Faculty Bibliography

OBJECTIVE: We raise the issue of scanning multifetal pregnancies of higher order as early as possible. A rare case of monochorionic/quadramniotic pregnancy seeking multifetal pregnancy reduction and its clinical management is presented. METHODS: Transabdominal scanning at 16 weeks was performed correctly diagnosing the monochorionic quadruplet pregnancy. RESULTS: Suspecting vascular connections between the placentae, the fetal reduction was declined. The patient was delivered at 31 weeks. The 4 female neonates survived with slight ventilatory assistance. CONCLUSION: Multifetal pregnancies in general, but those of higher order in particular, have to be scanned as early as 8-10 weeks to correctly and easily assign their chorionicity and amnionicity. The case of a monochorionic/quadramniotic pregnancy and its clinical course are presented

We have previously reported on the value of transvaginal color Doppler evaluation of the ureteral jets to confirm ureteral patency. In this study, we attempt to validate the simple and widely available gray-scale ultrasound technique to perform the same task. Fifty consecutive patients without a history of urinary complaints were recruited. The presence or absence of the right and left ureteral jets was registered using gray-scale imaging, comparing the technique to color Doppler as the 'gold standard'. The time to the detection of the first jet as well as the total scanning time were documented for each side. The jets were seen with equal frequency on both the right and the left sides (34 observations each). In 24 patients, both jets were visualized. The median time to detection of the first jet was 47 s (range 34-79 s) for the right jet and 53 s (36-84 s) for the left jet (p = 0.42). The median total scanning time was 176 s (139-259 s). Gray-scale imaging was associated with a sensitivity of 68% and a positive predictive value of 100%. Although color Doppler results may be more attractive because of their impressive color-coded appearance, the major disadvantage of this technique is that it requires sophisticated and costly equipment. Transvaginal gray-scale imaging is a reliable and useful test for the detection of ureteral jets in the bladder. It can be used as a first-line diagnostic tool, particularly in settings where color Doppler is not available. Its benefits include safety, low cost, convenience and simplicity. With a positive predictive value of 100%, this test may be used in the postoperative patient, especially when ureteral patency is in question

The goal of the gynecologist is to detect ovarian tumors in their earliest stages. Small virilizing tumors, which barely affect the size of the ovaries, are such lesions. Since the introduction of transvaginal sonography it is technically possible to detect small intraovarian neoplasms. Three cases of virilizing steroid cell tumors in postmenopausal women with ovarian volumes just exceeding the normal sizes for age are presented. High-frequency transvaginal ultrasound and color Doppler studies to measure flow parameters were used. These small tumors had different echogenicity from the surrounding ovarian tissue and two had low impedance-to-flow values. Gray-scale transvaginal sonography combined with color Doppler studies can make the diagnosis of small steroid cell tumors easier and, at times, better than other, more costly imaging modalities

The objective of this study was to determine the variation in first-trimester fetal size and fetal heart rates in multifetal pregnancies, and to study the effect of fetal reduction on the surviving fetal heart rate. Fetal crown-rump length and fetal heart rates were measured in 44 patients with multifetal pregnancies who underwent fetal reduction. The heart rates of the surviving fetuses were also measured immediately after, and 1 h following the procedure. A total of 143 fetuses were evaluated prior to reduction and 75 fetuses following the procedure. There was no significant difference in crown-rump length between fetuses of the same gestation. The interfetal fetal heart rate variation between fetuses of the same gestation, expressed as a standard deviation, was 4.78 +/- 0.51 beats/min (mean standard deviation +/- standard error of the mean) before reduction; this was a significantly greater variation than could be attributed to error in the measurement of heart rate. In the surviving fetuses, the mean heart rate did not change. However, immediately after the reduction, interfetal heart rate variation was abolished, but was observed again 1 h after the reduction. We conclude that in first-trimester multifetal pregnancies (1) there is no significant difference in fetal crown-rump length; (2) there is interfetal variation in heart rates; and (3) fetal reduction has only a limited effect on the heart rates of surviving fetuses

We aimed to determine the feasibility of imaging specific sulci, gyri and fissures using transvaginal sonography and to correlate their first sonographic recognition with gestational age. Retrospectively, 262 fetal brain scans were analyzed from a total of 337 scans. Scans were selected if any of the following structures were seen: in the coronal plane the lateral, callosal and cingulate sulcus and gyrus; in the median plane the parieto-occipital and calcarine fissures, and the cingulate gyrus and sulcus; and, in an oblique section, the lateral sulcus. The gestational age at which the fissures, sulci and gyri were first imaged was recorded and subsequently compared with similar anatomical studies from the literature. It was possible to identify all the targeted structures. The gestational ages at which the structures were first imaged were: the callosal sulcus, from 14 weeks; the lateral sulcus, from 18 weeks; the parieto-occipital sulcus and calcarine fissure, from 18 weeks; and the cingulate gyrus, from 26 weeks. We concluded that the developmental maturation of the normal fetal brain follows a predictable timetable, and that this maturation can be grossly followed with sonography. The sonographic recognition of the fissures, gyri and sulci lagged behind the observations by anatomical studies. The greatest discrepancy was the first appearance of the cingulate gyrus which, in the anatomical studies, could be seen by 18 postmenstrual weeks and, in our study, was seen after 26 postmenstrual weeks. The one exception was the callosal sulcus, which was first seen at 14 postmenstrual weeks in both the sonographic and anatomical studies. In conclusion, the recognition of specific structures of the cortical map is possible. Sonography may be used to image the developing cortical surface

OBJECTIVE: To evaluate the feasibility of the detection of ureteral jets into the bladder in obstetric-gynecologic patients using transvaginal color Doppler ultrasound. METHODS: Fifty-two women were recruited and categorized into four groups: 1) 20 normal nonsurgical, 2) 17 post-cesarean delivery, 3) 12 post-total abdominal hysterectomy, and 4) three with only one functional kidney or ureter. In the first three groups, transvaginal color Doppler sonography was used to evaluate the time to detection of the first jet and the number of jets in 5 minutes bilaterally. In the last group, the presence or absence of the jet was documented only on the functional side. Statistical analysis was performed using Student t test and analysis of variance followed by Tukey honestly significant difference. RESULTS: Urine jets could be detected bilaterally in all women except for those with only one functional kidney (accuracy 100%). Time to detection of the first jet did not differ significantly in the nonsurgical, cesarean, or hysterectomy patients on either the right side (P = .07) or the left side (P = .43). The total number of jets was similar in the nonsurgical and cesarean patients, but was significantly lower in the hysterectomy group (right side P = .006; left side P = .004). In the women with one functional kidney, the normal side was identified in all cases. CONCLUSION: Transvaginal color Doppler sonography is a simple, accurate technique that can be used to evaluate ureteral jets into the bladder in women. The length of time to detection of the first jet is not affected by the postoperative status. Fewer jets should be expected in women who have undergone hysterectomies. This method should be used when ureteral integrity is in question, especially after surgery

The decision whether to perform uterine curettage for postabortal bleeding depends on the ability to demonstrate placental remnants in the uterine cavity. However, diagnosis of postabortal trophoblastic residua by conventional ultrasonography may be inconclusive. We report our experience with the use of combined sonohysterography and color Doppler to demonstrate a placental polyp after early pregnancy termination

Cervical pregnancy is a rare type of ectopic pregnancy. A recurrent cervical pregnancy in conjunction with a viable intrauterine pregnancy is an even rarer event. We present a case in which a recurrent cervical pregnancy was treated by selective reduction using an injection of potassium chloride guided by transvaginal sonography. The intrauterine gestation was delivered at a gestation of 34 weeks and 4 days by Cesarean section. Subsequently, the patient was treated with intramuscular methotrexate with a prolonged, but complete, resolution of the cervical pregnancy

Published studies relating to the use of transvaginal sonography (TVS) in the evaluation of endometrial hyperplasia and carcinoma were reviewed. Approximately 80 percent of all curettage procedures performed for postmenopausal bleeding result in benign diagnoses, therefore, if a noninvasive modality such as TVS can be accurately used to determine endometrial thickness measurements below which pathology is less likely, sampling may be avoided. The largest study evaluating endometrial measurements in postmenopausal women with bleeding, known as the Nordic trial, found that for a cut-off value of < or = 4 mm, 96 percent sensitivity and 68 percent specificity was achieved. Another study evaluated endometrial echomorphology in addition to measurement and found that the combined approach improved the predictability of pathologic findings. TVS may also be used to assess the depth of myometrial invasion in patients already diagnosed histologically with endometrial carcinoma. Although MRI is considered the established tool in the presurgical evaluation of the patient with carcinoma, TVS was found to perform only slightly less accurately than MRI. The published studies regarding TVS and/or MRI are reviewed. Finally, the use of TVS in conjunction with a new modality, sonohysterography, in the evaluation of patients on tamoxifen therapy, is discussed. Although the published cut-off values for endometrial thickness measurements do not apply to this group of patients, a procedure whereby sterile saline is injected into the uterine cavity, via a thin catheter, provides additional information regarding endometrial contours. Once the procedure is performed, the supposed complex endometrial echo seen on TVS is often found to actually be located in the subendometrial myometrium and the endometrium itself is thin and regular. The role for TVS is well established in the search for endometrial hyperplasia and carcinoma, as well as evaluating the presence of myometrial invasion once the diagnosis is made

Cataracts are lens opacities that account for approximately 10% of blindness in children. We report on four consecutive pregnancies in a woman at risk for recurrent autosomal dominant cataracts in which extensive ultrasound studies were helpful in establishing the correct diagnosis. The normal appearance of the fetal lens is that of a ring with a central sonolucency, but in cases of cataracts the lens appears hyperechogenic to various degrees. In the first pregnancy, normal lenses were seen at 15 postmenstrual weeks and, at birth, the baby girl had normal lenses. In the second pregnancy, the male fetus was affected by a left-sided cataract and a right-sided anophthalmia which were diagnosed at 16 postmenstrual weeks. The histological examination of the specimen from the aborted fetus correlated with the sonographic diagnosis. The third pregnancy, also a male fetus, had bilateral cataracts suspected at 14 weeks, but the final diagnosis was made at 19 weeks and confirmed at 21 weeks. The couple opted to terminate the pregnancy and the histology confirmed the presence of congenital cataracts. In the fourth pregnancy, we diagnosed asymmetry of the orbital sizes and bilateral cataracts at 15 weeks. In conclusion, the diagnosis of fetal cataract from the second trimester of pregnancy is possible and imaging of the fetal lenses should be part of the routine anatomical survey. Since the exact onset of fetal cataracts is uncertain at present, in cases at risk, serial sonograms may be indicated