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Appropriate imaging for women undergoing infertility workup depends upon the clinician’s suspicion for potential causes of infertility. Transvaginal US is the preferred modality to assess the ovaries for features of polycystic ovary syndrome (PCOS), the leading cause of anovulatory infertility. For women who have a history or clinical suspicion of endometriosis, which affects at least one third of women with infertility, both MRI and pelvic US can provide valuable information. If tubal occlusion is suspected, whether due to endometriosis, previous pelvic inflammatory disease, or other cause, hysterosalpingogram (HSG) is the preferred method of evaluation. To assess for anatomic causes of recurrent pregnancy loss (RPL) such as Müllerian anomalies, synechiae, and leiomyomas, saline infusion sonohysterography, MRI and 3-D US are most appropriate. Up to 10 of women suffering recurrent pregnancy loss have a congenital Müllerian anomaly. When assessment of the pituitary gland is indicated, MRI is the imaging exam of choice.

ABSTRACT: The ultrasonographic diagnosis of cerebral ventriculomegaly carries grave implications, in that affected fetuses may suffer abnormal postnatal development or therapeutic abortion. It is important for pathologists to corroborate the clinical diagnosis, but because diagnostic methodologies and criteria differ so radically, this can be problematic. The clinical diagnosis is made primarily by serial ultrasound examinations of the cerebral ventricles, spaces that can be altered postmortem, particularly when the brain is autolysed or deformed artifactually. We therefore sought to learn if examination of tissue, rather than spaces, can identify accurately those fetuses diagnosed with cerebral ventriculomegaly by prenatal ultrasound. The thickness of the cerebral mantle was obtained in 100 control fetuses aged 14 to 26 postmenstrual weeks. Statistical analysis revealed significant correlation of cerebral mantle thickness with crown–rump length, foot length, and head circumference. Twenty fetuses diagnosed with ventriculomegaly showed mantle thicknesses that were less than the control mean. In a few cases, mantle thickness fell between the mean and −1 SD; in several others, thickness was diminished by −1 SD to −2 SD; in one-half of cases, mantle thickness was 2 SDs or more below the expected mean. Head circumference was within 2 SDs of the control mean in most cases, and increased beyond 2 SDs in only two cases. Head circumference is an unreliable indicator of ventriculomegaly in the midgestational fetus. By contrast, cerebral mantle thickness is a simple and useful way of corroborating ultrasonographic diagnoses at autopsy and may also prove useful in clinical settings.

Fetal anterior abdominal wall defects will be recognized with increasing frequency with the widespread use of maternal serum alpha-fetoprotein screening. A clear distinction must be made between omphalocele and gastroschisis, and counseling and obstetric management must be specific for each. Sixteen cases of gastroschisis were identified ante-partum and followed through delivery between 1980–1986. There was one antepartum fetal death before institution of a protocol to deliver all such affected fetuses at 36 weeks. One patient was lost to follow-up. There were no antenatal or neonatal deaths among the 14 infants seen subsequently, all of whom were delivered by cesarean section. Only one infant had an additional nongastrointestinal defect (mild hearing loss), and all 14 were of appropriate weight for gestational age. Twelve infants had a single operative procedure for repair of the defect, with a mean hospital stay of 19.6 days. Scheduled cesarean delivery at 36 weeks, after confirmation of fetal lung maturity, presents the infant to the pediatric surgeon under controlled conditions and shortens neonatal hospital stay.

Magnetic resonance (MR) imaging, performed on 31 women with 40 surgically proven adnexal masses, was reviewed to determine whether MR can distinguish hemorrhagic from nonhemorrhagic masses. Fourteen masses proved to be hemorrhagic at surgery including functional ovarian cysts (seven cases), cystadenoma (one case), endometriomas (three cases), hematosalpinx (one case), ectopic pregnancy (one case), and parametrial extension from cervical carcinoma (one case). A high signal intensity (compared with adjacent pelvic fat) on a Tl-weighted spin echo sequence was found to be a reliable indicator of hemorrhage and was demonstrated in all 14 hemorrhagic masses. The “hematocrit” effect was seen as an area of high signal intensity layering in the dependent portion of six hemorrhagic cysts. Only four of 26 nonhemorrhagic masses demonstrated high signal intensity on Tl-weighted sequences and, of these, three proved to be fat-containing dermoid cysts and one was a simple cyst with adherent mesenteric fat. We conclude that high signal intensity on a Tl-weighted spin echo pulse sequence is evidence for a hemorrhagic mass and that a hematocrit effect appears to be a specific sign for a hemorrhagic cyst. The clinical significance of hemorrhagic adnexal masses is discussed.

Computed tomography of 31 patients with infections of the face and neck was reviewed and correlated with the clinical and surgical results. Computed tomography was found to be valuable for (a) distinguishing cellulitis from abscess, (b) defining the precise location and extent of complex infections, (c) demonstrating secondary complications, and (d) occasionally suggesting the etiology of infection. Based on this review, we concluded that CT provides important diagnostic information that aids clinical assessment and guides medical and surgical management of cervical infections. The anatomic relationships of selected cervical spaces are reviewed with respect to pathways of spread and potential complications of cervical infections.

Computed tomography (CT) demonstrated nodular thickening with calcification in the anterior and lateral tracheal walls of a patient with tracheobronchopathia osteochondroplastica. The CT findings in this rare disease are pathognomonic.

The antenatal sonographic diagnosis of exencephaly in four gestations is reported. Exencephaly is an uncommon malformation of the cranium that characteristically involves a large, disorganized mass of cerebral tissue. The flat bones of the calvaria are absent, leaving the brain mass uncovered. Secondarily, anencephaly may develop as a result of prolonged exposure of the developing encephalon to amniotic fluid and trauma in utero. As in anencephaly, facial structures and the bony base of the calvarium are often preserved in exencephaly. Sonographically, the outstanding feature of exencephaly is the cerebral mass, with convolutions or “pseudo” sulcal patterns present. These findings correlate well with the pathologic examination and define a clinical entity that is incompatible with human life.

Subjects were asked to move their eyes as far as possible to the left and to the right (n= 40). The right movement was significantly greater in extent. The extent of lateral eye movement correlated positively with scores on the rod-and-frame test and negatively with those on the WAIS Block Design and Similarities. Maximum extent of lateral eye movement may be a simple and useful index of cognitive style.

We assessed the growth of congenital masses of the lung during gestation using computer-assisted planimetry. The prenatal sonograms of 8 fetuses with congenital masses of the lung were reviewed. The cross-sectional area of the mass and chest were measured on the same transverse image using computer-assisted planimetry, and the percentage of the chest occupied by the mass was determined for each study. Four masses had pathologic features of type II congenital cystic adenomatoid malformation and intralobar sequestration (CCAM/ILS), 2 were type II CCAM, 1 was type I CCAM, and 1 was bronchial atresia with bronchiectasis. Four masses increased in cross-sectional area during gestation, 1 decreased, 2 were essentially unchanged, and 1 showed an initial increase in cross-sectional area followed by a decrease later in gestation. No consistent growth pattern was seen among masses with similar histologic characteristics. The percentage of the cross-sectional area of the chest occupied by the mass decreased in 7 fetuses and was virtually unchanged in 1 during gestation. All the fetuses survived to term; the infants had an uncomplicated postnatal course and underwent surgical resection of the mass during the first year of life. This study showed that in a fetus with a congenital mass of the lung and a favorable clinical outcome, growth of the chest exceeds any growth of the mass that may occur and masses with the same pathologic diagnosis have different patterns of growth in utero. © 1997 John Wiley & Sons, Inc. J Clin Ultrasound 25:372–377, 1997.

Abstract: Background. The “disappearance” of congenital masses of the lung on prenatal sonograms has been described, but the importance of postnatal imaging studies in these children is unknown. Objective. The objective of this work was to study the utility of radiographs and CT scans in asymptomatic infants with congenital masses of the lung that partially or completely resolve on prenatal sonograms performed late in gestation. Materials and methods. The prenatal sonograms, postnatal imaging studies, surgical findings, and pathologic diagnoses of seven children with an echogenic mass of the lung that improved or disappeared on prenatal sonograms were reviewed. Results. All masses were type II congenital cystic adenomatoid malformation, with features of intralobar sequestration also being found in four. An unsuspected extralobar sequestration adjacent to a left lower lobe mass was found at surgery in one patient. All masses were hyperechoic compared with normal lung on sonograms prior to 32 weeks of gestation, with cysts being seen in four. On scans after 32 weeks, four of the masses had resolved completely and three showed subtle increased echogenicity compared with normal lung. Cysts completely resolved in two of four cases. Postnatal radiographs showed subtle abnormalities in four infants, a hyperlucent lobe in one, a soft tissue mass with adjacent hyperlucency in one, and normal findings in one. CT scans were abnormal in all cases, with air-filled cysts and soft tissue in six and a hyperinflated lobe in one. Conclusion. Children with “disappearing” fetal lung masses have persistent abnormalities after birth that are often subtle on radiographs but are well demonstrated with CT.

Debate continues over whether to screen pregnant women for fetal Down syndrome in the first or the second trimester of pregnancy or in both trimesters. The First- and Second-Trimester Evaluation of Risk Factors (FASTER) Trial obtained direct comparative data on current screening methods from 38,167 women with singleton pregnancies who were cared for at 15 U.S. centers over approximately 3 years in 1999–2002. Down syndrome was found in 117 instances. Inclusion criteria included a maternal age of 16 or older and a fetal crown-rump length of 36 to 79 mm—consistent with a gestational age of 10 weeks 3 days through 13 weeks 6 days. First-trimester screening combined measurement of the nuchal translucency with maternal serum pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotropin (fhCG) levels. Quadruple screening in the second trimester, from 15 to 18 weeks gestation, included alpha-fetoprotein, total hCG, unconjugated estriol, and inhibin. Stepwise sequential screening, in which the Down syndrome risk estimate was provided after each test, was compared with “fully integrated” screening, which yielded only a single risk result after both the first- and second-trimester screening tests had been done.

Combining biochemical and sonographic data is an efficient means of screening for Down syndrome in the first trimester, but it is not clear whether this holds for the second trimester as well. This study evaluated 7 sonographic markers and the triple test of maternal serum biochemical markers in 2183 women with seemingly normal singleton fetuses who had sonography at 14 to 22 weeks gestation. The triple test included estimates of human chorionic gonadotropin (hCG), alpha-fetoprotein, and estriol. Sonography assessed nuchal fold thickness, humerus length, femur length, renal pyelectasis, hyperechoic bowel, echogenic intracardiac focus, and choroid plexus cysts. Maternal serum levels of hCG correlated significantly (although weakly) and negatively with both femur length and humerus length. There were no other correlations that were significant at the 1% level between femur or humerus length and the biochemical markers. Nuchal fold thickness did not correlate significantly with any biochemical marker. At the 5% level, hCG levels were lower when an echogenic intracardiac focus was found. Hyperechoic bowel tended to correlate with higher hCG and alpha-fetoprotein levels. Mean maternal age did not correlate significantly with log-transformed multiples of the mean (MOM) for hCG, alpha-fetoprotein, estriol, nuchal fold thickness, or humerus length. Maternal age did correlate negatively with the log-transformed MOM for femur length. In this control population, sonographic and biochemical markers of Down syndrome, evaluated in the second trimester, were largely independent of one another. It follows that these markers may be used as independent modifiers when assessing the risk of fetal Down syndrome.

A number of studies have reported an association between low concentrations of serum folate and preterm birth. Folate supplementation during pregnancy increased the length of pregnancy in some but not all clinical trials. This cohort study investigated whether preconceptional folate supplementation (as ascertained by patient questionnaire in the first trimester of pregnancy) lowers the risk of spontaneous preterm birth. The investigators analyzed data collected from a cohort of 34,480 low-risk singleton pregnancies in women enrolled in a previous prospective cohort study on Down syndrome screening conducted at 15 US centers between 1999 and 2002. Duration of pregnancy was estimated by ultrasound measurement in the first trimester. Spontaneous preterm birth was defined as preterm birth between 20 and 37 weeks with no medical or obstetrical complications that constituted indications for delivery. The effects of the duration of preconceptional folate supplementation of ≥1 year (long-term), <1 year and the effect of no supplementation on risk of spontaneous preterm birth were compared using time-to-event analysis. Data were subjected to analysis with multivariable logistic regression.

Placental function in early pregnancy reportedly is associated with a risk of low birth weight. This study was planned to learn whether fetal growth in the first trimester is associated with the duration of pregnancy, birth weight, and/or the risk of having a small for gestational age (SGA) infant. Among more than 38,000 women taking part in a prospective multicenter study in the years 1999–2003 were 976 who conceived by assisted reproductive technology, had crown-rump length measured by ultrasound in the first trimester, and delivered a live singleton infant with no evidence of congenital or chromosomal abnormality. The difference between actual and predicted crown-rump length or the difference in days of gestation (GA) was the postconceptional age as estimated by crown-rump length minus the actual days since conception.