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A cervical pregnancy is an uncommon ectopic pregnancy that accounts for less than 1% of such gestations. This condition is associated with an extremely high risk of massive hemorrhage and previously often required hysterectomy. The current diagnostic modality of this potentially life-threatening condition is transvaginal sonography, supported at times by magnetic resonance imaging. The definitive diagnostic imaging feature of a cervical pregnancy is the location of a gestational sac in the cervix in the presence of a closed internal uterine cervical os. We report the 3-dimensional transvaginal sonographic findings of a cervical pregnancy at 6 weeks' gestation.

Objective The purpose of this study was to create reference range nomograms of the axial fetal neck circumference (FNC) and fetal neck area (FNA) throughout gestation. Methods This prospective cross-sectional study involved pregnant patients between 14 and 40 weeks' gestation. Inclusion criteria consisted of well-established dates (confirmed by early sonography) and nonanomalous singleton fetuses with intact fetal membranes. Sonographic measurements included biparietal diameter, head circumference, abdominal circumference, femur length, humerus length, transcerebellar diameter, and sonographically estimated fetal weight. Axial FNC and FNA values were calculated as means of 3 separate measurements. The 5th, 50th, and 95th percentiles were estimated at each week of gestational age (GA) by least squares regression for the mean and SD of the FNC and FNA as functions of GA. R(2) and associated P values for the relationships between the FNC, FNA, and other sonographic biometric measurements were calculated. Results The study included 720 consecutive patients. The mean maternal age +/- SD was 27.3 +/- 6.6 years; median gravidity, 3 (range, 1-13); and median parity, 1 (range, 0-10). The following equations were devised: mean FNC (centimeters) = -11.85 + 1.687 x GA (weeks) -0.043 x GA(2) + 0.0004951 x GA(3); SD(FNC) = 3.15 - 0.3823 x GA + 0.01733 x GA(2) - 0.0002179 x GA(3); mean FNA (square centimeters) = 37.29 - 7.0 x GA + 0.4717 x GA(2) - 0.01245 x GA(3) + 0.0001222 x GA(4); and SD(FNA) = 7.08 - 0.9413 x GA + 0.04135 x GA(2) - 0.0004829 x GA(3). Both the FNC and FNA correlated significantly and strongly with biparietal diameter, head circumference, abdominal circumference, humerus length, femur length, transcerebellar diameter, and sonographically estimated fetal weight. Conclusions Current nomograms of the axial FNC and FNA throughout gestation have been provided.

Leiomyomas of the genitourinary tract may originate from the renal pelvis, bladder, urethra, or epididymis. 1 Interestingly, leiomyomas of the bladder are more common among women (76% of cases).2 Development is usually endovesical (63%), yet extravesical (30%) and intramural cases are not rare.3 Patients may be asymptomatic or may have obstructive urinary symptoms, irritative symptoms, hematuria, flank pain, or, rarely, dysmenorrhea or dyspareunia. 2-5 Leiomyomas of the bladder have been reported in association with neurofibromatosis type 1, in which leiomyomas occur most often in the gastrointestinal tract (proximal small bowel) and tend to be multiple.6 Rarely, urinary bladder leiomyomas have been diagnosed during pregnancy 7,8 and in a woman with a previous hysterectomy. 9 Diagnostic imaging modalities used include both transabdominal and transvaginal sonography, computed tomography, and magnetic resonance imaging.10-12 Although asymptomatic, nonobstructive, and nonproblematic leiomyomas may be managed expectantly, treatment is surgical by a transurethral approach, laparoscopy, or laparotomy 1-4 We present color Doppler imaging and 3-dimensional sonographic findings of a woman with a urinary bladder leiomyoma.

Prenatal sonographic diagnoses of subcutaneous soft tissue masses include hemangiomas, malformations (capillary, lymphatic, venous, arterial, or mixed), teratomas, and, rarely, sarcomas. 1-5 Prenatally depicted malformations may be seen in association with more complex fetal conditions, including Klippel-Trenaunay-Weber (angio-osteohypertrophy) and Proteus syndromes.6"9 We present an unusual case in which extensive multiple soft tissue tumors encompassing the fetal upper chest, back, nuchal area, and bilateral axillae, considered consistent with multiple large lymphatic malformations noted at 23 weeks' gestation, decreased in size throughout the remainder of gestation. At delivery, relatively small subcutaneous masses remained. Tissue histopathologic findings obtained at biopsy and the neonate's clinical course during which the subcutaneous masses underwent a marked spontaneous decrease in size, were consistent with low-flow mixed lymphatic and venous malformations.

The differential diagnosis of highly vascular, intramural lesions of the myometrium Includes arteriovenous malformation, gestational trophoblastic neoplasia, hemangiomata, sarcoma, and interstitial pregnancy. We present an unusual case in which a patient with irregular uterine hemorrhage in the presence of increasing serum β-human chorionic gonadotropin (β-hCG) levels exhibited transvaginal sonographic and color Doppler imaging findings considered consistent with an interstitial pregnancy. After laparoscopy and curettage yielded normal findings but with the continuously rising serum β-hCG levels and the concern for gestational trophoblastic neoplasia, the patient underwent vaginal hysterectomy. Histopathologic findings confirmed choriocarcinoma.

Germ cell tumors are most commonly located within the gonads. 1 Rare extragondal locations of these tumors include the retroperitoneum, mediastinum, sacrococcygeum, and central nervous system and are considered to result from aberrant migration of germ cells from the yolk sac during fetal development. 1 - 3 We present the transvaginal sonographic diagnosis of a large retroperitoneal pelvic epidermoid cyst (monodermal teratoma).

Physiologic dilatation of the maternal urinary collecting system occurs in more than 80% of gravidas by mid gestation. 1 Caliceal and ureteral dilation are more common on the right, and, similarly, the degree of caliceal dilatation is more pronounced on the right (15 versus 5 mm). 2 Although most women with hydronephrosis during pregnancy are asymptomatic, a few may have clinical signs and symptoms related to the upper urinary system. 3 When left-sided hydronephrosis is greater than the right, particularly if the patient is symptomatic, the likelihood of a pathologic condition, especially obstructive, should be considered. We present an unusual case in which a large left upper abdominal cystic structure depicted sonographically at mid gestation, initially considered consistent with an ovarian cyst, resulted from marked maternal ureteropelvic obstruction and required nephrostomy.

The differential diagnosis of prenatally diagnosed adrenal masses includes neuroblastoma, adrenal hemorrhage, adrenal and cortical renal cysts, adrenal adenoma and carcinoma, subdiaphragmatic pulmonary sequestration, Beckwith-Wiedemann syndrome, duplication of the renal system, Wilms tumors, congenital mesoblastic nephroma, and mesenteric and enteric duplication cysts. 1-5 The worldwide annual incidence of childhood adrenal cortical neoplasms ranges between 0.3 and 0.38 per 1 million children younger than 15 years. 6 These neoplasms are even more unusual among infants, with only 23 cases reported in the literature. 6 We present the first report of prenatal sonographic findings of a fetus with adrenal cortical adenoma.

Conjoined twins, rare complications of monozygotic twinning, occur in approximately 1% of monozygotic twins or between 1 per 100,000 and 1 per 250,000 live births. 1,2 Thoracopagus is the most common type of conjoined twins, with approximately 75% of such cases having conjoined hearts. 3 Reported cases of first-trimester transvaginal sonographic diagnosis of conjoined twins have almost uniformly involved gestational ages ranging between 11 and 14 weeks. 4-11 Earlier diagnosis is uncommon, yet single cases have been reported at 9 and 10 weeks, respectively. 12-17 An additional case of conjoined twins in a triplet pregnancy at 10.5 weeks' gestation was reported by Sepulveda et al. 18 We report an unusual case in which transvaginal color Doppler imaging confirmed the presence of thoracopagus, suspected during real-time sonography at 7 weeks' gestation.

Received July 13, 2006, from the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York USA. Revision requested July 18, 2006. Revised manuscript accepted for publication July 19, 2006. Address correspondence to David M. Sherer, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, 445 Lenox Rd, Box 24, Brooklyn, NY 11203-2098 USA. E-mail: dmsherer@aol.com Abbreviations EXIT, ex utero intrapartum treatment; 3D, 3-dimensional n 18-year-old nulliparous patient was seen for a second opinion at the State University of New York Downstate Medical Center after the diagnosis of a fetal “neck tumor” at 35 weeks’ gestation. Real-time 2-dimensional sonography and 3-dimensional (3D) sonography (Philips Medical Systems, Bothell, WA; iU22 sonography machine with a 2to 6-MHz 3D broadband curved array transducer) depicted an appropriatefor-gestational-age singleton fetus with an 11 × 10 × 9-cm (calculated volume, 900 mL) multilobulated, semisolid, semicystic mass protruding from the oral orifice (Figures 1–3). Smaller tumors of similar consistency protruded from and completely obstructed both nostrils (Figure 3). The fetal stomach was visualized, yet polyhydramnios was suggestive of impaired (obstructed) swallowing. The fetal neck and other anatomic structures appeared normal. An epignathus (congenital teratoma) involving the oropharynx and nasopharynx was diagnosed.1 Because of the anticipated neonatal upper airway obstruction at delivery, the patient was transferred to a fetal surgery center. Ultrafast fetal magnetic resonance imaging confirmed the presence of a large, multilobulated mass in the nasopharynx, oropharynx, oral cavity, and nasal cavities projecting outside the fetus. At 36 weeks’ gestation after spontaneous rupture of membranes, a female fetus weighing 2348 g was born by cesarean delivery and a successful ex utero intrapartum treatment (EXIT) procedure (tracheotomy).2 In the early neonatal period, the tumor emanating from the oral orifice (the hard palate) was partially resected. Histopathologic examination showed a teratoma. Later, the smaller nasopharyngeal and residual oropharynx tumors were resected. The infant subsequently had swallowing and feeding difficulties and severe gastroesophageal reflux. Accordingly, gastric fundoplication and gastrostomy were planned.

Hematotrachelos, engorgement of the uterine cervix with retained blood, may represent congenital or acquired conditions. Congenital hematotrachelos may be associated with obstruction distal to the cervix in cons ditions that include imperforate hymen, complete transverse vaginal septum, and, rarely, agenesis of the vagina with cervical atresia. 1-3 In contrast, acquired hematotrachelos is usually associated with cervical stenosis as a result of destructive cervical surgeries, including cone biopsy and loop electrosurgical excision procedures performed in the clinical management of cervical dysplasia. 4-8 We report an unusual case in which the development of acute spontaneous hematotrachelos was sonographically depicted in a multiparous patient during a 5-week period in proximation with intramuscular methotrexate treatment of a suspected tubal pregnancy.

The reported incidence of a true knot of the umbilical cord is approximately 1.2% of all deliveries. 1 , 2 Prenatal sonographic diagnoses of cases of a true knot of the umbilical cord have been reported infrequently. 3 - 6 RamOn y Cajal and Martinez 7 recently reported characteristic sonographic findings of this condition, in which a detailed investigation disclosed a transverse section of the umbilical cord surrounded by a loop of umbilical cord. This finding, noted in 5 cases, was termed the "hanging noose" sign. We present an unusual case in which 2 true knots of the umbilical cord were noted by power Doppler sonography in close proximity to each other at 33 weeks' gestation and were confirmed as separate true knots of the umbilical cord by 3-dimensional sonographic imaging.

Monoamniotic twins occur in approximately 5% of monochorionic twin gestations as a result of splitting of the inner cell mass at 8 or more days after fertilization, and they are associated with high perinatal mortality rates, ranging between 28% and 47%. 1,2 These gestations have unique pathologic conditions, including conjoined twins, a high prevalence of discordancy for fetal structural anomalies (the former and possibly also the latter resulting from consequences of the twinning process), and cord entanglement. 1 We present a case in which monoamniotic twins at first-trimester transvaginal sonography were confirmed by color Doppler imaging as having entangled umbilical cords.

Gartner duct cysts, the most common benign cystic lesion of the vagina, represent embryologic remnants of the caudal end of the mesonephric (wolff-ian) duct. 1 These cysts are usually small and asymptomatic and have been reported to occur in as many as 1% of all women. Because the ureteral bud also develops from the wolffian duct, it is not surprising that Gartner duct cysts have been associated with ureteral and renal abnormalities, including congenital ipsilateral renal dysgenesis or agenesis, crossed fused renal ectopia, and ectopic ureters. 1,3-7 In addition, associated anomalies of the female genital tract, including structural uterine anomalies (ipsilateral mullerian duct obstruction, bicornuate uteri, and uterus didelphys) and diverticulosis of the fallopian tubes, have been described. 6,8,9 Transabdominal and transrectal ultrasonographic depiction of Gartner duct cysts have been reported previously. 2,5,7,10 Here we report the transvaginal ultrasonographic findings of this condition.

A 44 year old para 1 woman was referred because of com-plaints of constant urinary incontinence, vaginal pain, andbleeding of 6 months’ duration. Her past medical historyconsisted of benign thyroid goiter, current cocaine abuse,and cigarette smoking of 10 years’ duration. Physicalexamination on admission revealed a cachectic female inno acute distress, weighing 85 lb, with normal vital signs.Pertinent physical findings included a soft, nontenderabdomen with no palpable masses. Pelvic examination dis-closed a normal introitus and a 3 to 4 cm fungating massreplacing the lower anterior vaginal wall, encasing the ure-thra, with a palpable indentation suggestive of a possibleurinary fistula. The uterine cervix was normal in appear-ance, size, and palpation. A normal-sized uterus andadnexa were palpated. Biopsy of the vaginal mass revealedsquamous cell carcinoma. Cervical Papanicolaou smearwas indicative of high-grade squamous epithelial lesion,for which the patient underwent a loop electroexcision pro-cedure, which was negative for invasion. Owing to thelower location of the tumor, the constant urinary inconti-nence, and the concern about a possible vesicovaginal fis-tula, transperineal ultrasonography was performed. A5 MHz transvaginal probe attached to an ATL Ultramark 9HDI machine (Advanced Technology Laboratories, Bothell,WA) was placed transperineally and axial, sagittal, andparasagittal views were obtained. Varying degrees of angu-lation were used for the axial views. This procedureallowed the imaging of a vesicovaginal fistula (Figs. 1, 2).After extensive counseling the patient underwent exam-ination under anesthesia and proctoscopy. Cystoscopy,although planned, was not attempted owing to the tumor’sobstruction of the urethra. Exploratory laparotomy wasperformed, and multiple positive bilateral pelvic lymphnodes were encountered. Because of advanced metastaticdisease, pelvic exenteration was not attempted. However, adiverting transverse colon conduit was performed. Thepatient’s postoperative course was complicated by febrilemorbidity of unknown cause. She was discharged after anotherwise uneventful postoperative course.

A prospective blinded study was performed on 191 high-risk patients with pregnancies ranging from 25 to 42 weeks gestation to investigate the value of a single Doppler analysis of the umbilical artery blood flow waveform (systolic-to-diastolic ratio, S/D) for predicting poor perinatal outcome. This was defined as the presence of heavy meconium, delivery of a growth-retarded infant, an umbilical cord arterial pH less than 7.2, or a 5-minute Apgar score less than 7. The interval between Doppler examination and delivery ranged from 12 hours to 15 weeks. No clinical data were available to the examiner performing the Doppler study. Moreover, the Doppler measurements were unknown to the attending physicians. The sensitivity, specificity, and positive and negative predictive values of the Doppler study in predicting outcome were 30.4%, 92.9%, 36.8%, and 92.6%, respectively, with an adverse outcome prevalence of 12%. These results indicate that a single random S/D ratio from the umbilical artery is not an adequate screening test for the risk of perinatal complications.

Small follicular ovarian cysts are a common finding in fetal and neonatal ovaries. We present a case in which precise prenatal and neonatal sonographic data were used to diagnose complete torsion of the adnexa requiring immediate neonatal surgical treatment