Correlation of ultrasound findings and biochemical markers in the second trimester of pregnancy in fetuses with trisomy 21

OBJECTIVE: The aim of the present study was to assess possible correlations between ultrasound findings and maternal serum biochemical ('triple test') markers among fetuses with trisomy 21 in the second trimester of pregnancy. METHODS: The study was a retrospective cohort study of 72 pregnancies affected by trisomy 21 who had a second trimester ultrasound and biochemical screen performed at a single center between 1990 and 1999. The biochemical screen consisted of alpha-fetoprotein (AFP), total beta human chorionic gonadotrophin (hCG) and estriol (uE(3)). Marker levels were expressed in multiples of the median (MoM). The ultrasound findings assessed were major structural anomalies, short humerus length, short femur length, increased nuchal fold thickness (NF), hyperechoic bowel, echogenic intracardiac focus (EIF), ventriculomegaly, choroid plexus cysts and renal pyelectasis. RESULTS: Second trimester maternal serum biochemical markers and ultrasound findings appeared to be largely independent of each other. However, some significant correlations were observed. Estriol was significantly lower when a fetal cystic hygroma was detected on ultrasound compared to those with no cystic hygroma (0.40 vs. 0.70 MoM, p<0.05). The median hCG level was significantly lower in those pregnancies with a normal second trimester fetal ultrasound compared to those with positive ultrasound findings (2.07 vs. 2.87 MoM, p<0.05). Median hCG levels were also significantly higher in those cases with NF> or =5 mm as compared to those with NF<5 mm (2.99 vs. 2.49 MoM, p<0.05). This difference persisted after exclusion of the five cases with cystic hygromas (2.99 vs. 2.49 MoM, p<0.05). A significant positive correlation was observed between log(10) hCG and log(10) NF MoM (Spearman's rho=0.252, p<0.05). NF was significantly greater among fetuses with an identifiable cardiac defect compared with those without a detectable cardiac defect (median of 7.0 mm vs. 3.8 mm, p<0.01). This difference persisted when expressed as multiples of the median (2.8 vs. 1.3 MoM, p<0.01). CONCLUSION: Second trimester ultrasound and biochemical markers are largely independent in fetuses with trisomy 21, however significant correlations between the two were observed in the present series. These may be important in screening protocols that combine second trimester ultrasound and biochemical markers.     

Risks of fetomaternal hemorrhage resulting from amniocentesis with and without ultrasound placental localization.

The incidence of multiple abdominal punctures, blood-stained aspirates, and fetomaternal transfusion was compared in patients undergoin amniocentesis at various stages of pregnancy with and without prior placental localization by ultrasound. A lower incidence of complications was found in those on whom ultrasound examination had been performed.     

Ectopic Pregnancy — Potentials for Diagnosis Using Ultrasound and Urine and Serum Pregnancy Tests

The ultrasound findings from 260 patients with a clinical suspicion of ectopic pregnancy have been analysed and correlated with the results of urine pregnancy tests and tests of serum LH and/or HCG levels. Most importantly in a practical clinical context, it was found that a negative serum test virtually excludes an ectopic pregnancy, and an empty uterus with an adnexal mass and/or the presence of free fluid together with a positive urine test gives a very high probability of an ectopic pregnancy. The absolute diagnosis of an ectopic pregnancy by the demonstration of a living fetus outside the uterus is an uncommon finding (8%). Conversely, an empty uterus alone on ultrasound examination in the absence of other ultrasound findings in those patients with a positive serum test is not a reliable guide to the presence of an ectopic pregnancy unless there is an irrefutable conception date at least 5 weeks previously. It is recommended that pathology laboratories and ultrasound departments establish absolute levels of HCG above which an intrauterine pregnancy should always be visible within the uterus. Given appropriate attention to the clinical condition of the patient, the combined use of diagnostic ultrasound, simple urine pregnancy tests and serum assays of beta HCG levels goes a long way to discriminating between those patients with and those without an ectopic pregnancy.     

beta-Subunit of human chorionic gonadotropin, ultrasound, and ectopic pregnancy: a prospective study

This prospective study shows that the beta-subunit of human chorionic gonadotropin (beta-hCG) "screen" and ultrasound provide for nearly 100% clinical accuracy in diagnosing ectopic pregnancy in suspected cases. During the 14 months from February, 1981, to April, 1982, 81 consecutive patients believed to have ectopic pregnancies were screened. Fifty-six had a negative beta-hCG screen, thus ruling out early pregnancy complications. No false negative results were found. Twenty-seven patients had a positive screen, and 16 of these had an ectopic pregnancy. Twenty of the 27 patients with a positive beta-hCG screen underwent pelvic ultrasound examination. All of those with a positive beta-hCG screen and no intrauterine pregnancy on ultrasound had ectopic pregnancies. With the use of these clinical aids, morbidity and tubal damage are reduced because delay in operating upon those with ectopic pregnancy is avoided. Unnecessary operation is avoided in those patients who do not have an ectopic pregnancy.     

Normal and abnormal fetal cardiac anatomy

The heart is often perceived as a difficult organ to understand by ultrasound during fetal life. This is undoubtedly reflected in the low detection rate of cardiac abnormalities as compared to those of most other organ systems in the fetus. In this article we start by updating classical concepts of cardiac embryology, many of which were previously difficult to understand since they were overly simplistic or purely observational. We then lead on to the structure and growth of the fully formed fetal heart where we review the anatomy and ultrasound appearances in detail and provide comparisons with major abnormalities. We emphasise the fact that a solid understanding of cardiac anatomy can enable those involved in fetal medicine to make full use of the views of the heart that are obtained by ultrasound and which are often only transient.     

Fertilization and embryo development of oocytes obtained transvaginally under ultrasound guidance

The widespread use of ultrasound for follicle development assessment and ovum pickup has raised concerns about the theoretical possibility of adverse effects on oocyte function. Studies in other species do not demonstrate any adverse effects when using sonic energies as those presently used in diagnostic ultrasound. However, no data are available concerning the effects of diagnostic ultrasound on human preovulatory oocytes. This study was conducted to determine whether there were any adverse effects on the reproductive function of oocytes using transvaginal ultrasonography. No effect on fertilization and subsequent cleavage of oocytes was demonstrated. This method can, therefore, be recommended for follicle assessment and as a better alternative to laparoscopy for oocyte retrieval.     

How often does office hysteroscopy reveal pathology not previously noted on transvaginal ultrasound—a look at two typical reproductive endocrinology patient groups,including failed IVF–ET patients

Transvaginal ultrasound and office hysteroscopy are established diagnostic tools for the evaluation of infertility patients, with hysteroscopy often considered as the more precise method to evaluate the uterine cavity and ultrasound as the more readily available and less invasive method. We look at both methods in two typical infertility patient groups, including one group with a history of failed in vitro fertilization–embryo transfer (IVF–ET) cycles. Eighty patients were prospectively evaluated. Forty patients presented with a history of failed embryo transfer despite repeat normal transvaginal ultrasound examinations. Forty infertility patients with abnormal ultrasound testing served as a group for comparison. All patients underwent office hysteroscopy. In the subgroup with abnormal ultrasound findings, office hysteroscopy confirmed the diagnosis in 75% of cases but did not add new information. In patients with a history of failed embryo transfer and at least twice normal ultrasound examinations, only 1/40 patients (2.5%) was noted to have a minor abnormality on office hysteroscopy not previously diagnosed on ultrasound. In infertility patients, including those with a history of failed IVF–ET cycles, repeat normal transvaginal ultrasound appears to be an efficient method for the determination of significant intrauterine abnormalities.     

An abnormal screening ultrasound: concordance with a tertiary obstetrical ultrasound unit.

OBJECTIVE: To determine concordance of ultrasound diagnosis in referrals to a tertiary obstetrical ultrasound unit (TOU) for suspected abnormalities. STUDY DESIGN: Consecutive referrals for "abnormal outside ultrasound" during a 6-month period were compared with the TOU ultrasound diagnosis. Concordance of diagnosis was compared on the basis of organ system involved and referral for single or multiple suspected abnormalities. Chi(2) analysis was used; p < 0.05 was considered significant. RESULTS: Of 104 consecutive referrals reviewed, 42 (40.4%) had no abnormality documented at the TOU. Of the 62 abnormal ultrasound scans at the TOU, 78.3% were concordant. Concordance based on organ system involvement was central nervous system, 30.3%; cardiothoracic, 66.7%; gastrointestinal, 63.6%; genitourinary, 50%. Referrals for a single suspected anomaly were statistically no more likely to have a normal TOU ultrasound scan (40.4%) than those referred for multiple suspected anomalies (36.4%, p > 0.05). CONCLUSIONS: Most referrals to a tertiary center for "abnormal outside ultrasound" will be diagnosed with an abnormality.     

Evidence for an absence of deleterious effects of ultrasound on human oocytes

Animal and human data would suggest that ultrasound causes deleterious effects to oocytes during meiosis. We directly compared the fertilization rate and embryonic development following in vitro fertilization and embryo transfer of those oocytes exposed to ultrasound and those not exposed in the same patient. In 39 unscreened patients a combination of laparoscopy and ultrasound was used for oocyte recovery. Laparoscopy was performed first on the most accessible ovary (usually the right) and at least one oocyte was obtained. Ultrasoundguided oocyte recovery was successful in the other inaccessible ovary. To assess how oocytes obtained by ultrasound or laparoscopy related to the pregnancy rate, two groups of patients were evaluated in whom the embryos transferred either had been exposed to ultrasound or had not been. The fertilization and the embryo cleavage rates were not significantly different between the ultrasoundexposed and the unexposed groups. The pregnancy rate was also not significantly different [9 of 49 (18.4%) for ultrasound exposed versus 14 of 74 (18.9%) for unexposed]. There was one early spontaneous abortion in each group. Further analysis of a group of 40 patients, in whom the oocytes were exposed to ultrasound in situ, after the endogenous luteinizing hormone (LH) surge had begun 1–27 hr earlier, revealed that 6 became pregnant (15%). This preliminary study suggests that exposure of human oocytes to ultrasonic waves, either during the different phases of meiosis or after the completion of meiosis, did not significantly influence the developmental potential of the in vitro fertilized embryos.     

Are portable bladder scanning and real-time ultrasound accurate measures of bladder volume in postnatal women?

Real-time ultrasound and portable bladder scanners are commonly used instead of catheterisation to determine bladder volumes in postnatal women but it is not known whether these are accurate. Change in bladder volumes measured by ultrasound and portable scanners were compared with actual voided volume (VV) in 100 postnatal women. The VV was on average 41 ml (CI 29 - 54 ml) higher than that measured by ultrasound, and 33 ml (CI 17 - 48 ml) higher than that measured by portable scanners. Portable scanner volumes were 9 ml (CI -8 - 26 ml) higher than those measured by ultrasound. Neither method is an accurate tool for detecting bladder volume in postnatal women.     

The value of ultrasound examination for diagnosing postmenopausal metrorrhagia]

The results of transvaginal ultrasound diagnostic assessment of endometrium were compared with histopathological examination of endometrium by following diagnostic abrasion on examined group of 54 postmenopausal women. The method seems to be useful for diagnosis of postmenopausal metrorrhagia, when the "safe" thickness of endometrium layer is taken as 5 mm. It occurs in effect of our study the transvaginal ultrasound examination may decrease the number of subsequent diagnostic abrasions in those cases.     

Transvaginal ultrasound-guided embryo transfer improves outcome in patients with previous failed in vitro fertilization cycles

OBJECTIVE: To determine the effect of transvaginal ultrasound-guided ET in IVF cycles performed on patients who had previously failed to conceive from IVF and compare the results to previous cycles where ultrasound guidance was not used. DESIGN: Retrospective clinical study.Setting: Private practice IVF program. PATIENT(S): One hundred twenty-nine women undergoing consecutive cycles of IVF where fresh embryos were transferred. INTERVENTION(S): Transvaginal ultrasound guidance was used during transfer of embryos. MAIN OUTCOME MEASURE(s): Patient age, number of ampules of gonadotropin used, maximum E(2) level, number of oocytes retrieved, number of two pronuclei embryos obtained, number of embryos transferred, mean embryo score, implantation and pregnancy rate. RESULT(S): There was no difference in any of the clinical parameters measured in IVF cycles resulting in pregnancy when transvaginal ultrasound-guided ET was used compared to the failed cycles when there was no ultrasound guidance. Of the patients who previously had failed IVF cycles and subsequently had IVF cycles with ultrasound guidance, those who became pregnant had higher mean embryo scores than those who did not become pregnant. Overall implantation and pregnancy rates were higher during the study period when transvaginal ultrasound guidance was used than in the previous 3 years when it was not used. CONCLUSION(S): Transvaginal ultrasound-guided ET may be responsible for successful IVF cycles in patients who had previously failed to conceive when embryos were transferred by the clinical touch method. Transvaginal ultrasound guidance may also be responsible for an overall increase in embryo implantation and pregnancy compared to the use of the clinical touch method.     

Labor and membrane rupture in twin gestation. Can they affect the ability to estimate fetal weight?

OBJECTIVE: To determine whether labor or fetal membrane rupture adversely affects the ability of ultrasound to accurately estimate fetal weight (EFW) in a twin gestation. STUDY DESIGN: A medical record audit was performed of the two-year experience of women delivering live born twins and undergoing a complete ultrasound examination within 72 hours of delivery. Those patients experiencing labor or membrane rupture at the time of the previous ultrasound examination were compared to those without these factors to determine if there was any detrimental impact on the accuracy of ultrasound to EFW. RESULTS: The overall ability of ultrasound to accurately EFW was in the range of 64-76%. This was not significantly different from the accuracy in women experiencing labor (62-80%) or in women with membrane rupture (63-81%). The ability of ultrasound to detect fetal discordance is this series ranged from 78% to 100%, with specificity that ranged from 84% to 89%. CONCLUSION: The ability of sonography to accurately EFW as well as detect discordant twin gestation is not altered by the presence of labor or membrane rupture.     

Ultrasound diagnosis of complete abortion can reduce need for curettage.

One hundred and fifty-five patients presenting with signs of incomplete abortion were evaluated by ultrasound. Of these, 112 (72.26%) were found to have retained products of conception and were treated by dilatation and curettage. The remaining 43 (27.74%) were found on ultrasound to have no products of conception and were followed-up conservatively. Only one of the latter group of patients needed admission later for dilatation and curettage; this patient was found to have a small sub-mucus fibroid and endometritis. Predictive value for those not requiring D & C was 97.6%, suggesting that this test may be useful in identifying those patient who have had a complete abortion.     

A comparison of clinical assessment with ultrasound in the management of secondary postpartum haemorrhage

OBJECTIVE: To compare the diagnostic accuracy of clinical assessment with transabdominal ultrasound in the management of secondary postpartum haemorrhage (PPH). DESIGN: A prospective cohort study. METHODS: Fifty-three women who presented to a teaching hospital obstetric unit with secondary PPH were studied. Patients were divided into those in whom retained placental tissue was or was not the suspected cause of bleeding. This diagnosis was based on history/examination and transabdominal pelvic ultrasound scan. The definitive diagnosis was made following uterine evacuation or was assumed in women who stopped bleeding without surgical management. Likelihood ratio (LR) was used as an accuracy measure. RESULTS: The positive LR for clinical assessment was 5.5 (95% CI 2.7-12.1) compared with 2.4 (95% CI 1.5-3.7) for ultrasound. The negative LRs were 0.1 (95% CI 0.04-0.5) and 0.1 (95% CI 0.02-0.5) for clinical and ultrasound assessment, respectively. CONCLUSION: Clinical examination and ultrasound scan assessment have limited diagnostic accuracy in secondary PPH.     

Megacystis-microcolon-intestinal hypoperistalsis syndrome: the difficulties with antenatal diagnosis. Case report and review of the literature

Megacystis on antenatal scan in female fetuses is rare and has serious diagnostic implications. We report two cases of megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) in female infants in whom antenatal scan abnormalities were identified, but the diagnosis not made until after delivery. MMIHS is a rare autosomal recessive condition which is usually lethal in the first year of life. Prenatal diagnosis is hampered by the lack of specific diagnostic findings on ultrasound and the absence of an identified genetic locus. The prenatal findings in MMIHS are reviewed and contrasted with those of other causes of lower abdominal masses on antenatal ultrasound.     

Organisation of obstetric ultrasound in Denmark 1990.

To provide an overview of the current organisational status of obstetric ultrasound in Denmark, a questionnaire was sent in spring 1990 to all 59 departments responsible for the hospital antenatal care program and to the 25 imaging diagnostic departments providing ultrasound services for those of the 59 departments that had either insufficient or no ultrasound facilities. The response rate was 100%. Obstetric ultrasound was performed in 25 obstetric, 11 surgical, 22 radiology, 2 clinical physiology departments and 1 ultrasound laboratory (total 61). The departments had a total of 110 ultrasound scanners. The median year of purchase of these scanners was 1985 (range 1976-1990). 488 persons performed ultrasound examinations; the examiners were mainly doctors (72%). 40% of the pregnant population was routinely offered an ultrasound scan in the 15-20th week of gestation. Of these 2/5 were offered screening for fetal malformations. One department offered examinations in both the 19th and 34th week. The scanning capacity, as judged by the departments themselves, was also assessed through the study.     

Ultrasonic diagnosis of fetal life in early pregnancy.

Ultrasound methods for detecting fetal life during early pregnancy are reviewed. By using recently developed techniques, fetal heart function can be detected as early as the 44th to 45th day of amenorrhea. Fetal movements in the amniotic cavity can be visualized from the 10th week on. If no signs of fetal life can be detected by ultrasound examination by the 10th week, the pregnancy is in jeopardy. However, the prognosis is favorable in over 90% of those cases of threatened abortion in which fetal life has been confirmed by ultrasound.     

Missed abortion, and later spontaneous abortion, in pregnancies clinically normal at 7–12 wk

One thousand nine hundred and thirty-eight mothers were examined by ultrasound at 7–12 wk gestation. Eighty-three (4.28%) were found to have a dead fetus or an empty gestation sac. Twenty-five (1.29%) had a live fetus at that scan but spontaneously aborted 1–13 wk later. The earlier in pregnancy the ultrasound was carried out the more likely was the pregnancy to be dead or subsequently to abort. Mothers aged 35 or over were more likely than other women to have dead pregnancies at the initial ultrasound or subsequently to abort: those of 19 or less were less likely than other age groups to have a missed abortion but they had a rate of spontaneous abortion similar to those of 35 or more.     

Elevated maternal serum alpha-fetoprotein with normal ultrasound: is amniocentesis always appropriate? A review of 26,069 screened patients

We reviewed our experience with a policy of revising the estimated probability of an open neural tube defect for those cases in which maternal serum alpha-fetoprotein (MSAFP) was elevated and the ultrasound examination was normal. Assuming a sensitivity for the ultrasound diagnosis of neural tube defects of 90%, the risk estimate derived from the MSAFP was reduced by that amount when ultrasound was adequate and normal. When counseled regarding this revised risk estimate, 67% of our patients declined amniocentesis. The sensitivity for the ultrasound diagnosis of anencephaly in our series was 100%; for open spine defects, 80%; and for all open neural tube defects, 91%. The two patients in whom an open spine defect was not detected with ultrasound had elevated revised risk estimates. When appropriate criteria are met, the estimated sensitivity of ultrasound in diagnosing open neural tube defects may be used for counseling patients at risk for a fetus with an open neural tube defect.