First-trimester treatment of fetal anemia secondary to parvovirus B19 infection.

Here we report two cases of first-trimester parvovirus B19 (PV-B19) infection that were successfully treated by intrauterine blood transfusion into the umbilical vein. At 13 weeks' gestation both fetuses presented with increased nuchal translucency (NT) and cardiomegaly. In both cases pulsed Doppler ultrasound examination of the fetal middle cerebral artery (MCA) revealed increased peak systolic velocity (PSV), which led to a suspicion of fetal anemia. Maternal PV infection was confirmed by a positive polymerase chain reaction result. Each fetus received a 3-mL intravenous transfusion of packed red blood cells into the umbilical vein, using a 25-G spinal needle. Follow-up ultrasound and Doppler examination demonstrated fetal well-being, decline of the MCA-PSV and resolution of the NT. Case 1 was readmitted at 25 weeks' gestation with severe hydrops fetalis, and both mother and fetus still tested positive for PV-B19 DNA. Three more intrauterine blood transfusions were performed and the fetal hydrops resolved. In Case 2 no additional transfusions were needed. Both babies had a good neonatal outcome and uneventful follow-up. Our findings demonstrate that the MCA-PSV is helpful in establishing the diagnosis of first-trimester fetal anemia. Intravasal transfusion can be attempted as early as the first trimester.     

Prenatal diagnosis of an aneurysm of the vein of Galen with three-dimensional color power angiography.

The prenatal diagnosis of an aneurysm of the vein of Galen has been reported on only a few occasions. This rare arterio-venous fistula is suspected when an intracerebral hypoechoic cyst is found in which blood flow can be demonstrated by Doppler ultrasound. This is one of the few conditions where Doppler ultrasound is critical for the diagnosis. Three-dimensional color power Doppler (3D-CPA) is a recent ultrasound modality which enables the three-dimensional visualization of vessels and which is more readily available than magnetic resonance imaging (MRI) We report a fetus in which an aneurysm of the vein of Galen was detected at 33 weeks' gestation and where the application of 3D-CPA enabled a better understanding of the spatial orientation and course of the dilated vessels. The neonate was successfully treated with coil angiography but subsequently died at 5 months of age from cardiac decompensation. Where fetal malformations involve the vascular system, 3D-CPA appears to be a promising technique.     

Prenatal diagnosis of cleft palate: contribution of color Doppler ultrasound.

The antenatal diagnosis of cleft palate by ultrasound can sometimes be difficult by conventional B-mode imaging, especially when the tongue is in its normal position.We describe two cases which illustrate the value of color Doppler in the antenatal diagnosis of cleft palate. In the first case, at 32 weeks' gestation, there was a large defect with a massive passage of flow extending from the buccal cavity into one of the nasal fossae. In the second case, at 22 weeks' gestation, a parasagittal view demonstrated the fetal tongue to be in the normal position, but there was an abnormal trajectory off low from the buccal cavity into one of the nasal fossae followed by an exit at the level of the cleft. Although a cleft lip was demonstrated on B-mode imaging, we would not have been able to make the diagnosis of cleft palate without color Doppler.This is the first report describing the contribution of color Doppler to the antenatal diagnosis of cleft palate.     

The pathophysiology of acute syphilitic funisitis.

There is an increase in the number of cases of syphilis in pregnancy in the United States. Fetal death may occur in syphilis from acute or chronic infections. A case is presented in which an acute fetal infection occurred. The patient presented at 31 weeks' gestation, with a decrease in fetal movements and non-reactive cardiotocography. Ultrasound and Doppler analysis of the fetal heart, cerebral and umbilical arteries, aorta and umbilical vein led to the suspicion of acute cardiac failure. An amniocentesis yielded a white cell count of 1122 white blood cells, with 91% polymorphs, but the Gram stain was negative. The fetus developed a persistent bradycardia and was delivered. The diagnosis of acute severe syphilitic funisitis was suspected from histological sections of the cord. Diagnosis was established from maternal and fetal blood. Modern ultrasound techniques, including imaging, Doppler and cardiotocography, can lead to the analysis of the pathophysiology of disease states. An acute syphilitic infection should be suspected when this constellation of findings is found.     

Prenatal diagnosis of thrombosis of the dural sinuses with real-time and color Doppler ultrasound.

OBJECTIVE: To assess the sonographic findings and clinical implications of fetal thrombosis of dural sinuses. DESIGN: Retrospective study of cases with a prenatal diagnosis of thrombosis of the dural sinuses. RESULTS: The diagnosis of fetal thrombosis of the dural sinuses was established in three uncomplicated pregnancies at 21, 22 and 28 weeks' gestation by transabdominal and transvaginal sonography, demonstrating a blood clot within the dilated dural sinuses, always in the region of the torcular Herophilii. The diagnosis was further confirmed by the color Doppler demonstration of absence of blood flow within the dilated dural sinuses. Upon request of the couples two pregnancies were terminated. One infant was delivered at term by Cesarean section and died during neurosurgery. CONCLUSIONS: Thrombosis of the cerebral venous circulation can occur antenatally. Accurate diagnosis can be made using fetal real-time and color Doppler ultrasound.     

Prenatal diagnosis of a fetus with lumbar myelocystocele.

We present a case of a fetal lumbar myelocystocele, a rare congenital malformation, characterized by herniation of the central canal through a bony spina bifida. Routine ultrasound examination at 11 weeks' gestation by the primary obstetrician showed a suspicious cyst on the fetal back. Initially, the suspected diagnosis was a meningocele. After sonographic detection of newly developed fetal brain anomalies at 22 weeks' gestation the patient was referred to us. The enlarged cyst, which floated freely in the amniotic fluid, had a funnel-like appearance and was covered by a very thin layer of skin. With the help of ultrafast fetal magnetic resonance imaging the diagnosis of a fetal myelocystocele was made.     

Myocardial motion imaging: a new application of power color flow and frequency-based color flow Doppler in fetal echocardiography.

OBJECTIVE: Myocardial motion imaging is a new way of looking at the fetal heart using power color flow and frequency-based color flow Doppler to demonstrate heart wall movement in color. This study set out to assess the value of myocardial motion imaging in fetal echocardiography in a routine clinical setting. DESIGN: In our hospital, all patients at high risk of carrying a fetus with a cardiac abnormality are offered detailed ultrasound scanning, including fetal echocardiography, at 20 weeks' gestation. A prospective study was carried out over a 2-month period and, in addition to conventional fetal echocardiography, myocardial motion imaging was also carried out on all patients, by means of both power color flow and frequency-based color flow Doppler ultrasound. RESULTS: Myocardial motion imaging demonstrated fetal heart wall movement in 26 of the 27 patients. Myocardial motion imaging using power color flow gave a global view of fetal heart wall movement, demonstrating both atrial and ventricular contraction simultaneously. Myocardial motion imaging using frequency-based color flow Doppler demonstrated atrial and ventricular contractions separately. In addition, as the direction of fetal heart wall motion can be color coded, atrial contractions, ventricular relaxation and ventricular contraction were demonstrated, providing a functional assessment of fetal heart wall movement. Two cases of cardiac abnormality were also studied, one case of hypoplastic left heart syndrome and one case of atrioventricular septal defect. In both cases functional information was obtained using myocardial motion imaging, and the technique also highlighted the anatomical defect. CONCLUSIONS: Myocardial motion imaging produces both a global view of fetal cardiac anatomy and a functional assessment of individual chamber contraction in the normal and abnormal heart. It may prove to be a useful adjunct to conventional color flow Doppler assessment of the fetal heart.     

Placenta accreta diagnosed at 9 weeks' gestation.

The majority of cases of placenta accreta are unanticipated and initially identified intraoperatively. Although color Doppler ultrasound is adequate for the evaluation of placenta accreta in the third trimester, ultrasound diagnosis in the first trimester has never been reported. To our knowledge, this is the first case of placenta accreta detected at 9 weeks' gestation by ultrasound. Placenta accreta with intraplacental lacunae can be identified together with a loss of the hypoechogenic retroplacental myometrial zone. Based on this case, we found that early diagnosis of placenta accreta in the first trimester by ultrasound is possible.     

Prenatal ultrasound diagnosis of fetal candida infection: a complication of a retained intrauterine contraceptive device.

A 32-year-old woman was referred complaining of abdominal pain and bleeding at 18 weeks' gestation. The striking finding on ultrasound examination was of symmetrically enlarged echogenic fetal lungs. In addition, mediastinal compression, increased echogenicity of the kidneys and bowel, an enlarged liver of decreased echogenicity, and hydrops fetalis, as evidenced by ascites and skin edema, were all present. The differential diagnosis included upper respiratory tract obstruction and cystic kidney disease. The presence of fetal hydrops together with the other findings suggested a poor outcome, and on these grounds therapeutic abortion was recommended and performed. Subsequent postmortem findings explained all the ultrasound abnormalities on the basis of extensive fetal candida infection. The presence of a retained intrauterine contraceptive device was considered to be the likely cause and the implications of this, together with the ultrasound abnormalities and differential diagnoses, are discussed.     

Transvaginal 3-d power Doppler ultrasound evaluation of the fetal brain at 10-13 weeks' gestation

The objective of this study was to measure the fetal brain volume (FBV) and vascularization and blood flow using transvaginal 3-D power Doppler (3DPD) ultrasound late in the first trimester of pregnancy. 3DPD ultrasound examinations with the VOCAL imaging analysis program were performed on 36 normal fetuses from 10-13 weeks' gestation. FBV and 3DPD indices related to the fetal brain vascularization (vascularization index [VI], flow index [FI] and vascularization flow index [VFI]) were calculated in each fetus. Intra- and interclass correlation coefficients and intra- and interobserver agreements of measurements were assessed. FBV was curvilinearly correlated well with the gestational age (R2 = 0.861, p < 0.0001). All 3-D power Doppler indices (VI, FI and VFI) showed no change at 10-13 weeks' gestation. FBV and all 3-D power Doppler indices (VI, FI and VFI) showed a correlation > 0.82, with good intra- and interobserver agreement. Our findings suggest that 3-D ultrasound is a superior means of evaluating the FBV in utero, and that 3-D power Doppler ultrasound histogram analysis may provide new information on the assessment of fetal brain perfusion.     

Three-dimensional (3D) and 4D color Doppler fetal echocardiography using spatio-temporal image correlation (STIC).

OBJECTIVE: Color Doppler echocardiography is used to visualize three transverse planes: the four-chamber, five-chamber, and three vessels and trachea views. Color Doppler spatio-temporal image correlation (STIC) is a new three-dimensional (3D) technique allowing the acquisition of a volume of data from the fetal heart that is displayed as a cineloop of a single cardiac cycle. The aim of the study was to examine the potential of color Doppler STIC to evaluate normal and abnormal fetal hearts. METHODS: This prospective study included 35 normal fetuses and 27 fetuses with congenital heart defects (CHD) examined between 18 and 35 weeks of gestation. Volume acquisition was achieved by initiating the image capture sequence from the transverse four-chamber view. Volumes were stored for later offline evaluation using a personal computer-based workstation in a multiplanar mode and as spatial volume rendering. RESULTS: Successful acquisition was possible in all 62 cases. The three planes could be demonstrated in 31/35 healthy fetuses and in 24/27 fetuses with CHD. Spatial volume rendering was attempted in 18 fetuses with CHD. In the four normal fetuses with inadequate visualization using color Doppler STIC, the region of interest was perpendicular to the ultrasound beam. In two fetuses with CHD inadequate visualization was related to an enlarged heart in late gestation, in which the entire cardiac volume could not be acquired. The third case was an 18-week fetus with complex CHD and transposed great vessels in which artifacts were related to confluent color signals as a result of low resolution in the reconstructed plane. CONCLUSIONS: STIC in combination with color Doppler ultrasound is a promising new tool for multiplanar and 3D/4D rendering of the fetal heart. Limitations may be found later in gestation in fetuses with large hearts and early in gestation as a result of low discrimination of signals. In addition, insonation perpendicular to the structure of interest does not image color Doppler signals and should be avoided during acquisition.     

大脑中动脉血流参数比值在胎儿高动力循环状态中的初步应用

目的 探讨预测胎儿高动力循环状态的血流参数比值指标。方法 应用二维超声、彩色多普勒能量图及脉冲多普勒技术对17例17－31孕周高动力循环状态胎儿及215例16－31孕周正常胎儿大脑中动脉血流参数及头围进行检查。结果 高动力循环状态组胎儿每分钟单位头围大脑中动脉的最大速度及平均速度均高于正常组（P＜0．05）。结论 大脑中动脉血流参数比值能预测胎儿高动力循环状态。     

彩色多普勒超声检测12～14孕周胎儿三尖瓣反流的应用价值

目的探讨彩色多普勒超声检测孕12—14周胎儿三尖瓣反流的临床价值。方法52例孕12-14周发现三尖瓣反流的胎儿为反流组,根据反流程度分为轻度反流和中重度反流;50例孕12-14周未见三尖瓣反流的胎儿为对照组。两组均于孕中晚期行彩色多普勒系统畸形筛查。结果反流组胎儿轻度反流46例,中重度反流6例;检出胎儿异常10例,检出率为19．2％。对照组检出胎儿异常2例,检出率为4．0％;反流组胎儿异常检出率高于对照组（P〈0．05）。结论孕12-14周三尖瓣反流的胎儿发生异常的风险高于正常胎儿,彩色多普勒超声检测孕早期胎儿三尖瓣反流有重要的临床价值。     

彩色多普勒超声诊断胎儿唇腭裂畸形

目的通过分析胎儿唇腭裂畸形的声像图特征及其相应的生理、病理学基础,提高彩色多普勒超声对胎儿唇腭裂的诊断率。方法采用彩色多普勒超声检查20周以上孕妇,最晚不宜超过28孕周,尤其有畸形胎儿家族史的孕妇,分析经分娩（包括引产、剖宫产）证实的23例胎儿唇腭裂的超声声像图表现。结果彩色多普勒超声诊断的敏感性高,声像图上,唇裂表现为上唇回声光带中断（单侧、双侧和正中）,双侧唇裂或伴腭裂时,正常鼻唇结构消失,鼻子、上唇回声不连续,呈三瓣状,鼻子塌陷,似兔唇。腭裂不易直接显示。结论彩色多普勒超声对胎儿唇腭裂畸形有很高的诊断价值。     

Enlarged nuchal translucency and low serum protein concentrations as possible markers for Zellweger syndrome.

We present a case of a fetus in which an enlarged nuchal translucency was detected at 12 weeks' gestation. The karyotype was normal. Subsequent ultrasound examination showed no obvious fetal abnormalities apart from a mild pericardial effusion. Serum screening revealed very low concentrations of estriol and human chorionic gonadotropin. After birth the diagnosis of Zellweger syndrome was made. Nuchal translucency screening, estriol level identification and detailed ultrasound scanning may help to identify fetuses affected by this syndrome.     

Prenatal diagnosis of placental chorioangioma: contribution of color Doppler ultrasound.

A case of placental chorioangioma was diagnosed at 35 weeks' gestation using color Doppler ultrasound. Color flow imaging showed an intraplacental hypoechoic mass fed directly by the anomalous chorionic tumor vessels arising from the insertion of the umbilical cord. Hypervascularization was present in some areas of the tumor. The diagnosis of typical 'angiomatous' type was confirmed by histopathological examination following delivery.     

Prenatal depiction of angioarchitecture of an aneurysm of the vein of Galen with three-dimensional color power angiography.

A fetus with a large supratentorial cyst and cardiomegaly was encountered at 33 weeks of gestation. The cyst appeared as an aneurysmal, fluid-filled structure extending posteriorly with a finger-like appendage. Using color flow mapping, we disclosed rapid in-and-out blood flow with marked turbulence within the cyst. For evaluation of its blood supply and venous drainage of the vascular malformation, a three-dimensional reconstruction of the power Doppler image was conducted. The results revealed that the vascular malformation was supplied by a small contralateral aneurysm from the branches of Willis' circle, draining posteriorly into an abnormal falcine sinus and then into the superior sagittal sinus. No other fetal abnormality such as hydrocephalus or hydrops was discovered. The prenatal diagnosis of an aneurysm of the vein of Galen was made on the basis of the gray-scale, color Doppler findings, and also the angioarchitecture obtained by three-dimensional power Doppler imaging. The woman was admitted at 37 weeks of gestation due to labor onset and delivered the baby via the vaginal route without complication. Postnatal angiography and magnetic resonance imaging confirmed the diagnosis of an aneurysm of the vein of Galen, and the angioarchitecture depicted it before birth. We suggest that three-dimensional power Doppler ultrasonography may assist in the diagnosis of an aneurysm of the vein of Galen, and precisely delineate the complicated corresponding vasculature. This may guide postnatal management and predict the prognosis more accurately.     

孕早期颈项透明层超声联合孕中期彩色多普勒超声可提高产前胎儿畸形检出率

目的探究孕早期颈项透明层（NT）超声联合孕中期彩色多普勒超声在产前胎儿畸形筛查中的应用价值。方法选择2017年8月~2019年12月在我院行胎儿畸形筛查的2417例孕妇作为研究对象,所有孕妇于孕11~14周行NT超声检查,并于孕22~28周行二维、四维彩超检查。以引产或分娩结果为“金标准”,比较畸形胎儿、正常胎儿的NT值及NT异常率,对比NT超声检查、二维联合四维彩超检查结果,并就NT超声、二维及四维彩超及二者联合在诊断胎儿畸形中的诊断率进行比较。结果2417例孕妇最终确诊异常胎儿88例,发病率为3.64%。畸形胎儿的NT值明显高于正常胎儿,NT异常率（93.18%）明显高于正常胎儿（1.33%）,差异比较有统计学意义（P < 0.05）。NT超声检查共检出异常胎儿82例,诊断准确率为93.18%;二维联合四维彩超共检出异常胎儿85例,诊断准确率为96.59%。二维联合四维彩超的诊断准确率略高于NT超声检查,差异无统计学意义（P>0.05）。NT超声联合二维、四维彩超在诊断胎儿畸形中的敏感度、特异度和准确度分别为100.00%、99.57%、99.59%,高于NT超声、二维和四维彩超（分别为93.18%、98.67%、98.47%和96.59%、99.06%、98.97%）,组间比较差异有统计学意义（P < 0.05）。结论孕早期NT超声及孕中期彩色多普勒超声在产前筛查胎儿畸形上各具有优势,均具有较好的诊断价值。二者联合应用能够进一步提升胎儿畸形的检出率,对尽早终止胎儿畸形孕妇继续妊娠,减少畸形胎儿出生具有重要意义。      

四腔心切面联合三血管气管切面彩色多普勒超声在孕11~13+6周胎儿严重先天性心脏畸形筛查中的应用价值

目的探讨四腔心切面联合三血管气管切面彩色多普勒超声在孕11~13⁺⁶周胎儿严重先天性心脏畸形筛查中的应用价值。 方法选择2018年1月至12月在四川省妇幼保健院行孕期检查的9756例孕妇,分别于孕 11~13⁺⁶周及孕16~24周进行胎儿心脏超声检查。采用四腔心切面联合三血管气管切面彩色多普勒超声对孕11~13⁺⁶周胎儿筛查心脏畸形,采用标准化胎儿超声心动图筛查孕16~24周胎儿心脏畸形,并对分娩后所有新生儿及引产胎儿进行随访。 结果9756例胎儿孕11~13⁺⁶周超声筛查发现心脏畸形38例（51.4%,38/74）,其中非严重心脏畸形5例（14.2%,5/35）,严重心脏畸形33例（84.6%,33/39）。出生或引产后诊断先天性心脏畸形74例,其中严重先天性心脏畸形39例,非严重心脏畸形35例。 结论运用四腔心切面联合三血管气管切面彩色多普勒超声能筛查出大部分严重胎儿心脏畸形,可为临床咨询、预后提供及时有力的证据。     

Three-dimensional ultrasound diagnosis of Larsen syndrome with further characterization of neurological sequelae.

Larsen syndrome consists of skeletal dysplasia with multiple joint dislocations and a characteristic facies. The basis of this abnormality is a generalized mesenchymal disorder involving connective tissues. We describe our findings in a woman who was referred at 28 weeks' gestation due to multiple fetal anomalies suspected initially at an 18-week ultrasound examination. On three-dimensional (3D) ultrasound we found the fetus had bilateral genu recurvatum. Further 3D examination at 36 weeks confirmed the lower limb anomaly and revealed facial anomalies that led to the diagnosis of Larsen syndrome. An elective Cesarean section was performed at 38 weeks' gestation to minimize neurological sequelae. Magnetic resonance imaging was performed postnatally and showed pachygyria, colpocephaly and agenesis of the corpus callosum. In this case, 3D ultrasound facilitated the prenatal diagnosis of Larsen syndrome. A careful prenatal investigation for other associated anomalies such as those of the cardiovascular or neurological systems is warranted with this diagnosis. These associated lesions are likely to have a greater impact on prognosis than the classic symptoms of Larsen syndrome and a collaborative approach is necessary to optimize delivery and postnatal management of an affected fetus.