胎盘间叶发育不良的超声诊断及鉴别诊断

目的探讨胎盘间叶发育不良的超声声像图特征及鉴别诊断要点。 方法分析2013年1月至2017年12月在首都医科大学附属北京妇产医院超声检查并经手术及病理证实为胎盘间叶发育不良患者的超声声像图特征,总结胎盘间叶发育不良超声诊断及鉴别诊断要点。 结果6例胎盘间叶发育不良在不同妊娠阶段表现为不同的超声特征：妊娠12周前后胎盘非均质弥漫性增厚,胎盘实质内出现微小囊性病变,直径小于1 mm;至妊娠22周前后囊性病变扩张最显著,主要超声特征是胎盘子面局部蜂窝状低回声区,与正常胎盘组织分界清晰,病变区内大小不等的囊性回声多数呈长圆形,平行于胎盘长轴分布;随后病变区囊性改变逐渐缩减,至妊娠28周前后病变区逐渐缩至与妊娠12周前后相似状态,但与周边正常胎盘组织分界清晰,部分病例出现脐静脉迂曲扩张等表现。1例合并Beckwith-Wiedemann综合征,胎儿脐膨出。 结论胎盘间叶发育不良有特征性的超声表现及规律的疾病演变过程。胎盘间叶发育不良与葡萄胎的预后不同,因此二者的鉴别诊断非常重要,超声在胎盘间叶发育不良的早期诊断中具有重要价值。     

Placental mesenchymal dysplasia associated with trisomy 13: sonographic findings

Placental mesenchymal dysplasia (PMD) is a rare placental abnormality with sonographic and macroscopic features similar to those seen in a partial hydatidiform mole, and which has usually been reported with a normal female karyotype. We report a case of prenatally suspected PMD associated with trisomy 13. Sonography performed at 17 weeks' gestation showed multiple cystic spaces in the placenta resembling molar tissue, and a fetus with postaxial polydactyly and an atrial septal defect. An amniocentesis revealed a fetal karyotype of 46,XY,der(13), t(13;13)(q11;q11)[20]/47,XY,+13[11], consistent with trisomy 13. Cordocentesis confirmed the cytogenetic diagnosis. Histopathologic examination of the placenta following termination of the pregnancy at 22 weeks' gestation showed enlarged stem villi with loose connective tissue and cistern formation and no evidence of trophoblastic hyperplasia or stromal trophoblastic inclusions, which was consistent with PMD. PMD should be considered in the differential diagnoses of a placenta showing multiple cystic lesions on prenatal sonography, and karyotypic analysis should be performed.     

Interobserver Reproducibility of Transabdominal 3‐Dimensional Sonography of the Fetal Brain

Objective. The purpose of this study was to assess the interobserver reproducibility of transabdominal 3‐dimensional (3D) fetal neurosonography. Methods. This was a prospective observational study. We studied 23 consecutive singleton pregnancies between 18 and 23 weeks' gestation. All cases had normal fetal neurosonographic examination findings, which were confirmed after birth. A 3D sonographic volume of the fetal head was acquired transabdominally by a single operator using an axial approach. Fetal brain anatomy was later analyzed offline by 2 different operators. Axial, sagittal, and coronal views of the fetal brain were obtained to perform a detailed evaluation of the fetal brain. Each operator defined the scanning planes obtained as adequate or inadequate. Results were evaluated with 2 × 2 tables and the Cohen κ coefficient to assess interobserver agreement. Results. Good‐quality multiplanar images were obtained in 23 of 23 cases. The rate of adequate visualization was 100% for all of the axial planes, with κ values of 1.00. For sagittal and coronal planes, the rate of visualization ranged between 78% and 91%, with κ values ranging between 0.61 and 0.83. Conclusions. Transabdominal 3D sonography of the fetal brain at 18 to 23 weeks' gestation has an acceptable degree of interobserver reproducibility.     

A Method to Visualize 3‐Dimensional Anatomic Changes in the Cervix During Pregnancy

Objective. The purpose of this study was to develop a method to visualize 3‐dimensional (3D) anatomic changes in the cervix and lower uterine segment during the antepartum period. Methods. An observational study of patients with both uncomplicated and complicated pregnancies was performed. To visualize 3D anatomic changes, solid models were constructed from 3D sonographic data. Model construction followed a 3‐step protocol. First, 3D transvaginal sonographic data of the cervix and lower uterine segment were obtained. Second, sonographic data were exported to a medical image‐processing program, which was used to align 3D sonographic data obtained from a single patient at different time points. Last, sonographic data were used to guide construction of solid models using mechanical design software. Anatomic changes were visualized by comparing solid models constructed from sonographic data obtained at different time points. Results. From 16 patients who consented, 5 patients were selected for this study. Two to 4 models were derived from each of the 5 patients at 15 to 38 weeks' gestation. To show anatomic changes in the cervix and lower uterine segment, solid models from different time points in the same patient were superimposed. A total of 16 solid models were constructed. In addition, 3D changes associated with second‐trimester cervical failure and successful therapeutic cerclage were shown. Conclusions. A method to visualize 3D cervical changes is presented, revealing complex anatomic changes in the lower uterine segment, cervical stroma, and cervical mucosa as pregnancy progresses.     

Sonographic diagnosis of a viable abdominal pregnancy with planned delivery after fetal lung maturation

We report a case of a viable abdominal pregnancy with successful outpatient management until fetal lung maturation and planned delivery. Advanced abdominal pregnancy is a very rare extrauterine pregnancy, which results in serious maternal and fetal morbidity. A 28‐year‐old nullipara was referred from the local clinic to our tertiary center at 18 weeks' gestation. We diagnosed an extrauterine fetus on sonographic examination. The patient had weekly antenatal sonographic examinations. We performed a planned laparotomy at 34 weeks' gestation, and a female baby weighing 2,100 g was delivered. The placenta was completely removed and the uterus was preserved. Both the mother and the baby had no postoperative morbidity. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound 41 :563–565, 2013.     

Transient Distention of Right Posterior Located Sigma,a New Sonographic Sign for the Prenatal Diagnosis of Anal Atresia

We describe a new sonographic sign for the detection of anal atresia in the early midtrimester on transvaginal sonography. In six cases of fetal anal atresia, the finding of a transient, distended, and right‐sided sigmoid colon was observed at 13–16 weeks' gestation. Three cases have undergone pregnancy termination due to multiple anomalies. In the other three, the colonic distension resolved by 19 weeks' gestation. In two of these, the finding was isolated, and no other anomalies were detected. In all six cases, anal atresia or cloaca was confirmed on postabortal autopsy or after delivery. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :160–162, 2017     

Cervical varices: An unusual source of first‐trimester hemorrhage

Endocervical varices are a rare cause of obstetrical hemorrhage. Usually presenting in the second and third trimesters, bleeding varices often require pregnancy termination or indicated preterm birth via cesarean delivery. Our patient experienced variceal hemorrhage at 12 weeks' gestation in a dichorionic twin pregnancy conceived through in vitro fertilization. A low‐lying placenta resolved at 19 weeks followed by variceal regression at 22 weeks' gestation. Endocervical varices causing first‐trimester hemorrhage may regress with resolution of a coexisting low placental implantation, permitting planned vaginal delivery, despite progressive hemodynamic changes of pregnancy. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46 :218–221, 2018     

Metastatic neuroblastoma diagnosed on prenatal sonographic examination performed for decreased fetal movement

We report a case of fetal neuroblastoma presenting with massive liver metastasis diagnosed during the biophysical profile sonographic examination performed for decreased fetal movement. The patient presented at 37 weeks' gestation with limited fetal movement over 24 hours. Biophysical profile showed marked polyhydramnios and an enlarged abdomen filled with a homogeneous mass lesion suspicious for liver metastasis. Primary urgent cesarean section was performed revealing a cachectic neonate with a rigid and grossly distended abdomen. Neonatal evaluation confirmed the etiology of the abdominal mass to be liver metastasis from neuroblastoma. The child died on the 46th day. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45 :502–506, 2017     

Clinical Findings of Multiple Pregnancy With a Complete Hydatidiform Mole and Coexisting Fetus

Objective. The aim of this series was to evaluate the clinical features, management, and outcomes of multiple pregnancy with a complete hydatidiform mole and coexisting fetus (CHMCF). Methods. Between 1998 and 2008, we investigated 6 women with a diagnosis of a CHMCF. The gestational age at diagnosis, symptoms, serum b‐human chorionic gonadotropin levels, cytogenetic and molecular analysis findings, complications, routes of delivery, and pregnancy outcomes were assessed. Results. All cases were diagnosed before 14 weeks' gestation by sonography. Only 1 ended with the delivery of a live‐born neonate, whereas the other 5 cases required termination of pregnancy (TOP) before 21 weeks' gestation because of severe maternal complications (eg, preeclampsia, thyrotoxicosis, lung metastasis, and heavy bleeding) or intrauterine fetal death. The pathologic diagnosis of a complete hydatidiform mole was confirmed in all cases. Two patients required methotrexate for treatment of persistent trophoblastic disease (PTD). Conclusions. On the basis of our experience, in cases with a normal karyotype and no gross fetal abnormalities on sonography, we carefully recommend continuation of pregnancy as long as maternal complications are absent or controllable. However, updated treatment criteria are still needed, and intensive maternal follow‐up is necessary in the postpartum period because maternal complications during pregnancy and PTD after TOP are not uncommon.     

Sonographic Findings of Acute Vasitis

Objective. The purpose of this study was to describe the sonographic findings of acute vasitis. Methods. This was a retrospective analysis of 12 cases of acute vasitis. The following gray scale and color Doppler sonographic features were analyzed: location, echogenicity of the lesion, presence of hydrocele, epididymal involvement, and blood flow within the lesion. Results. Of the 12 patients, 10 had acute vasitis in the scrotal segment; 1 had acute vasitis in the suprascrotal segment; and 1 had acute vasitis in both the scrotal and suprascrotal segments. The sonographic finding for acute vasitis of the scrotal segment was a heterogeneously hypoechoic appearance of the vas deferens (n = 11). The vas deferens was thickened (6.4 mm in diameter) in the 2 patients with suprascrotal involvement; it was heterogeneously hypoechoic in 1 and had a normal appearance in the other. On color Doppler sonography, the degree of blood flow was increased in all of the cases. Of the 12 patients, 11 had inflammation of the epididymis. Conclusions. Acute vasitis usually presents with infection combined with acute epididymitis, and it usually appears as a heterogeneously hypoechoic lesion in the scrotal segment, suprascrotal segment, or both.     

Prenatal diagnosis of robinow syndrome: A case report

Robinow syndrome, also known as fetal face syndrome, is a rare genetically heterogeneous condition characterized mainly by mesomelic limb shortening, facial malformations, and genital abnormalities. This report describes the sonographic findings in a case of autosomal‐dominant Robinow syndrome diagnosed at 23.1 weeks' gestation, in a patient with no history of affected relatives. Here we describe the sonographic characteristics of this syndrome from the diagnosis until birth. The prenatal and postnatal findings, the differential diagnosis, and the prognosis of patients with this syndrome are discussed. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound, 42 :297–300, 2014     

Solid masses on the fetal surface of the placenta: differential diagnosis and clinical outcome.

We identified 10 cases of solid masses on the fetal surface of the placenta prospectively that were thought to represent chorioangiomas. Pathologic assessment of the placenta revealed five chorioangiomas and five placental hemorrhages. The five chorioangiomas ranged in size from 4 to 10 cm and four of these five fetuses were delivered uneventfully at term. Only one fetus showed evidence of cardiac decompensation and did not survive. Three of the five women with placental bleeds delivered their infants between 33 and 34 weeks' gestation, but all five infants did well. This series shows that the sonographic appearance of chorioangioma was indistinguishable from placental hemorrhage, and even large chorioangiomas may be associated with good neonatal outcome.     

Development of the Fetal Spinal Cord

Objective. The purpose of this study was to perform high‐resolution sonographic examinations to determine the normal anatomic relationship of the conus medullaris (CM) of the spinal cord with the vertebral column during different stages of gestation. Methods. In this prospective study, fetal sonographic evaluations were performed between 13 and 40 weeks' gestation. Transvaginal probes (7.5–8 MHz) or abdominal probes (5–8 MHz) were used, depending on gestational age and position of the fetus. The CM was located in coronal longitudinal sections. The positions of the kidneys and lumbosacral junction and the origin of the ribs determined the location of the vertebrae. The locations of the CM were divided into 5 groups according to their positions relative to the vertebrae. Results. A total of 110 fetuses between 13 and 40 weeks' gestation were studied. Between 13 and 18 weeks' gestation, the CM was situated at the level of the L4 vertebra, or more caudally, in 100% of the fetuses. At term, all fetuses showed the CM above L2. A distinct ascent of the CM was detected between 13 and 40 weeks' gestation. The results were statistically significant (P <.0001). Conclusions. A distinguishable ascent of the CM in relation to the vertebral column during fetal life was detected.     

Two- and three-dimensional sonographic diagnosis of fetal intra-abdominal umbilical vein varix: A case report

Fetal intra‐abdominal umbilical vein varix is a rare condition characterized by focal dilatation of the umbilical vein of the fetus. We report a case of fetal intra‐abdominal umbilical vein varix associated with additional sonographic abnormalities and detected at 31 weeks' gestation. Several follow‐up sonographic examinations were performed, and the prenatal findings were confirmed on postnatal ultrasound. The diagnosis was facilitated by the use of three‐dimensional power Doppler sonography. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2012;     

A rare giant placental chorioangioma with favorable outcome: A case report and review of the literature

We describe a rare giant placental chorioangioma in a patient who had a favorable outcome with close prenatal surveillance in a 28‐year‐old primigravida who was referred to our clinic for ultrasound evaluation of a suspected placental mass at 23 weeks' gestation. A detailed ultrasound scan revealed a well‐circumscribed, echogenic lesion measuring 11.0 × 10.3 × 7.3 cm and protruding into the amniotic cavity. A diagnosis of placental chorioangioma was made and intensive prenatal surveillance was scheduled. A small‐for‐gestational age (2,325 g) but normal female neonate was delivered at 37 weeks by cesarean section and discharged from hospital on the second day of the delivery. A giant chorioangioma may not cause any adverse effect to the fetus and may not require any medication or invasive intervention. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43 :254–256, 2015     

Placenta previa—is the traditional diagnostic approach satisfactory?

The accuracy of the diagnosis of placenta previa using transvaginal sonography (TVS) was compared to that of the traditional transabdominal sonography (TAS). Seventy seven women were scanned by both methods and each sonographic diagnosis was compared to the placental location at delivery. TVS was superior to TAS in diagnosing placenta previa and invariably correct in ruling it out. TVS (and TAS) failed to predict the placental location at delivery only in women diagnosed as having marginal placenta previa prior to 35 weeks gestation. The use of the vaginal probe significantly improved the accuracy of the diagnosis of placenta previa.     

Is Transabdominal Sonography of the Cervix After Voiding a Reliable Method of Cervical Length Assessment?

Objective. The purpose of this study was to assess the correlation and agreement between transvagi‐nal and transabdominal cervical length measurement after bladder emptying as well as the feasibility of transabdominal sonography in cervical length screening. Methods. This was a prospective cohort study involving 287 participants (14–34 weeks' gestation) from January to December 2003. After voiding, transabdominal and transvaginal cervical length measurements were obtained. The optimal trans‐abdominal technique was established during an unblinded series of transabdominal and transvaginal cervical length measurements (n = 96). The same measurements were obtained in 191 participants under a blinded 2‐sonographer protocol. The transabdominal cervical length cutoff to ensure 100% sensitivity in detecting a short cervix (≤2.5 cm) was determined. Results. There was no difference between mean transabdominal and transvaginal cervical lengths ± SD (3.57 ± 0.74 versus 3.61 ± 0.74 cm; P = .20). The Pearson correlation coefficient was 0.824. The 95% tolerance interval for any paired observation (transabdominal minus transvaginal) was ?0.92 to 0.84 cm. All transvaginal cervical lengths of 2.5 cm or less were associated with paired transabdominal cervical lengths of 3 cm or less. Conclusions. With an optimal sonographic technique, postvoid transabdominal cervical measurement shows a close correlation and agreement with transvaginal assessment and is useful for cervical length screening.     

Three‐Dimensional Ultrasonography of the Fetal Vermis at 18 to 26 Weeks' Gestation

Objective. The purpose of this study was to establish the normality of the fetal vermis, ie, the time of appearance of the primary fissure, as well as its measurements between 18 and 26 weeks' gestation, using 3‐dimensional (3D) ultrasonography. Methods. A prospective cross‐sectional study of normal singleton pregnancies was conducted. Examinations were performed with high‐resolution transabdominal ultrasonography using the axial plane in 173 fetuses between 18 and 26 weeks' gestation. Postprocessing measurements of the fetal vermis were done with 4‐dimensional software using static volume contrast imaging and tomographic ultrasound imaging in the C‐plane. Detection of the primary fissure was evaluated in all cases, and the time of appearance was documented. Results. Adequate vermis measurements were obtained in 173 fetuses. Vermian length as a function of gestational age was expressed by regression equations, and the correlation coefficients were found to be highly statistically significant (P < .001). The normal mean ± 2 SD for each gestational week was defined. The primary fissure was observed at 24 weeks' gestation in all cases, at 22 weeks in 94% of cases, and as early as 18 weeks in 40%. Conclusions. This 3D study documents the appearance of the primary fissure and presents the normal range of vermian measurements, confirming normal development of the fetal vermis starting as early as 18 weeks' gestation. It also shows an easy method for visualizing the vermis with 3D ultrasonography at every gestational week regardless of fetal presentation.     

First-Trimester Placental Volume and Vascularization Measured by 3-Dimensional Power Doppler Sonography in Pregnancies With Low Serum Pregnancy-Associated Plasma Protein A Levels

Objective. The purpose of this study was to investigate the first-trimester placental volume and 3-dimensional (3D) power Doppler vascularization of pregnancies with low serum pregnancy-associated plasma protein A (PAPP-A) levels and to relate these findings to pregnancy outcomes. Methods. Three-dimensional power Doppler sonography of the placenta was performed at gestational ages of 11 weeks to 13 weeks 6 days in 84 pregnancies with PAPP-A concentrations of less than 0.4 multiple of the median (MoM). With a standardized setting, the placental volume and vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated and related to pregnancy outcomes. Results. Pregnancy outcomes were as follows: 57 pregnancies with birth weights at or above the 10th percentile (group A), 16 pregnancies with birth weights below the 10th percentile and normal Doppler findings in the umbilical artery throughout gestation (group B), and 11 pregnancies with birth weights below the 10th percentile and abnormal umbilical Doppler findings later in gestation (group C). No differences were found in PAPP-A levels among groups. Placental volume values were significantly lower than reference limits, but no differences were found between groups. In groups A and B, there were no significant differences in 3D Doppler indices. However, these indices were significantly lower in group C (VI mean difference, −1.904; P < .001; FI mean difference, −1.939; P < .001; VFI mean difference, −1.944; P < .001). Placental vascular indices were significantly related to the severity of intrauterine growth restriction (IUGR; VI, r = 0.438; P < .001; FI, r = 0.482; P < .001; VFI, r = 0.497; P < .001) but not to the PAPP-A MoM and placental volume values. Conclusions. Low serum maternal PAPP-A levels are associated with altered 3D placental Doppler indices, and these changes are related to subsequent development of IUGR and adverse pregnancy outcomes.     

Association of Crown‐Rump Length at 11 to 14 Weeks' Gestation and Risk of a Large‐for‐Gestational‐Age Neonate

Objective. The purpose of this study was to evaluate the association between crown‐rump length (CRL) and the risk of a large‐for‐gestational‐age (LGA) neonate. Methods. Data were retrospectively collected on consecutive women with a healthy singleton pregnancy followed to delivery at our center from 2003 to 2006 who underwent nuchal translucency, pregnancy‐associated plasma protein‐A, and free β‐human chorionic gonadotropin screening at 11 to 14 weeks' gestation. Pregnancies were dated by the last menstrual period (LMP) confirmed by CRL at 6 to 10 weeks or the known time of fertilization. The fetal CRL at 11 to 14 weeks was obtained from frozen sonographic images. The measured CRL was converted to gestational weeks using the method of Hadlock et al (Radiology 1992; 182:501–505). The expected gestational age (GA) by the LMP was subtracted from the measured GA to yield the ΔCRL. The association between the ΔCRL and birth weight was statistically analyzed. Results. The sample included 521 women. Fifty neonates (9.6%) were LGA (≥90th percentile), 38 (7.3%) small for gestational age, and 433 (83.1%) appropriate for gestational age. The LGA group was characterized by significantly larger‐than‐expected CRL measurements (P = .033). The birth weight percentile and rate of LGA neonates were significantly higher in pregnancies in which the ΔCRL was ½ week or greater (P = .007 and .033, respectively). There was a significant linear correlation between the ΔCRL and birth weight percentile (P = .001). On multivariate logistic regression analysis, the ΔCRL was the only significant predictor of an LGA neonate (odds ratio, 1.6; 95% confidence interval, 1.07–2.4; P = .023). Conclusions. Pregnancies with LGA neonates are characterized by larger‐than‐expected CRL measurements at 11 to 14 weeks' gestation.