives

Durante as últimas décadas, o desenvolvimento da ultrassonografia em tempo real tem possibilitado a visibilização direta do feto no útero, bem como a avaliação de sua atividade. Com o advento da ultrassonografia tridimensional (3D) no final dos anos 1980, iniciou-se uma nova era no diagnóstico por imagem em Obstetrícia, ampliando-se sobremaneira a possibilidade do estudo fetal. Recentemente, uma técnica que permitiu que a imagem 3D fosse transformada em um modo em tempo real foi introduzida e tem sido chamada de ultrassonografia em quarta dimensão (4D), a qual permite o monitoramento contínuo da face fetal e de outras áreas da superfície do feto, como, por exemplo, suas extremidades. Alguns estudos já se ocuparam em avaliar esta nova metodologia na observação do comportamento fetal durante diferentes estágios da gestação, na tentativa de melhor entender as relações entre a maturação do sistema nervoso central do feto e suas implicações em seu padrão de comportamento. No presente artigo, os autores realizam uma revisão sobre o uso atual da ultrassonografia 4D na avaliação do comportamento fetal, discorrendo sobre as perspectivas da técnica em espelhar, por meio da observação de padrões de movimentos e expressões faciais, o desenvolvimento neurológico do feto, destacando as potenciais aplicabilidades dessa tecnologia como nova área de pesquisa em medicina fetal.

In the last decades, the development of real-time ultrasonography has allowed the direct view of the fetus in the uterus, as well as assessing its activity. The advent of threedimensional ultrasonography (3D) at the end of the 80s initiated a new era in diagnostic imaging for Obstetrics, dramatically increasing the possibility of studying the fetus. Recently, a new technique allowing the 3D image to be transformed into real-time was introduced: the four-dimensional (4D) ultrasonography. It allows the continuous monitoring of fetal face and other surface areas, such as the extremities. Some studies have already assessed this new methodology for fetal behavior observation during different stages of pregnancy, trying to understand better the relationship between fetal central nervous system maturation and the implications for its behavior. In this article, the authors review the current use of 4D ultrasonography in the assessment of fetal behavior, and discuss the possibilities of the technique to show the neurological development of the fetus, by means of watching movement and facial expressions. They also highlight the potential applicability of this new method in this new research area of fetal medicine.

Achados radiológicos em pacientes portadores de apneia obstrutiva do sono / Radiological findings in patients with obstructive sleep apnea

A apneia obstrutiva do sono (AOS) é caracterizada por obstruções recorrentes das vias aéreas superiores durante o sono que ocorrem no nível da faringe. Apesar de a análise cefalométrica ser um importante método no diagnóstico das deformidades craniofaciais, a TC e a ressonância magnética vêm se destacando como os principais métodos de imagem para a investigação das eventuais causas da AOS que, na maioria das vezes, é multifatorial. Esses métodos permitem uma excelente avaliação nos diversos planos anatômicos do eventual sítio da obstrução, o que permite uma melhor avaliação clínica e abordagem cirúrgica. O presente ensaio pictórico tem como objetivo descrever os aspectos que devem ser avaliados no diagnóstico por imagem dos principais fatores predisponentes para a AOS.

Obstructive sleep apnea (OSA) is characterized by recurrent upper airway obstruction occurring at the level of the pharynx during sleep. Although cephalometric analysis is an important method in the diagnosis of craniofacial deformities, CT and magnetic resonance imaging have been highlighted as the major imaging methods to investigate the possible causes of OSA, which, in most cases, is multifactorial. Magnetic resonance and CT both allow an excellent evaluation of the various anatomical planes of the site of obstruction, which enables better clinical assessment and surgical approach. This pictorial essay aims to describe the aspects that must be evaluated in the diagnostic imaging of patients presenting with the major predisposing factors for OSA.

Placenta: angiogenesis and vascular assessment through three-dimensional power Doppler ultrasonography.

The placenta is fundamental for fetal development. It combines the functions of an endocrine organ, kidneys, lungs and intestines, purifying catabolites, oxygenating and nourishing the conceptus. Its fetal portion is the largest part develops from the chorionic sac. The maternal portion, which is smaller, is originated in the endometrium, more specifically in the decidua basalis. The placenta starts its function closer to the fourth week of gestation, when anatomical arrangements for the physiological exchanges are already established. The circulatory function of the placenta appears at an early stage of embryo-placental development and it is strongly related to fetal growth, to the placental size and to uterine and umbilical blood flows. Therefore, an adequate placental angiogenesis is critical for the establishment of a normal placental vascularization with consequent normal development of the fetus. In this review article, the authors discuss about placental ontogeny, focusing on the main aspects of its normal development, and about the recent advances in ultrasonography for the study of the vascular architecture of the placenta through three-dimensional power Doppler ultrasonography.

XI VOCAL (eXtended Imaging VOCAL): a new modality for three-dimensional sonographic volume measurement.

INTRODUCTION: The important technological evolutions that three-dimensional ultrasonography devices have gone through in the last years have brought great benefits for the volumetric measurement of fetal organs and structures. In clinical practice, three-dimensional volumetry has helped to identify abnormalities in fetal compartment and other related organs, assisting in the diagnosis and risk estimation of several pathological conditions in fetal medicine. AIM: The authors describe a new methodology for volumetric calculation through three-dimensional ultrasonography called eXtended Imaging VOCAL (XI VOCAL), which is part of the software Three-dimensional eXtended Imaging (3DXI). This software virtualizes real organs, by analyzing the volume through a diagram of slice sections (Multi-slice view) that simultaneously shows a sequence of images in parallel planes, and establishes the volume of the organ. Because of the importance of accurate volumetric measurements in obstetric ultrasonography, a new method allowing this measurement should be regarded as of great interest.

Treatment of twin reversed arterial perfusion sequence by septostomy and amniodrainage: a case report.

INTRODUCTION: An acardiac fetus is the most severe malformation seen in humans. It is an extremely rare complication, occurring in approximately 1% of all monozygotic twin gestations, with an incidence of about 1 in 35,000 births. This malformation happens as a result of the syndrome of reversed arterial perfusion of the acardiac twin from the other normal fetus (pump twin), due to the presence of arterio-arterial anastomoses in a monochorionic placenta. Several obstetric and perinatal complications have been associated to this anomaly and several treatments have been proposed to reduce the morbimortality of the pump twin. There's no report in MEDLINE about the treatment of twin gestations with acardiac fetus through septostomy. CASE REPORT: The present article reports a case of reversed arterial perfusion sequence complicated by polyhydramnios diagnosed at 19th week of pregnancy, treated with septostomy and serial amniodrainage. DISCUSSION: This case presented it demonstrate favorable development of the gestation, with labor happening at 35 weeks gestation and pump twin presenting good vitality conditions. In cases with no major factors of bad prognosis, septostomy combined with amniodrainage could be an interesting therapeutic option for a safe and efficacious management of selected cases of TRAP sequence.

Septostomy with amniodrainage in the treatment of twin-to-twin transfusion syndrome: a 16-case report.

OBJECTIVE: To report the treatment results of 16 monochorionic and diamniotic gestations cases, which had complications due to the twin-to-twin transfusion syndrome (TTTS), the neonatal and other possible complications of the septostomy associated to the amniodrainage. METHOD: Based on ultrasonographic findings, 16 pregnant women were diagnosed with the twin-to-twin transfusion syndrome (TTTS). These cases were divided in two groups: one of them included the fetuses without hydrops and the second included the "recipient" fetuses with hydrops. The therapy measures included septostomy with or without amniodrainage. The following parameters were evaluated: gestational age at the time the septostomy was performed, volume of drained amniotic fluid, gestational age at delivery, birth weight, postnatal evolution, and procedure complications. RESULTS: The average gestational age for this procedure was of 23.6 weeks (from 14 weeks and 1 day to 33 weeks). The gestational age for the septostomy until the delivery was of 8.18 weeks (from 1.0 to 21.3 weeks). The survival rate in the group without hydrops was of 68.7%, while in the second group it was of 25%. Some of the complications were as follows: two cases of premature membrane rupture and one case of preterm labor. CONCLUSION: Septostomy with amniodrainage, when performed on the initial stages and on earlier gestational ages has good perinatal results.