Role of color Doppler imaging in diagnosing and managing pregnancies complicated by placental chorioangioma

PURPOSE: The purpose of this study was to evaluate the role of color Doppler imaging in the diagnosis and management of placental chorioangioma. METHODS: The medical records, sonographic reports, and sonograms of all pregnant women who had placental masses diagnosed in our sonography unit during the years 1992 through 2000 and had been evaluated using both gray-scale and color Doppler sonography were included in this study. Subjective evaluation of the amount and distribution of intralesional vascularity by color Doppler imaging was made in all cases. Cases of chorioangioma of the placenta were compared with cases of placental hemorrhage or subchorionic hematoma. The outcomes of the pregnancies were also recorded. RESULTS: Fifteen cases of placental masses were evaluated; 8 of them were identified as placental hemorrhage or subchorionic hematoma on the basis of the sonographic findings. The other 7 cases were identified prenatally as placental chorioangioma, at a mean menstrual age of 23 weeks and a mean maternal age of 29 years. The mean size of the tumor was 6.5 cm (range, 4-13 cm). All cases of chorioangioma showed either substantial internal vascularity or a large feeding vessel within the tumor. Three infants were delivered at term with favorable outcome; 2 of them demonstrated reduction of the intratumoral blood flow during follow-up. The other 4 cases were delivered at or before 32 weeks' menstrual age (1 intrauterine fetal death, 2 terminated pregnancies, and 1 normal infant). No case of placental hematoma demonstrated blood flow within the lesion or was associated with complications of the pregnancy. CONCLUSIONS: Color Doppler imaging helps differentiate placental chorioangioma from other placental lesions and may be useful in the prenatal follow-up of chorioangioma.     

The likelihood ratio of sonographic findings for the diagnosis of hemorrhagic ovarian cysts.

OBJECTIVE: The purpose of this study was to quantify the likelihood ratio (LR) of specific sonographic features and experienced sonologist assessment in diagnosing a hemorrhagic ovarian cyst and to better understand the diagnostic power of sonography in making this diagnosis. METHODS: Two sonologists, blinded to the patient's clinical history, independently reviewed the sonograms of 252 adnexal masses. For each mass, each sonologist recorded features using a standardized checklist, which included observations regarding the presence of fibrin strands, a retracting clot, septations, and wall irregularity. Each reviewer independently chose 1 specific conclusion from a list of possibilities that included the diagnosis of a hemorrhagic ovarian cyst. Sonographic observations and sonologist predictions were compared with pathologic findings (n = 214) or follow-up sonography (n = 38). RESULTS: Of the 252 masses, there were 30 hemorrhagic cysts. One sonologist correctly identified 25 hemorrhagic cysts, with 1 false-positive, 2 false-negative, and 3 indeterminate calls (LR 185). The other sonologist correctly identified 24 hemorrhagic cysts, with 1 false-positive, 0 false-negative, and 6 indeterminate calls (LR 178). The 2 cases incorrectly diagnosed as hemorrhagic cysts were endometriomas at pathologic diagnosis. Specific sonographic observations and combinations of observations performed as follows: retracting clot (LR >67); fibrin strands (LR 40); fibrin strands and no septations (LR 100); and fibrin strands, no septations, and smooth wall (LR 200). CONCLUSIONS: Fibrin strands and a retracting clot are paramount observations in allowing high confidence in the diagnosis of hemorrhagic ovarian cysts. Approximately 90% of hemorrhagic ovarian cysts will exhibit at least 1 of these 2 features.     

Separated chorioamnion and elevated chorion: sonographic features and clinical significance

The clinical presentation and outcome of pregnancy was analyzed in thirteen patients in whom a free-floating intrauterine membrane was found on sonography. The cases were divided into two groups: those with elevated chorion and those with chorioamniotic separation. Five of seven patients with chorioamniotic separation progressed normally to term and delivered normal infants. In the two pregnancies with chorioamniotic separation that did not progress to term, one was associated with a placental chorioangioma and the other had a dead fetus that had a cystic hygroma indicative of Turner's syndrome. Of the six patients with elevated chorion, all presented with an episode of vaginal bleeding in the early second trimester. Five of six patients with elevated chorion progressed to term with the delivery of normal infants. One patient with extensive elevation of the chorion aborted. Three patients with elevated chorion had a subchorionic clot, whereas this was not present in patients with separated chorioamnion. Follow-up sonographic examination of patients with separated chorioamnion and elevated chorion revealed that most (11 of 13), but not all pregnancies in which an intrauterine membrane was found progressed to term without complications.     

Placental changes in fetal triploidy syndrome

The sonographic findings in fetal triploidy syndrome include intrauterine growth retardation, hydrocephalus, oligohydramnios, and hydropic changes of the placenta. Ultrasonography can establish the diagnosis only when placental findings coexist with a fetus. Although the majority of triploid conceptions abort spontaneously in the first trimester, occasionally they will progress further, but rarely to term. Six cases are presented in which the diagnosis was suspected by early ultrasound examinations, including one case in which there was an unusually large trophoblastic cyst. Determination of the karyotype is important for the management of a pregnancy with a live fetus, and has implications for genetic counseling of subsequent pregnancies.     

Fetuses with trisomy 21 having conflicting findings on antenatal testing for fetal well-being.

OBJECTIVE: This series reports 3 cases with conflicting antenatal sonographic findings: intrauterine growth restriction, absent or reversed end-diastolic flow in umbilical artery Doppler imaging, and reassuring biophysical test results. METHODS: We conducted a retrospective review of medical records. RESULTS: Three fetuses had intrauterine growth restriction and absent or reversed end-diastolic flow in umbilical artery Doppler studies, but the biophysical test results and amniotic fluid volume assessment were normal. We found no other signs of fetal jeopardy from placental insufficiency. In these cases, trisomy 21 was established after birth by karyotyping. Ventricular septal defects and aortic regurgitation were noted in 2 of the 3 affected fetuses. CONCLUSIONS: When there is an unusual combination of antenatal sonographic findings such as presented here, fetal cardiac abnormalities and aneuploidy should be considered.     

Chorioangiomas of the placenta: sonographic and Doppler flow characteristics.

OBJECTIVE: To evaluate our experience with sonography and color Doppler blood flow in the diagnosis and management of chorioangiomas of the placenta. METHODS: All cases with placental chorioangiomas diagnosed in our sonography unit between 1992 and 2001 were included in the study. Sonographic and color Doppler flow characteristics were evaluated in all cases. Our cases were compared with all cases of placental chorioangiomas diagnosed antenatally by sonography published in the English literature between 1978 and 2001. RESULTS: Six cases of placental chorioangioma were identified antenatally, with a mean size of 6.5 cm (range, 4-13 cm). With the use of color Doppler flow, all cases of chorioangioma were shown to have either abundant blood flow or a large feeding vessel within the tumor. During follow-up, 2 cases had reduction of the intratumoral blood flow, and the outcomes were favorable. Three of our cases had delivery before 33 weeks' gestation (1 with intrauterine fetal death and 1 with termination of pregnancy). Review of the literature revealed 72 cases of antenatally diagnosed placental chorioangioma. Two thirds of the cases had dismal outcomes. CONCLUSIONS: The sonographic diagnosis of chorioangiomas of the placenta is feasible and necessitates close surveillance of these pregnancies because of the dismal prognosis in more than half. The addition of color Doppler flow is important in the diagnosis and antenatal follow-up of these pregnancies.     

Sonographic features of retroperitoneal neurilemoma

Seven cases of retroperitoneal neurilemoma confirmed by histology had an ultrasound examination. There were 5 women and 2 men with a mean age of 55. Most of the cases (5/7) had a palpable mass clinically. Of the 7 cases, 4 had a mass with cystic degeneration and internal echoes on sonogram, consistent with the macroscopic findings of tumors. The internal echoes represented blood clots and residual tissue (or septa) in cyst. Or the remaining 3 cases, one showed a confluent lobulated mass, the second had a solitary homogeneous mass with small cysts, and the third one, which was the smallest (4 cm × 4 cm × 6 cm), had a hypoechoic and homogeneous pattern. The sonograms of all 7 cases were consistent with the macroscopic features of the tumors. The sonographic pattern of tumor parenchyma is either homogenously hyperechoic or hypoechoic. Because of the cystic degeneration, hemorrhage, and residual tissue of retroperitoneal neurilemoma, the sonographic pattern was variable. © 1993 John Wiley & Sons, Inc.     

Significance of sonographically detected second-trimester choroid plexus cysts: a series of 211 cases and a review of the literature.

A retrospective analysis of all fetuses with prenatally detected choroid plexus cysts, identified at our institution between 1988 and 1993, was performed. Cytogenetic data, associated sonographic findings, obstetric outcome and pediatric follow-up was obtained to determine the incidence of aneuploidy and the rate of associated congenital anomalies in second-trimester fetuses with this finding. There were 211 second-trimester fetuses identified with a choroid plexus cyst. Amniocentesis was performed in 175 (83%) and postnatal chromosome analysis was performed in one newborn. Follow-up data are available on 203 (96%). Of the 176 cytogenetically studied fetuses, eight (4.5%) were aneuploid (including four cases of trisomy 18). In four of the aneuploid fetuses, the choroid plexus cyst was the only abnormal sonographic finding identified (including one case of trisomy 18). From this study and a review of the literature, we confirm that choroid plexus cysts are a sonographic marker for trisomy 18, even when identified as an isolated finding in an otherwise normal-appearing fetus. We conclude that the detection of a choroid plexus cyst merits further careful evaluation of fetal anatomy and consideration of cytogenetic evaluation.     

Relationship between sonographic and pathologic findings in epidermal inclusion cysts

PURPOSE: We evaluated the sonographic findings in epidermal inclusion cysts and related them to the pathologic findings. METHODS: We retrospectively reviewed the sonograms and pathology specimens of 24 patients with pathologically proven epidermal inclusion cysts. We evaluated the lesions for shape, size, internal echogenicity, posterior sound enhancement, and presence of color Doppler signals. We classified the masses into 5 sonographic types according to their internal echogenicity. The relationship between the sonographic types and the pathologic findings was examined. RESULTS: The masses were ovoid or spherical in 17 cases (71%), lobulated in 5 (21%), and tubular in 2 (8%). The longest diameter ranged from 1 to 6 cm (mean, 3.1 cm). Twenty-three cases (96%) were associated with posterior sound enhancement. Color Doppler signals were absent in 20 cases, but some vascularity was noted in 4 ruptured epidermal cysts, in areas of granulation tissue. The most common sonographic type was a hypoechoic lesion with scattered echogenic reflectors (10 cases). Sonographic findings were related to the lamellation of keratin debris and the granulation tissue secondary to rupture. Most cases with a lobulated configuration (4 of 5) or color Doppler signals (4 of 4) were ruptured cysts. CONCLUSIONS: Epidermal inclusion cysts most often appeared sonographically as a hypoechoic mass containing variable echogenic foci without color Doppler signals. Ruptured epidermal cysts, however, may have lobulated contours and show color Doppler signals, mimicking a solid mass.     

Placental blood flow measured by simultaneous multigate spectral Doppler imaging in pregnancies complicated by placental vascular abnormalities.

OBJECTIVE: To evaluate the role of placental blood flow measurements by simultaneous multigate spectral Doppler imaging in pregnancies complicated by intrauterine growth restriction (IUGR), and for early detection of placental vascular abnormalities in high- and low-risk pregnancies. METHODS: To assess the sensitivity and specificity of abnormal placental blood flow in detecting IUGR, we followed 22 women whose pregnancies were complicated by IUGR at 28-34 weeks' gestation, and compared the findings with those obtained in 22 matched controls. We defined placental blood flow impedance as abnormal when 10% of placental pulsatility index (PI) measurements were greater than, or equal to, the mean umbilical artery PI (placental PI/umbilical PI > or = 1). To determine the predictive value of abnormal placental blood flow measurement for identifying developing uteroplacental insufficiency, we examined an unselected group of 100 low- and high-risk patients at 20-22 weeks' gestation. We correlated the Doppler findings with the development of pre-eclampsia, IUGR, placental abruption, oligohydramnios and the presence of persistent late decelerations during labor. RESULTS: Placental blood flow determination was more sensitive than umbilical artery blood flow in detecting abnormal umbilical-placental flow impedances as manifested by the presence of IUGR. Of the 100 mixed high- and low-risk patients examined at 20-22 weeks, 32 had abnormal placental blood flow. Of these, 19 (59.4%) subsequently developed pathologies associated with placental vascular disease. Of the 68 patients with normal placental blood flow, only six (8.8%) developed such pathologies. The sensitivity was 76% (19/25), with positive predictive value 59.4% (19/32); the specificity was 82.7% (62/75), with negative predictive value 91.2% (62/68). CONCLUSIONS: Abnormal intraplacental blood flow at 28-34 weeks' gestation is strongly associated with IUGR. In addition, it has moderate positive and negative predictive values for identifying subsequent development of uteroplacental vascular abnormalities.     

Sonographic findings in focal fibrocystic changes of the breast

The purpose of this study was to identify the spectrum of sonographic appearances in histologically proven focal fibrocystic changes (FC) of the breast to enhance understanding of imaging findings in this commonly encountered benign condition of the breast. During a 28-month period, the pathology database at two breast centers was searched to identify all patients with a pathologic diagnosis of focal FC resulting from biopsy of a focal mammographic, sonographic, or palpable abnormality and who had undergone sonographic evaluation before biopsy. The authors included lesions with a pathologic diagnosis of FC with or without a specific histologic subtype, such as stromal fibrosis, sclerosing adenosis, and apocrine metaplasia. In 58 patients, there were 60 lesions with a pathologic diagnosis of focal FC. Sonographically, focal FC appeared as solid mass in 28 cases (46.6%) and as cysts in eight (13.3%). In nine cases (15%), heterogeneously echogenic tissue was seen, and in the remaining 15 (25%) cases, there was no sonographically visible focal change. Thirteen of the 28 (46.4%) masses were classified as sonographically indeterminate. One mass was classified as probably malignant, and 14 masses were sonographically benign. A significant number of focal FC appear as solid masses. The sonographic features are not specific enough to differentiate between those that have a dominant component of focal fibrosis, sclerosing adenosis, or apocrine metaplasia from FC without a specific histologic subtype. Many of these solid masses may appear indeterminate, based on published criteria. An understanding of the imaging findings also helps to avoid repeat biopsy for discordant histologic and imaging findings.     

Sonographic findings of ruptured epidermal inclusion cysts in superficial soft tissue: emphasis on shapes, pericystic changes, and pericystic vascularity.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the sonographic findings of ruptured epidermal inclusion cysts in superficial soft tissue, with an emphasis on shapes, pericystic changes, and pericystic vascularity. METHODS: The cases of 61 patients with surgically confirmed epidermal inclusion cysts were reviewed, and 13 patients were found to have ruptured cysts. The Ethics Committees of our institutions did not require patient approval or informed patient consent for this retrospective study. We evaluated the shapes, sizes, locations, pericystic changes, and pericystic vascularity for the 13 cases. RESULTS: The shapes of the ruptured epidermal inclusion cysts were classified into 3 types: with lobulations (type I, 2 cases), with protrusions (type II, 8 cases), and with abscess pocket formations (type III, 3 cases). The mean long diameter of the cysts was 3 cm. Common sites of ruptured epidermal inclusion cysts were the plantar surface of the metatarsophalangeal joint (4 cases) and buttocks (3 cases). Pericystic changes were noted in all of the type II and III cysts. Increased vascularity on color Doppler sonography was prominent in 3 type II cysts and 3 type III cysts. Deep abscess formation was noted in the epidermal inclusion cysts, especially for the type III cysts. CONCLUSIONS: A ruptured epidermal inclusion cyst visualized by sonography had variable shapes; the sonographic findings can be useful for obtaining a correct diagnosis of a ruptured epidermal inclusion cyst.     

First trimester bleeding evaluation

First trimester bleeding is a common presentation in the emergency room. Ultrasound evaluation of patients with first trimester bleeding is the mainstay of the examination. The important causes of first trimester bleeding include spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease; 50% to 70% of spontaneous abortions are due to genetic abnormalities. In normal pregnancy, the serum beta hCG doubles or increases by at least 66% in 48 hours. The intrauterine GS should be visualized by TVUS with beta hCG levels between 1000 to 2000 mIU/mL IRP. Visualization of the yolk sac within the gestational sac is definitive evidence of intrauterine pregnancy. Embryonic cardiac activity can be identified with CRL of >5 mm. A GS with a mean sac diameter (MSD) of 8 mm or more without a yolk sac and a GS with an MSD of 16 mm or more without an embryo, are important predictors of a nonviable gestation. A GS with a mean sac diameter of 16 mm or more (TVUS) without an embryo is a sonographic sign of anembryonic gestation. A difference of <5 mm between the mean sac diameter and the CRL carries an 80% risk of spontaneous abortion. Approximately 20% of women with first trimester bleeding have a subchorionic hematoma. The presence of an extra ovarian adnexal mass is the most common sonographic finding in ectopic pregnancy. Other findings include the tubal ring sign and hemorrhage. About 26% of ectopic pregnancies have normal pelvic sonograms on TVUS. Complete hydatidiform mole presents with a complex intrauterine mass with multiple anechoic areas of varying sizes (Snowstorm appearance). Twenty-five percent to 65% of molar pregnancies have associated theca-leutin cysts. Arteriovenous malformation of the uterus is a rare but life-threatening cause of vaginal bleeding in the first trimester. The sonographic findings in a patient with first trimester bleeding should be correlated with serum beta hCG levels to arrive at an appropriate clinical diagnosis.     

Usefulness of ovarian volume and cysts in female isosexual precocious puberty

The real-time pelvic sonograms of 32 girls under 8 years old with true isosexual precocity (23 cases), pseudosexual precocity (four cases), premature adrenarche (four cases), and an undetermined problem (one case) were evaluated retrospectively for ovarian volume and presence and size of cysts. Sonographic findings were compared to those of 181 age-matched controls to determine the best sonographic indicator of precocious puberty. Ovarian volume was 4.6 cm3 in girls with true isosexual precocity, 4.1 cm3 in girls with pseudosexual precocity, and less than 1 cm3 in the other patients as well as in the control population. Ovarian enlargement was bilateral in true precocity and unilateral in pseudosexual precocity. Of the 181 subjects in the control group, 96 (53%) had ovarian cysts, almost all of which were small (less than 9 mm in diameter). Ovarian cysts occurred in 22 of 32 patients (69%) with precocity. The cysts generally were smaller than 9 mm in true isosexual precocity and larger than 9 mm in pseudosexual precocity. In conclusion, small ovarian cysts are not specific to precocious puberty and its various subtypes. Bilateral ovarian enlargement appears to be a reliable indicator of true isosexual puberty, whereas unilateral ovarian enlargement in combination with macrocysts is suggestive of pseudosexual precocity.     

Presence of cell-free fetal DNA in plasma of women with ectopic pregnancies

BACKGROUND: The quantity of cell-free fetal DNA in the plasma of pregnant women changes during pregnancy and seems to be different in normal and pathologic pregnancies. We investigated the possible diagnostic applications of the detection and measurement of cell-free fetal DNA by comparing quantities found in women with ectopic (EP) or intrauterine (IUP) pregnancies. METHODS: We collected blood samples from 58 women who had positive pregnancy tests and specific complaints and sonographic findings suggestive of EP and from 45 women with confirmed IUP. We performed quantitative real-time PCR analysis of the sex-determining region Y (SRY) gene to detect and measure the amount of cell-free fetal DNA. The diagnosis of EP was confirmed by histologic examination. RESULTS: SRY was detected in 15 EP and 14 IUP cases. The mean (SD) amount of cell-free fetal DNA was significantly higher (P<0.005) in women with EP [565 (136) genome-equivalents (GE)/mL] than in women with IUP [72 (19) GE/mL] at the same gestational age. CONCLUSIONS: Our results confirm that cell-free fetal DNA is present in plasma of women with EP. The finding of higher amounts of cell-free fetal DNA in EP cases than in IUP cases suggests that this method might be useful for early diagnosis of EP.     

Congenital lung malformations in the second trimester: prenatal ultrasound diagnosis and pathologic findings

PURPOSE: To correlate prenatal sonographic diagnosis of cystic lung malformations with fetopathologic findings after termination of pregnancy. METHODS: We retrospectively analyzed the data of 16 terminated cases in which a cystic lung lesion was diagnosed pre- or postnatally. RESULTS: On average, prenatal diagnosis was established on the 21(st) gestational week (range, 19-26 weeks). The cause of termination was severe polyhydramnios in 4 cases, nonimmune fetal hydrops in 4 cases, other congenital malformation in 5 cases (renal malformation, 2 cases; congenital diaphragmatic hernia, 3 cases), and obstetrical conditions (intrauterine death, placental abruption, spontaneous abortion) in 3 cases. In 11 cases, congenital cystic adenomatoid malformation (CCAM) was the presumptive prenatal diagnosis. Autopsy confirmed the prenatal diagnosis in 6 of them, while in the other 5 cases, an enteric cyst, a laryngeal atresia, an unidentified tumor, a pulmonary hypoplasia, and an extralobar pulmonary sequestration were found on histologic examination. On the other hand, the autopsy revealed CCAM in those 5 cases in which other malformations were suggested prenatally. CONCLUSION: The prenatal sonographic diagnosis of CCAM is difficult. Our cases emphasize the important role of fetopathology even today in the verification of prenatal diagnosis based on sonographic examinations.     

实时灰阶超声造影在宫腔异常回声鉴别诊断中的应用

目的探讨实时灰阶超声造影技术对宫腔异常回声鉴别诊断的应用价值。方法以意大利Bracco公司生产的声诺维（SonoVue）为造影剂,对27例宫腔异常回声者行实时灰阶超声造影检查,观察造影剂在病灶内充盈方式及增强程度,以手术病理结果为标准,分析比较不同病因的宫腔异常回声造影显像特点。结果27例宫腔异常回声的组织病理结果分别为子宫内膜息肉、子宫黏膜下肌瘤、子宫内膜癌、不全流产宫腔残留和宫腔黏连,各种病变的超声造影表现明显不同。结论实时灰阶超声造影技术能够较准确地鉴别诊断宫腔异常回声。     

Ultrasonographic features of gastrointestinal duplications.

The variable sonographic appearance of duplication cysts is presented. Eighteen sonograms from 14 patients, aged 1 day to 8 years, were reviewed over an 8 year period. Water and other aqueous contrast agents were used in six patients as part of the sonographic evaluation. All lesions were confirmed by surgery. All but two patients were symptomatic. Twenty-four cysts were detected, ranging in size from 1.7 to 15.5 cm. The duplication cysts revealed a spectrum of sonographic findings (cystic to solid appearing masses). The mass characteristics, including the "muscular rim sign," and internal debris or hemorrhage, were demonstrated. Multiple unsuspected cysts (3 of 14 or 20%) and complications such as perforation were readily seen with ultrasonography. Serial sonograms demonstrated the changing morphology of two cysts. Other unsuspected intra-abdominal and pelvic pathologic conditions, including pyloric stenosis and ovarian cysts, were identified. Identification of the muscular rim sign is the most reliable indication of a duplication cyst. Multiple masses as well as possible accompanying anomalies in the abdomen and pelvis are readily evaluated with sonography. Lesions are easily followed with serial studies if there is no surgical intervention.     

睾丸表皮样囊肿的超声表现及其与病理的关系

目的探讨睾丸表皮样囊肿的超声表现及其与病理的关系。方法回顾性分析10例经病理证实为睾丸表皮样囊肿的声像图资料并与病理结果对照分析。结果10例病灶均边界清晰,内无血流信号。7例病灶内部呈“洋葱皮”样或“漩涡”状改变,2例病灶内有“多层薄片状”改变,4例病灶周边有环状或蛋壳样强回声,3例病灶同时具有内部“洋葱皮”样或“漩涡”状改变和周边强回声。超声诊断正确提示睾丸表皮样囊肿5例,5例由于早期认识不足误诊为睾丸恶性肿瘤。结论睾丸表皮样囊肿的超声表现极具特征性,能够根据典型声像图作出准确的提示性术前诊断,与其他影像检查的比较有待进一步研究。