Short and thick corpus callosum - the thin border between a minor anatomical variant to very poor outcome.

The corpus callosum (CC) is the largest commissure connecting the cerebral hemispheres. Its components are recognized sonographically at 18-20 GW and from that point forward, its growth can be assessed using nomograms for CC length and thickness according to gestational week. Prenatal diagnosis of agenesis of the CC has been reported comprehensively. On the contrary, information regarding findings as short or thick CC is very rare. Is short CC an expression of callosal dysgenesis or could it be a variant of the normal development when all its parts exist? We discuss this issue through this case report.

Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain.

PURPOSE: To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion. MATERIALS AND METHODS: Retrospective cohort analysis of 322 women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion. RESULTS: The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026). CONCLUSION: Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.

First trimester expression of anorectal malformation: Case report and review of the literature.

A 26-years-old woman, underwent an ultrasound examination at 13.4 weeks. A cystic structure was identified in the right lower abdomen. Gradually, the cystic mass was replaced by echogenic content and eventually attained the appearance of hyperechoic bowel. At 21.2 weeks, the anal sphincter could not be demonstrated which was consistent with the diagnosis of isolated anal agenesis. Amniocentesis revealed 46XY karyotype with normal comparative genomic hybridization. After termination of pregnancy at 23 weeks, an autopsy revealed an isolated high type anorectal malformation (ARM) without fistula. We reviewed all 14 cases reported in the literature of first trimester sonographic expression of ARM.

Diagnosis of deep pelvic masses on a gynaecology service: Trans-vaginal ultrasound-guided needle aspiration of pelvic solid and cystic lesions.

OBJECTIVES: Women with undiagnosed pelvic lesions are often referred for evaluation and treatment. Transvaginal ultrasound-guided fine needle aspiration (TVUS-FNA) biopsy can assist in making management decisions. We describe our experience with this modality. METHODS: We performed a retrospective chart review of all women who had a TVUS-FNA biopsy between January 2004 and December 2014. Charts were reviewed for clinicopathologic information. The pathologic results of the TVUS-FNA were compared with the final diagnosis. RESULTS: Fifty-nine women underwent TVUS-FNA; the median age was 66 years (range 27-85). Thirty-three lesions were evaluated by fine-needle aspiration biopsy of the solid structure and 26 by aspiration of fluid for cytology. Pathologic feasibility rate was 88% (52/59). Of those with evaluable tissue, the sensitivity of the procedure was 100% and the specificity 92%. Considering the seven inconclusive results, the procedure had sensitivity of 88% (29/33) and specificity of 88% (23/26). Overall accuracy of TVUS-FNA for this patient cohort was 85%. No patient characteristics were found to distinguish between accurate and inaccurate or inconclusive TVUS-FNA result. No complications were noted. CONCLUSIONS: TVUS-FNA offers an excellent modality for the diagnosis and management of deep pelvic lesions otherwise not amenable for histologic evaluation.

Comorbidity of Post-traumatic Stress Symptoms and Depressive Symptoms among Obstetric Nurses with Perinatal Death Exposure.

BACKGROUND: Mental health and well-being among obstetric nurses after perinatal death is understudied. The primary goal of this study is to explore the comorbidity of post-traumatic stress disorder (PTSD) symptoms and depressive symptoms among obstetric nurses. In addition, we explore associations between personal resources - coping self-efficacy and active social support - and comorbidity symptoms. METHOD: One hundred and twenty-five obstetric nurses who represent 25% of the entire population of Israeli obstetric nurses completed self-report questionnaires regarding demographic data, coping self-efficacy, active social support, history of exposure to traumatic events, PTSD symptoms and depressive symptoms. RESULTS: An elevated risk of PTSD among obstetric nurses was positively associated with an elevated risk of depression and age while negatively associated with coping self-efficacy. CONCLUSIONS: These findings may suggest that nurse educators, administrators and leaders in the midwifery practice should promote stress intervention, supportive clinical environments and educational programs among obstetric nurses.

Psychological response to multifetal reduction and pregnancy termination due to fetal abnormality.

OBJECTIVE: To investigate the emotional response in cases of multifetal reduction and pregnancy termination and to compare the psychological response between these two groups. METHODS: A prospective study in a tertiary-care, university-affiliated medical center. The study group included 65 women who had been advised to terminate pregnancy because of a finding of a severe fetal abnormality on ultrasound screening (pregnancy termination group) and 41 women advised to undergo reduction because of the presence of multiple fetuses (multifetal reduction group). All women underwent psychological testing using validated questionnaires addressing perinatal grief and anxiety levels. RESULTS: Women in both the multifetal reduction and the pregnancy termination groups reported significant degree of grief and anxiety before and after the procedure, although the levels of anxiety on the day of procedure and anxiety and grief at follow up were higher in the pregnancy termination group (t = 2.438, p = 0.016; t = 2.441, p = 0.017; and t = 3.111, p = 0.03, respectively). In both groups there was a gradual decrease in the state anxiety with time (48.01 ± 8.26 to 37.59 ± 9.23; t = -9.931; p < 0.001). Several factors affected the emotional response in the cases, including marital status, level of education, employment status, and gestational age. There was no association between a history of prior perinatal loss and emotional response. CONCLUSION: There is need for a continuing psychosocial support of women undergoing multifetal reduction and pregnancy termination for fetal abnormalities.

Fetal sex and intrauterine growth patterns.

OBJECTIVES: To analyze the effect of fetal sex on intrauterine growth patterns during the second and third trimesters. METHODS: We conducted a cross-sectional study of women with uncomplicated singleton pregnancies who underwent sonographic fetal weight estimation during the second and third trimesters in a single tertiary center. The effect of fetal sex on intrauterine growth patterns was analyzed for each of the routine fetal biometric indices (biparietal diameter, head circumference, occipitofrontal diameter, abdominal circumference, and femur length) and their ratios. Sex-specific regression models were generated for these indices and their ratios as a function of gestational age. Sex-specific growth curves were generated from these models for each of the biometric indices and their ratios for gestational weeks 15 to 42. RESULTS: Overall, 12,132 sonographic fetal weight estimations were included in the study. Fetal sex had an independent effect on the relationship between each of the biometric indices and their ratios and gestational age. These effects were most pronounced for biparietal diameter (male/female ratio, 1.021) and the head circumference/femur length and biparietal diameter/femur length ratios (male/female ratios, 1.014 and 1.016, respectively). For the head measurements, these sex-related differences were observed as soon as the early second trimester, whereas for abdominal circumference, the differences were most notable during the late second and late third trimesters. CONCLUSIONS: Female fetuses grow considerably slower than male fetuses, and these differences are observed from early gestation. However, the female fetus is not merely a smaller version of the male fetus, but, rather, there is a sex-specific growth pattern for each of the individual fetal biometric indices. These findings provide support for the use of sex-specific sonographic models for fetal weight estimation as well as the use of sex-specific reference growth charts.

Sonographic evaluation of kidney parenchymal growth in the fetus.

OBJECTIVE: The aim of the study was to establish a nomogram for renal parenchymal thickness throughout pregnancy. METHODS: One-hundred and twenty-eight healthy women with singleton, well-dated, uncomplicated second- or third-trimester pregnancies were prospectively evaluated for renal parenchymal thickness on routine ultrasound scans. The renal parenchyma was measured in transverse and sagittal sections using predefined criteria. RESULTS: There were no differences in anterior or posterior parenchymal measurements in either plane by fetal sex. On sagittal-section analysis, no differences were noted between the right and left kidneys. A nomogram was established on the basis of the findings. The results showed constant linear growth of the fetal parenchyma during pregnancy. CONCLUSIONS: The normal fetal parenchyma grows at a constant, linear rate throughout pregnancy. The nomogram formulated may serve as a basis of future studies of the correlation of parenchymal thickness with postnatal kidney function in fetuses with urinary tract anomalies.

Sonographic diagnosis of ovarian torsion: accuracy and predictive factors.

OBJECTIVES: The purpose of this study was to determine the accuracy of sonographic diagnosis of ovarian torsion and the predictive value of typical sonographic signs. METHODS: The study included 63 women attending an ultrasound unit of a tertiary obstetrics and gynecology department in 2002 through 2008 who had suspected ovarian torsion on sonography and subsequently underwent laparoscopy. RESULTS: Sonography had diagnostic accuracy of 74.6% for ovarian torsion. Abnormal ovarian blood flow and the presence of free fluid were the most diagnostically accurate isolated sonographic signs (positive predictive values, 80.0% and 89.2%, respectively; negative predictive values, 46.2% and 46.2%). Using combinations of sonographic signs yielded higher specificity and positive predictive values and lower sensitivity and negative predictive values for ovarian torsion. The diagnostic accuracy was largely affected by the ultrasound operator (mean ± SD, 78.8% ± 16.0%; range, 60.0%-100%). CONCLUSIONS: In the setting of a specialized ultrasound unit, sonographic diagnosis of ovarian torsion had high (74.6%) accuracy compared with previous reports. The absence of typical sonographic signs does not rule out ovarian torsion, especially when the clinical presentation is suggestive. Basing assessments on multiple sonographic signs, including Doppler evaluation, increases the diagnostic specificity.

Sonographic prediction of fetal macrosomia: the consequences of false diagnosis.

OBJECTIVE: The purpose of this study was to determine the effect of false diagnosis of macrosomia (<4500 g) on maternal/perinatal outcomes. METHODS: We conducted a case-control study of women (n = 1938) in whom sonographically estimated fetal weight (EFW) was determined up to 3 days before delivery and actual birth weight (BW) was 3500 to 4499 g. Women with false-positive and -negative findings for macrosomia were compared, respectively, with women with true-negative and -positive findings for outcome variables. RESULTS: The cesarean delivery (CD) rate was 2 to 2.5 times higher when EFW was 4000 to 4499 g, regardless of actual BW. Failure to detect macrosomia was associated with higher rates of perineal trauma, 5-minute Apgar scores less than 7, and neonatal trauma, mostly related to the higher rate of surgical vaginal deliveries. The use of another sonographic model with a lower false-positive rate could theoretically reduce the CD rate by approximately 5%. CONCLUSIONS: False diagnosis of macrosomia substantially increases the CD rate and leads to maternal/neonatal complications.

Sonographic fetal weight estimation: which model should be used?

OBJECTIVE: The purpose of this study was to compare the accuracy of different sonographic models for fetal weight estimation. METHODS: We evaluated 26 different models using 3705 sonographic weight estimations performed less than 3 days before delivery. Models were ranked on the basis of systematic and random errors and were grouped according to the combination of biometric indices in each model. Cluster analysis was used to compare the accuracy of the different model groups. RESULTS: A considerable variation in the accuracy of the different models was found. For birth weights (BWs) in the range of 1000 to 4500 g, models based on 3 or 4 fetal biometric indices were significantly more accurate than models that incorporated only 1 or 2 indices. The accuracy of weight estimation decreased at the extremes of BWs, leading to overestimation in low-BW categories as opposed to underestimation when the BW exceeded 4000 g. The precision of most models was lowest in the low-BW groups. CONCLUSIONS: To improve the accuracy of fetal weight estimation, sonographic models that are based on 3 or 4 fetal biometric indices should be preferred. Recognizing the accuracy and the tendency for underestimation or overestimation of each of the available models is important for the judicious interpretation of fetal weight estimations, especially at the extremes of fetal weight.

Reference values for gamma-glutamyl-transferase in amniotic fluid in normal pregnancies.

OBJECTIVE: Nonvisualization of the fetal gallbladder by ultrasound poses a diagnostic dilemma. The aim of the study was to establish reference values for the hepatobiliary enzyme gamma-glutamyl-transferase (GGT) in amniotic fluid in normal pregnancies, and to determine the maximal week of gestation in which reference values can be determined. METHOD: A cross-sectional design was used. The study group consisted of pregnant women at 16 gestational weeks or more referred to our ultrasound unit for amniocentesis. Amniotic fluid was assayed for levels of GGT and other hepatobiliary enzymes using the Integra 800 device. The 5th and 95th percentiles for each gestational week were calculated. RESULTS: A total of 263 samples were analyzed. After conversion to log units, enzyme levels showed a good correlation with gestational week (Pearson). The mean values and the 5th and 95th percentiles were calculated for gestational weeks 16 to 22. Beyond 22 weeks, the number of examinations was insufficient for analysis. On multiple regression analysis, log values of alkaline phosphatase, maternal age, and gestational age independently affected log GGT values. Levels of alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were too low, and their correlation with gestational week too poor for calculation of reference values. CONCLUSION: GGT reference values in amniotic fluid in normal pregnancies were defined for gestational weeks 16 to 22. These data may be useful for differentiating isolated absence of fetal gallbladder from extrahepatic biliary atresia.

New regression formulas for sonographic weight estimation within 10, 7, and 3 days of delivery.

OBJECTIVES: The purpose of this study was to develop new regression formulas based on large numbers of sonographic examinations performed within 10, 7, and 3 days of delivery. METHODS: Sonographic fetal biometric measurements and delivery ward data for an unselected population were analyzed. Multivariate linear regression models were fitted to the sonographic data to predict the actual birth weight (BW) within 10, 7, and 3 days. RESULTS: The analyses included 6289, 5449, and 4007 patients who underwent sonographic examinations within 10, 7, and 3 days of delivery, respectively. All models yielded very high correlation coefficients (r = 0.927-0.958; R(2) = 0.859-0.918), low mean deviations between the calculated and actual BWs (6.4%-6.6% +/- 1 SD of 5.5%-5.9%), and high percentages of the calculated BW within 10% of the actual BW (78.5%-80.4%). Estimated fetal weight analyses made within 3 days of delivery yielded slightly better results than within 7 and 10 days. CONCLUSIONS: The new regression formulas yielded overall similar results, with a small advantage for estimates calculated within 3 days of delivery. Further prospective studies are needed to compare the accuracy of these formulas with those used to date.

Use of the amniotic fluid index combined with estimated fetal weight within 10 days of delivery for prediction of macrosomia at birth.

OBJECTIVE: The purpose of this study was to assess the value of combining the sonographically estimated fetal weight (EFW) and amniotic fluid index (AFI) measured within 10 days of term delivery for prediction of macrosomia at birth. METHODS: Prospective sonographic fetal biometric measurements and delivery ward data of a single center, uploaded separately over a 4-year period, were retrospectively linked to yield an unselected sample of nondiabetic pregnancies with live-born term neonates. RESULTS: Of the 1925 pregnancies evaluated, 140 (7.2%) were macrosomic (birth weight > or =4000 g). The AFI was significantly higher in the macrosomic group (P < .001). On receiver operating characteristic curve analysis, the area under the curve was larger for predictions based on the EFW alone than on the AFI. An EFW of 4000 g or higher had a positive predictive value of 46.6% for macrosomia at birth. Use of the previously suggested combined EFW and AFI cutoffs of 3689 g and 119 mm, respectively, yielded a positive predictive value of 30.3%. CONCLUSIONS: Combined use of the EFW and AFI rather than the EFW alone does not improve prediction of macrosomia at birth.

Transvaginal sonographic fetal axis determination in early second trimester.

OBJECTIVE: Correct prenatal determination of the fetal right/left axis is essential for the diagnosis of fetal malformations, in particular congenital heart anomalies. A reliable method of transabdominal echocardiographic assessment of the fetal situs in the late second trimester was established. We aimed to determine the validity of the transvaginal approach to assess fetal axis. METHOD: The study group consisted of 108 consecutive women in the second trimester of a singleton pregnancy, undergoing elective transvaginal anatomy scans. All had undergone previous transabdominal echocardiography to establish fetal axis. The same technique was used to assess the fetal axis during the transvaginal study, and the findings were compared. RESULTS: There was total agreement in fetal axis determination between transabdominal and transvaginal scans in all cases. The accuracy of the transvaginal study was not affected by maternal obesity, fetal position or the presence of cardiac malformation (in one case). CONCLUSION: Transvaginal ultrasonography is the reliable and accurate means of determining the fetal axis.

Normal range of fetal finger movements.

A congenital limitation of finger movements is associated with many syndromes that interfere with child well-being. The normal range of fetal finger movements during the second and third trimester is unknown. The aim of this study was to measure the normal range. In this study, fetal finger flexion and extension were examined during routine ultrasound screening in 260 consecutive normal fetuses at gestational age 16-41 weeks. Full extension and flexion of the fingers were noted in 110 fetuses examined at 16-26 weeks. Of the 150 fetuses examined at 27-41 weeks, full flexion and extension were noted in 118 (78.7%), full flexion and partial extension in 30 (20%), and full flexion without extension in two (1.3%). Knowledge of the normal range of fetal finger movements will assist clinicians in the prenatal diagnosis of other anomalies and syndromes.

Pregnancy outcome of threatened abortion with subchorionic hematoma: possible benefit of bed-rest?

BACKGROUND: Bleeding in the first trimester of pregnancy is a common phenomenon, associated with early pregnancy loss. In many instances a subchorionic hematoma is found sonographically. OBJECTIVE: To evaluate the possible benefit of bed-rest in women with threatened abortion and sonographically proven subchorionic hematoma, and to examine the possible relationship of duration of vaginal bleeding, hematoma size, and gestational age at diagnosis to pregnancy outcome. METHODS: The study group consisted of 230 women of 2,556 (9%) referred for ultrasound examination because of vaginal bleeding in the first half of pregnancy, who were found to have a subchorionic hematoma in the presence of a singleton live embryo or fetus. All patients were advised bed-rest at home; 200 adhered to this recommendation for the duration of vaginal bleeding (group 1) and 30 continued their usual lifestyle (group 2). All were followed with repeated sonograms at 7 day intervals until bleeding ceased, the subchorionic hematoma disappeared, or abortion occurred. The groups were compared for size of hematoma, duration of bleeding, and gestational age at diagnosis in relation to pregnancy outcome (spontaneous abortion, term or preterm delivery). RESULTS: The first bleeding episode occurred at 12.6 +/- 3.4 weeks of gestation (range 7-20 weeks) and lasted for 28.8 +/- 19.1 days (range 4-72 days). The women who adhered to bed-rest had fewer spontaneous abortions (9.9% vs. 23.3%, P = 0.006) and a higher rate of term pregnancy (89 vs. 70%, P = 0.004) than those who did not. There was no association between duration of vaginal bleeding, hematoma size, or gestational age at diagnosis of subchorionic hematoma and pregnancy outcome. CONCLUSIONS: Fewer spontaneous abortions and a higher rate of term pregnancy were noted in the bed-rest group. However, the lack of randomization and retrospective design of the outcome data collection preclude a definite conclusion. A large prospective randomized study is required to confirm whether bed-rest has a real therapeutic effect.

Accuracy of sonographic estimation of fetal weight before induction of labor in diabetic pregnancies and pregnancies with suspected fetal macrosomia.

AIMS: To evaluate the accuracy of sonographic estimation of fetal weight (EFW) in diabetic pregnancies and pregnancies with suspected fetal macrosomia. METHODS: 63 women with diabetic pregnancies, 74 nondiabetic women with suspected large-for-gestational-age (LGA) infants, and 161 controls underwent ultrasound assessment prior to induction of labor. EFW was compared to the weight at birth, 1-3 days later. RESULTS: EFW was highly correlated to birth weight. Absolute or actual weight differences between the birth weight and the EFW, and the rate of EFW within 10% of birth weight were not different between the groups. A linear regression model controlling for maternal and gestational age, diagnosis of gestational or pregestational diabetes, birth weight, gravidity, parity, nulliparity, placental location and AFI was not significantly correlated to the absolute or actual weight differences. In pregnancies with suspected LGA, higher birth weight was an independent and significant predictor of high weight difference inaccuracy. CONCLUSIONS: The ultrasonographic EFW 1-3 days before delivery is highly correlated with birth weight, reaffirming the clinical use of abdominal circumference and femur length in estimating fetal weight near labor at term. In pregnancies with suspected LGA fetuses and higher prevalence of macrosomia, ultrasound has higher sensitivity but lower specificity than the controls.