First Trimester Neurosonogram-Our Experience.

Central nervous system (CNS) malformations represent 1% of all births. For this reason, efforts are being made to increase detection of such anomalies prenatally. Consequently, a detailed assessment of the fetal nervous system in the first trimester of pregnancy is no longer a utopia as this kind of evaluation can detect severe malformation such as acrania, neural tube defects, holoprosencephaly or can draw attention regarding to anomalies currently detected in the second trimester due to certain markers of diagnosis. MATERIAL AND METHODS: The study included 1376 pregnant women with gestational ages between 11 and 14 weeks, who were referred to our unit for sonographic evaluation. We analyzed in all patients the fetal brain in axial and mid-sagittal views, assessing markers like intracranial translucency, brainstem/brainstem-occipital bone (BS/BSOB) ratio, choroid plexus (CP/HA) ratio, the octopus sign in order to detect as many anomalies in the first trimester of pregnancy. RESULTS: We detected 6 CNS anomalies during our search. All markers assessed were abnormal in all pathological cases. CONCLUSION: A detailed assessment of the fetal brain is recommended at 11-14 weeks because the earlier the diagnosis is confirmed, the lower the chances of obstetrical, psychological complications to supervene.

First Trimester Ultrasound Diagnosis of Right Aortic Arch (RAA).

OBJECTIVES: In the present research we proposed to evaluate the cases diagnosed in the first trimester of pregnancy by ultrasound with RAA, knowing the fact that although, in most cases the disease is isolated and asymptomatic, in some cases the presence of RAA can be associated with other fetal structural abnormalities that must be detected and monitored during pregnancy. We established correlations between the postnatal or anatomopathological examination (in cases ended by therapeutic abortion) and the presence of RAA detected in the first trimester. MATERIAL AND METHOD: We conducted a retrospective analytical study that investigated the role of the RAA early detection (isolated or associated with other cardiac abnormalities) for a correct pregnancy monitoring and postpartum management. Between 2012 and 2018, patients admitted in the first Obstetrics and Gynecology Clinic-the Prenatal Diagnostic Unit-of the Emergency County Hospital from Craiova, were evaluated in the first trimester of pregnancy for genetic abnormalities and early morphology. The study material was represented by the patient's medical records (observation sheets, surgical protocol records, anatomopathological diagnostic records). The obtained information was stored in Microsoft Excel files and statistically processed. RESULTS: During the study period, 14 cases with right aortic arch were diagnosed in the first and second trimester of pregnancy. 4 cases were detected in the first trimester: 2 cases (50%) presented left ductus arteriosus (DA)-RAA type 2 ("U" sign) and 2 cases (50%) presented right DA-RAA type 1 (mirror image-"V" sign). RAA type 1 associated Tetralogy of Fallot in one case (25%) and in another one case (25%) the anomaly was isolated. RAA type 2 associated atrio-ventricular septal defect (AVSD) in one case (25%) and in another one case (25%) the anomaly was isolated. There were no fetal extracardiac structural abnormalities associated with the RAA diagnosis in the first trimester. CONCLUSIONS: Over a seven years study period (2012-2018), 14 cases with RAA in the first and second trimester of pregnancy were detected. In the low-risk pregnancies group, the first trimester incidence of the RAA was 0.11% and the association of congenital heart abnormalities was 50%.

Implications of the First Trimester 2d and 3d Ultrasound in Pregnancy Outcome.

BACKGROUND: In this study we researched for the first trimester pregnancy measurements by transabdominal and transvaginal ultrasound: gestational sac volume (GSV), embryo volume (EV), placenta volume (PV), yolk sac volume (YSV) and crown rump lengh (CRL) in predicting pregnancy outcome. Our goals was to demonstrate the ability of the first trimester ultrasound in identifying patients at high risk for abortion, intrauterine growth restriction (IUGR) and low birth weight. METHODS: Prospective observational clinical study that investigated the role of the first trimester 2D and volumetric (3D) measurements in predicting pregnancy outcome. The study was carried out in the Obstetrics and Gynecology Department of the Emergency County Hospital in Craiova during a study period of 3 years (between 2016 and 2018). The study included a number of 87 pregnancies. Patients included in the study were offered an early 2D and 3D transabdominal and transvaginal ultrasound and afterwards they were followed up until delivery. The statistical analyses (standard deviation, coefficient of variety, Cohen K correlation coefficient) determined a correlation between the two ultrasound methods, between the values of these parameters and pregnancy prognosis, the correlation being more relevant for the 3D ultrasound. The GSV, EV, YSV, PV, CRL and pregnancy outcome was established. RESULTS: Our study showed that the concordance degree between the two methods was 89.7%. 3D ultrasound had a diagnostic impact in 96.6% of the cases, while 2D ultrasound had a diagnostic impact in 89.6% of the cases. The incidence of the patients at high risk for complications was recorded in pregnancies with abnormal early ultrasound markers. CONCLUSIONS: First trimester ultrasound is a capable method for identifying a higher percentage of patients at risk of pregnancy complications, counseling and monitoring compared to 2D ultrasound. Also, because there is no radiation exposure, the risks are non-existent.

Therapeutic Options in Pregnant Women with Thrombophilia Depending on the Genetic Mutations- a Prospective Study.

The aim is to evaluate the effects of anticoagulant therapy (Enoxaparine) compared to antiaggregant therapy (Aspirin) on pregnancy outcome depending on the mutational status of clotting factors. The study was conducted prospectively over a 2 years period and included 110 pregnant women, of whom 80 patients diagnosed with hereditary thrombophilia and 30 healthy pregnant women, representing the control group. After careful observation, we concluded a positive influence of Enoxaparine on pregnancy outcome in pregnant women homozygous carriers for factor V Leiden gene mutation and compound heterozygous for Factor V Leiden and Prothrombin G20210A gene mutation. The study did not find significant positive results in women with heterozygous Factor V Leiden and G20210A prothrombin gene mutation who received anticoagulant therapy as well as pregnant women who received low-dose Aspirin compared with controls.

The Importance of Ultrasound Monitoring of the Normal and Lesional Cervical Ectropion Treatment.

OBJECTIVE: to investigate the importance of various ultrasound prognosis features in the assessment of the cervical ectropion treatment monitoring. METHOD: The inclusion criteria was the presence of ectropion and the selection was based on clinical examination performed during routine consultations in specialized clinics, later confirmed by colposcopic evaluation of cervix. The evaluation protocol included: clinical evaluation completed with colposcopy, guided biopsy when lesions were suspected, serological assay of day 21 progesteronemy, presence of Chlamydia, Mycoplasma, Ureaplasma, HVS type II, HPV and bacterial infections, transvaginal ultrasound serial evaluation at the 7th, 14th and 21st day before and after tretment concerning: cervical volumetric calculations and velocimetric measurements of uterine arteries flows. Progestative treatment was prescribed, and antiinfectious specific treatment when needed. Patients were reevaluated after 3 months. RESULTS: The prospective study included 45 patients between 2013-2014. 28 presented serum progesterone levels below the reference range or borderline. We noted a moderate reduction of the ectropion area in 42 % and a marked reduction in 58% of the cases. No statistically significant differences were found between the size of the cervix before or after treatment, except certain evaluations (the 7th and the 14th day) in the presence of bacterial coinfections. Evaluation of pulsed Doppler velocimetric indices of uterine arteries flows showed generally minor variations with no constant positive or negative trend. CONCLUSION: Based on the data obtained in our study, we conclude that ultrasound monitoring of ectropion treatment do not provide reliable prognosis data regarding the evolution of cervical lesion.

Acceptability of Intrapartum Ultrasound Monitoring - Experience from a Romanian Longitudinal Study.

OBJECTIVES: To assess the acceptability of intrapartum ultrasound (IPUS) labor monitoring in unselected Romanian women attending a tertiary maternity unit and the patients' experience of the examination (i.e. the perceived difficulty regarding the evaluation protocol). METHODS: The research was a prospective longitudinal observational study on unselected low-risk women that delivered in our unit. IPUS monitoring of active labor was proposed for observational purposes in low-risk population. Transabdominal and transperineal scans were performed hourly in the first stage of labor and at every 15 minutes in the second stage. The second day after birth, consenting women were invited to take part in a questionnaire survey with features regarding the patient's impression about the ultrasound monitoring scans during labor, and the acceptability of having an IPUS protocol for labor monitoring in the future. RESULTS: From 200 parturient women questioned, 98% of them agreed to IPUS investigation protocol. The demographic characteristics did not influence the acceptance. However, due to the small number of women declining IPUS we were not able to compare the characteristics and perceptions of women who declined the scan with those who accepted it. Most of the women (93% of accepters and 75% of decliners) had little difficulty deciding whether or not to have the scan protocol. All laboring women who had the IPUS scan found it an acceptable experience; 21% of women without epidural anesthesia rated the perceived difficulty as "mild" or "discomforting". Women rated having the IPUS scan as being significantly less difficult than having a cervical smear, transvaginal scan or having a digital clinical evaluation. 67% of the studied patients expressed increased confidence while being able to follow along the medical personnel the progression of the labor on the ultrasound screen. 97% of the consenting women who had the IPUS scans and all the 4 decliners said they would definitely or probably agree such ultrasound monitoring in a future labor, if this technique is proven useful for the labor outcome. CONCLUSIONS: IPUS protocol for labor monitoring was overwhelmingly acceptable in our population of women, despite the fact that they were learning about the procedure for the first time. The demographic characteristics did not influence acceptance, but due to the high rate of acceptance, predictors of acceptance could not be analyzed. More than two thirds of the patients expressed increased confidence while being able to follow along the medical personnel the progression of the labor on the ultrasound screen and almost all the participants were willing to have the procedure again in future, further reinforcing their favorable attitude to the procedure.

Agenesis of ductus venosus in sequential first and second trimester screening.

OBJECTIVE: The goal of this study is to evaluate the potential of first trimester (FT) screening in the diagnosis of agenesis of the ductus venosus (ADV) and to study its prevalence in a low-risk population, the associated conditions, and pregnancy outcome. METHOD: Prospective, sequential screening study at two tertiary units with morpho-functional evaluation of the ductus venosus during the first and second trimester screening. We quantified the FT detection rate, prevalence, and associated conditions: umbilical shunting type, concomitant anomalies, and outcome. RESULTS: In 6114 consecutive pregnancies, we identified 11 cases of ADV. Ten (91%) were identified during the FT examination. The prevalence was 1 in 556, similar for both centers (1/478 vs. 1/691). Major structural defects and fetal effusions were detected in 8 (73%). twenty two percent had a major chromosomal abnormality. In 3 cases, the anomaly was isolated and had normal outcome, independent of liver by-pass, caliber of the shunt, and NT thickness. CONCLUSIONS: Agenesis of the ductus venosus can be detected during FT. The early detection of ADV is important given its high association with major abnormalities.

Intrapartum ultrasound assessment of fetal head position, tip the scale: natural or instrumental delivery?

OBJECTIVES: The main objective of this study was to observe the behavior of the fetal head position during labor, when starting from occiput anterior or posterior position and also to determine their importance in labor management (if the starting fetal head position can be a strong argument in favour of vaginal or cesarean delivery). METHODS: 187 patients in labor were included in this study, with gestational age over 37 weeks and estimated fetal weight over 2500 g, singleton pregnancy, cephalic presentation, empty urinary bladder. For these patients the ultrasound assessed parameters were: fetal head position at the beginning of labour and fetal head rotation during labour. RESULTS: 89,18 percent of the patients starting from OTP (occiput transverse or posterior position) had a vaginal birth after an anterior rotation of the fetal head, and only 10,82 % presented persitent occiput posterior requiring cesarean section for delivery. Furthermore, considering only initial occiput posterior position, we observed an increased rate for cesarean section delivery (22,72%) by persistence of this position during labour. None of the patients starting with an anterior fetal head position rotated posteriorly. CONCLUSIONS: vaginal delivery in occiput anterior position was the most common result in both OTP and OP fetal head initial position. The main reason for cesarean delivery was persistent OP position. Patients with occiput posterior position were subsequent only to an initial posterior/transverse position.

Improved detection rate of structural abnormalities in the first trimester using an extended examination protocol.

OBJECTIVE: To assess the potential of first-trimester sonography in the detection of fetal abnormalities using an extended protocol that is achievable with reasonable resources of time, personnel and ultrasound equipment. METHODS: This was a prospective two-center 2-year study of 5472 consecutive unselected pregnant women examined at 12 to 13 + 6 gestational weeks. Women were examined using an extended morphogenetic ultrasound protocol that, in addition to the basic evaluation, involved a color Doppler cardiac sweep and identification of early contingent markers for major abnormalities. RESULTS: The prevalence of lethal and severe malformations was 1.39%. The first-trimester scan identified 40.6% of the cases detected overall and 76.3% of major structural defects. The first-trimester detection rate (DR) for major congenital heart disease (either isolated or associated with extracardiac abnormalities) was 90% and that for major central nervous system anomalies was 69.5%. In fetuses with increased nuchal translucency (NT), the first-trimester DR for major anomalies was 96%, and in fetuses with normal NT it was 66.7%. Most (67.1%) cases with major abnormalities presented with normal NT. CONCLUSIONS: A detailed first-trimester anomaly scan using an extended protocol is an efficient screening method to detect major fetal structural abnormalities in low-risk pregnancies. It is feasible at 12 to 13 + 6 weeks with ultrasound equipment and personnel already used for routine first-trimester screening. Rate of detection of severe malformations is greater in early- than in mid-pregnancy and on postnatal evaluation. Early heart investigation could be improved by an extended protocol involving use of color Doppler.

First trimester two- and four-dimensional cardiac scan: intra- and interobserver agreement, comparison between methods and benefits of color Doppler technique.

OBJECTIVE: To evaluate intra- and interobserver agreement for first-trimester fetal cardiac structural assessment, using two-dimensional (2D) ultrasound (2D-US) and 4D-US (4D spatiotemporal image correlation (STIC) technology), to compare the methods and to assess the advantages of adding color Doppler to each technique. METHODS: Digital videoclips (B-mode and color Doppler) and 4D-STIC volumes (gray-scale and color Doppler) from 632 pregnancies with normal fetal hearts were acquired and stored at the time of detailed first-trimester ultrasound examination. Later analysis on a randomized sample of 100 cases was performed, targeting 11 cardiac structures and features. We compared visualization of fetal heart parameters using 2D-US vs 4D-US and gray-scale vs color Doppler imaging. RESULTS: STIC volumes were considered satisfactory (adequate visualization of at least 8/11 parameters) in 78% of cases and 2D-US acquisitions in 89% of cases. The intra- and interobserver agreement was good for both 2D and 4D methods (kappa > 0.6), and the percentage overall agreement was very high using both methods (95%). 2D- and 4D-US identification of the fetal cardiac parameters did not differ significantly. The differences between gray-scale and color Doppler imaging were statistically significant in identifying similar key cardiac parameters, for both 2D- and 4D-US (P < 0.05). CONCLUSION: Both 2D and 4D methods for assessing first-trimester heart parameters are feasible and repeatable within and between observers. Color Doppler adds valuable information to both methods.

The contribution and the importance of modern ultrasound techniques in the diagnosis of major structural abnormalities in the first trimester - case reports.

We describe a series of cases where modern ultrasound (US) techniques diagnosed major structural abnormalities of the fetus in the first trimester (FT), unapparent when using the basic protocol of US investigation. In some cases, major structural abnormalities can be revealed in the FT scan solely to specialized personnel. Perhaps early screening should be confined in specialized centers, because congenital abnormalities detailed diagnostic has a huge impact in counseling the couple and also in prenatal advice of future pregnancies.

Uterine pseudotumors.

Pseudotumoral uterine lesions include benign reactive and artefactual changes, epithelial and mesenchymal, which occasionally are incorrectly interpreted as malignant or even premalignant lesions. Although some of these changes may have architectural or cytological abnormality, they are different from those observed in premalignant and malignant uterine lesions. The most common pseudotumoral lesions of the endometrium include various types of epithelial and stromal metaplasia, pseudolymphomas, inflammatory pseudotumor, adenomyosis, post-therapy surgical changes, artefactual changes, etc. Most of these changes may coexist with endometrial hyperplasia or endometrial carcinoma, and also with some benign conditions such as polyps or in combination with hormonal therapy or even in normal cyclic endometrium. These associated endometrial changes may raise important issues regarding the diagnosis and subsequent therapy.

Neuroimaging parameters in early open spina bifida detection. Further benefit in first trimester screening?

OBJECTIVE: Morphological investigation of the central nervous system (CNS) in fetuses with positive markers for open spina bifida (OSB) detection, visualized by ultrasound during the first trimester of pregnancy. MATERIALS AND METHODS: Data from fetuses that underwent routine first trimester ultrasound scan in our center during September 2007-March 2011 and presented abnormal aspects of the fourth ventricle, also referred as intracranial translucency (IT), provided the morphological support to evaluate CNS features. A neuro-histological study of posterior cerebral fossa illustrated anatomical features of the structures involved in the sonographic first trimester detection of neural tube defects. RESULTS: Abnormal IT aspects were found in OSB cases examined in the first trimester, but also in other severe cerebral abnormalities. Brain stem antero-posterior diameter (BS) and brain stem to occipital bone (BSOB) ratio may be more specific for OSB detection. Correlations between histological aspects of posterior brain fossa and ultrasound standard assessment have been made; highlighting the anatomical features involved by the new techniques developed for OSB early detection. CONCLUSIONS: Preliminary results show that modern sonographic protocols are capable to detect abnormalities in the morphometry of the posterior brain. First trimester fourth ventricle abnormalities should be followed by careful CNS evaluation because are likely to appear in OSB affected fetuses, but also in other CNS severe anomalies; in such cases, normal BS and BSOB ratio may serve as indirect argument for spine integrity, if specificity is confirmed in large series of fetuses.

The vasculogenesis--a possible histological identification criterion for the molar pregnancy.

The benign hydatidiform mole (partial and complete) practically represents an associated pathology of the first trimester miscarriage; it is considered that it represents the initial pathology, which, evolutionally, may be followed by the appearance of invasive mole and choriocarcinoma. The authors have studied clinical and cytogenetical 61 cases selected according to some specific criteria for the suspicion of molar pregnancy or hydropic abortion and 21 cases that represented the control group made by patients with normal pregnancy which have been presented for legal abortion. In all cases has been made a histological exam and has been studied the vasculogenesis by immunohistochemistry labeling for CD31 and CD34. Following-up the results has been established a number of histological and immunohistochemical criteria for the evaluation and differentiation of various molar pregnancy types and the vasculogenesis characteristics. The most important differential diagnosis criteria between partial and complete mole is represented by the trophoblast disposition and the atypical trophoblast in the complete mole.

Colposcopic evaluation of neoplasic and preneoplasic lesions of the cervix - a retrospective study.

Based on observation sheets and the existing database in Obstetrics - Gynecology Department, we reviewed the outcome for patients diagnosed with neoplasic and preneoplasic lesions of the cervix that were examined in our clinic. Colposcopic diagnosis efficiency was analyzed retrospectively reported to the histopathologic diagnosis and to the results of other studies. Our results were similar to those presented in international literature, showing a carefull evaluation of cervical lesions in our colposcopy department.