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David M Sherer, Sara Al-Haddad, Regina Cheng, Mudar Dalloul The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USACorrespondence: David M ShererDivision of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Avenue, Box 24, Brooklyn, NY, USATel +1 718 270-2081Fax +1 718 270-4122Email davidmsherer@gmail.comAbstract: The umbilical cord constitutes a continuation of the fetal cardiovascular system anatomically bridging between the placenta and the fetus. This structure, critical in human development, enables mobility of the developing fetus within the gestational sac in contrast to the placenta, which is anchored to the uterine wall. The umbilical cord is protected by unique, robust anatomical features, which include: length of the umbilical cord, Wharton’s jelly, two umbilical arteries, coiling, and suspension in amniotic fluid. These features all contribute to protect and buffer this essential structure from potential detrimental twisting, shearing, torsion, and compression forces throughout gestation, and specifically during labor and delivery. The arterial components of the umbilical cord are further protected by the presence of Hyrtl’s anastomosis between the two respective umbilical arteries. Abnormalities of the umbilical cord are uncommon yet include excessively long or short cords, hyper or hypocoiling, cysts, single umbilical artery, supernumerary vessels, rarely an absent umbilical cord, stricture, furcate and velamentous insertions (including vasa previa), umbilical vein and arterial thrombosis, umbilical artery aneurysm, hematomas, and tumors (including hemangioma angiomyxoma and teratoma). This commentary will address current perspectives of prenatal sonography of the umbilical cord, including structural anomalies and the potential impact of future imaging technologies.Keywords: prenatal ultrasound, umbilical cord, color Doppler imaging

Umbilical cord accidents preceding labor are uncommon. In contrast, nuchal cords are a very common finding at delivery, with reported incidences of a single nuchal cord of approximately between 20% and 35% of all singleton deliveries at term. Multiple loops occur less frequently, with reported incidence rates inverse to the number of nuchal cords involved. Rare cases of up to 10 loops of nuchal cord have been reported. While true knots of the umbilical cord have been associated with a 4-10-fold increased risk of stillbirth, nuchal cord(s) are most often noted at delivery of non-hypoxic non-acidotic newborns, without any evidence of subsequent adverse neonatal outcome. Prior to ultrasound, nuchal cords were suspected clinically following subtle (spontaneous or evoked) electronic fetal heart rate changes. Prenatal sonographic diagnosis, initially limited to real-time gray-scale ultrasound, currently entails additional sonographic modalities, including color Doppler, power Doppler, and three-dimensional sonography, which have enabled increasingly more accurate prenatal sonographic diagnoses of nuchal cord(s). In contrast to true knots of the umbilical cord (which are often missed at sonography, reflecting the inability to visualize the entire umbilical cord, and hence are often incidental findings at delivery), nuchal cord(s), reflecting their well-defined and sonographically accessible anatomical location (the fetal neck), lend themselves with relative ease to prenatal sonographic diagnosis, with increasingly high sensitivity and specificity rates. While current literature supports that single (and possibly double) nuchal cords are not associated with increased adverse perinatal outcome, emerging literature suggests that cases of ≥3 loops of nuchal cords or in the presence of a coexisting true knot of the umbilicus may be associated with an increased risk of stillbirth or compromised neonatal status at delivery. This commentary will address current perspectives of prenatal sonographic diagnosis and clinical management challenges associated with nuchal cord(s) in singleton pregnancies.

Characteristic phenotypic features of 16p13.3 microduplication include impaired mental development, arthrogryposis-like musculoskeletal anomalies (club-feet, congenital hip dislocation, and camptodactyly of fingers and toes), facial dysmorphology, and at times congenital cardiac disease. Most of the described affected individuals have microduplications involving the CREBBP gene. Findings indicate this gene to be dosage-sensitive and likely involved in the phenotypes of 16p13.3 microduplication syndrome. We describe the incidental finding of 16p13.3 microduplication in a fetus with mid-trimester sonographic examination showing absent nasal bone and transient unilateral hydronephrosis.

Liver herniation commonly associated with omphalocele occurs in only approximately 2.3% to 16% of fetuses with gastroschisis. Liver herniation in such cases is associated with considerably decreased survival rates (43% vs 97% with or without liver herniation, respectively). Rarely, abnormally positioned fetal hepatic vasculature has been reported mainly in association with congenital diaphragmatic hernia. In these rare cases, intrathoracic depiction of hepatic venous vasculature has assisted in confirming intrathoracic displacement of the fetal liver. We present a case of a large gastroschisis with complete herniation of the fetal liver in which prenatal sonography depicted an extracorporeal ductus venosus.

We describe unusual mid-trimester sonography of subtle fetal facial dysmorphic features including; flattened nasofrontal angle with an almost vertically positioned nasal bone, acute nasolabial angle, and convexity of the maxillary areas in a fetus with otherwise normal anatomy. Microarray identified a 64.5 KB interstitial deletion of 2q25.3, which includes one exon of MYT1L. Mutations and deletions in MTY1L have been associated with autosomal dominant intellectual disability, autistic features, and obesity. Association of these features and 2p25.3 microdeletion has not been reported previously. This case emphasizes the importance of detailed microarray analysis following the sonographic recognition of subtle fetal dysmorphic features.

David M Sherer, Crystal Roach, Sarin Soyemi, Mudar Dalloul The Division of Maternal-Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, Brooklyn, NY, USACorrespondence: David M ShererDivision of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Avenue, Box 24, Brooklyn, NY, 11203, USATel +1 718 270-2081Fax +1 718 270-4122Email davidmsherer@gmail.comAbstract: Diagnosis of potential umbilical cord compromise, namely, true knots of the umbilical cord and nuchal cords has been enabled with increasing accuracy with current enhanced prenatal sonography. Often an incidental finding at delivery, the incidence of true knots of the umbilical cord has been estimated at between 0.04% and 3% of deliveries. This condition has been reported to account for a 4 to 10-fold increase of stillbirth and perinatal morbidity of 11% of cases. Nuchal cords, commonly observed at the delivery of uncompromised, non-hypoxic non-acidotic newborns occur more frequently with single nuchal cords noted in between 20% and 35% of all deliveries at term. Multiple nuchal cords are considerably less frequent, with decreasing frequencies inverse to the number of nuchal cord loops. While clearly single (and likely double) nuchal cords are almost uniformly associated with favorable neonatal outcomes, emerging data suggest that cases of ≥ 3 loops of nuchal cords are more likely to be associated with an increased risk of adverse perinatal outcome (either stillbirth or compromised neonatal condition at delivery). We define cases of a true knot of the umbilical cord, cases of ≥ 3 loops of nuchal cords, any combination of a true knot and nuchal cord, or any umbilical cord entanglement (nuchal or true knot) in the presence of a single umbilical artery, in singleton gestations as complex umbilical cord entanglement. Two concurrent developments, the increase in accuracy of prenatal sonographic diagnosis of complex umbilical cord entanglement and recent data confirming fatal compromise of the umbilical circulation in approximately 20% of cases of stillbirth, suggest that establishing governing body guidelines for reporting of potential umbilical cord compromise, and recommendation of consideration for early-term delivery of select cases, may be warranted. This commentary will address current perspectives of prenatal diagnosis and clinical management challenges of complex umbilical cord entanglement.Keywords: prenatal ultrasound, complex umbilical cord entanglement, true knot of the umbilical cord, nuchal cord, clinical management

Placental abruption occurs clinically in approximately 1% of births although placental pathology assessment suggests a higher incidence. Ultrasound rarely plays a role in the diagnosis or clinical management of patients with suspected placental abruption. A patient with an incidental sonographic finding of a large concealed abruption at 36 weeks' gestation, led to induction of labor. This case and the established association of increased stillbirth with placental abruption among patients of advanced maternal age, suggest that at term, following sonographic findings of abruption, consideration should be given to elective delivery of these patients even in the absence of clinical symptomatology.

Background: In the United States, hyperemesis gravidarum is the most common cause of hospitalization during the first half of pregnancy and is second only to preterm labor for hospitalizations in pregnancy overall. In approximately 0.3-3% of pregnancies, hyperemesis gravidarum is prevalent and this percentage varies on account of different diagnostic criteria and ethnic variation in study populations. Despite extensive research in this field, the mechanism of the disease is largely unknown. Although cases of mortality are rare, hyperemesis gravidarum has been associated with both maternal and fetal morbidity. The current mainstay of treatment relies heavily on supportive measures until improvement of symptoms as part of the natural course of hyperemesis gravidarum, which occurs with progression of gestational age. However, studies have reported that severe, refractory disease manifestations have led to serious adverse outcomes and to termination of pregnancies. Summary: Despite extensive research in the field, the pathogenesis of hyperemesis gravidarum remains unknown. Recent literature points to a genetic predisposition in addition to previously studied factors such as infectious, psychiatric, and hormonal contributions. Maternal morbidity is common and includes psychological effects, financial burden, clinical complications from nutritional deficiencies, gastrointestinal trauma, and in rare cases, neurological damage. The effect of hyperemesis gravidarum on neonatal health is still debated in literature with conflicting results regarding outcomes of birth weight and prematurity. Available therapy options remain largely unchanged in the past several decades and focus on parenteral antiemetic medications, electrolyte repletion, and nutritional support. Most studies of therapeutic options do not consist of randomized control studies and cross-study analysis is difficult due to considerable variation of diagnostic criteria. Key Messages: Hyperemesis gravidarum carries a significant burden on maternal health and US health care. Most published research on pathogenesis is observational and suggests multifactorial associations with hyperemesis gravidarum. Precise, strictly defined criteria for clinical diagnosis are likely to benefit meta-analyses of further research studies regarding pathogenesis as well as therapeutic options.

In contrast to complete trisomy 8, which occurs in 0.8% of spontaneous pregnancy losses and is usually lethal, trisomy 8 mosaicism (Warkany syndrome 2), occurs in between 1:25,000 and 1:50,000 births and entails a widely variable phenotype including central nervous, ocular, cardiac, gastrointestinal, genitourinary and musculoskeletal abnormalities. Individuals with trisomy 8 mosaicism may exhibit developmental delays and are at increased risk of developing leukemia and myelodysplastic syndrome. We present an unusual case in which midtrimester sonographic diagnosis of fetal truncus arteriosus type I at 18 weeks' gestation, led to amniocentesis with an initial normal karyotype. Microarray analysis detected fetal trisomy 8 mosaicism. Systematic literature search reveals that the association between truncus arteriosus and trisomy 8 mosaicism has not been reported previously.

Multiple endocrine neoplasia (MEN) type 2a (Sipple's syndrome) is characterized by medullary thyroid carcinoma and pheochromocytoma, and in a smaller percentage of cases, multiglandular parathyroid hyperplasia. This autosomal-dominant syndrome is due to a mutation in the rearranged during transfection (RET) proto-oncogene located on chromosome 10cen–10q11.2 and rarely complicates pregnancy. We present an unusual case in a patient with an enlarged thyroid with sonographic findings characteristic of thyroid cancer, which led to diagnosis and subsequent management of RET proto-oncogene-positive MEN type 2a complicating pregnancy.

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.

Background Pulmonary embolus (PE) remains a leading etiology of maternal mortality in the developed world. Increasing utilization of retrievable inferior vena cava (IVC) filter placement currently includes pregnant patients. Case A 22-year-old woman at 27 weeks' gestation was diagnosed with Stage IV high-grade malignant B cell lymphoma following pathologic femur fracture. Significant risk factors for PE led to placement of primary prophylaxis IVC filter before cesarean delivery, open reduction and internal fixation of the fractured femur, and chemotherapy. Conclusion This case supports that primary prophylaxis placement of IVC filters in highly selected pregnant patients may assist in decreasing PE-associated maternal mortality.

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.

The purpose of this study is to assess whether serum beta-human chorionic gonadotropin (beta-hCG) levels on day 4 following methotrexate (MTX) treatment in patients with ectopic pregnancy predict successful single-dose therapy or the need for subsequent surgical intervention. Retrospective analysis of patients with ectopic pregnancies treated with MTX (50 mg/m (2)) was conducted. Inclusion criteria for MTX management were serum beta-hCG < 15,000 mU/mL, absent fetal cardiac activity, ultrasonographic gestational sac < 3.5 cm, normal liver function tests, hemodynamically stable patient with no evidence of hemoperitoneum, and informed consent. Day 1, 4, and 7 serum beta-hCG levels were obtained. Outcome parameters included successful single-dose MTX management, the requirement for multiple treatments, and whether subsequent surgery was required. Receiver operator characteristic (ROC) curves were used. P < 0.05 was considered significant throughout. Eighty-three patients were studied. Of these, 60 patients were treated successfully with single doses, 16 patients required two doses, and two patients required three doses of MTX, and five underwent surgical management. Mean day 1 serum beta-hCG levels of patients successfully treated with single-dose MTX was 3938.5 (+/- 589.2 [standard deviation]) versus 1767.65 (+/- 1237.8) mU/mL in patients requiring multiple doses of MTX therapy, ( P < 0.0001). ROC curves for serum beta-hCG levels on days 1, 4, and 7 were 0.449, 0.592, and 0.754, respectively, indicating that only day 7 serum beta-hCG levels were associated with successful single-dose MTX therapy. Serum beta-hCG levels on day 4 of MTX in patients with ectopic pregnancy do not predict successful single-dose therapy or the need for surgery.

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.

Objective To assess whether fetal cerebral vascular resistance is affected by the presence of nuchal cord(s) in the third trimester. Methods A set of 115 patients with well-established dates and singleton, appropriate for gestational age (GA), nonanomalous fetuses with nuchal cord(s) diagnosed with prenatalcolorDopplerimaging,between28and41 weeks and 115 controls matched for GA, were studied. Patients with hypertension, diabetes and autoimmune conditions were excluded. Doppler indices were obtained from the umbilical artery (UA) and the fetal middle cerebral artery (MCA) upon initial diagnosis of the nuchal cord. Results Of 115 GA-matched pairs of pregnancies, 103 fetuses had a single nuchal cord and 12 a double nuchal cord. No significant differences were noted in patient age, gravidity, parity, sonographically estimated fetal weight (SEFW), and growth centile at ultrasonographic diagnosis. Mean UA systolic/diastolic ratio (S/D) was 2.28 ± 0.32 and 2.36 ± 0.33 (P = 0.03) and UA resistance index (RI) 0.55 ± 0.06 and 0.57 ± 0.06 (P = 0.02) among study and controls, respectively. Mean fetal MCA S/D and RI did not differ significantly between the two groups (fetal MCA S/D 5.01 ± 1.28 and 5.04 ± 1.71 (P = 0.86), and mean fetal MCA RI 0.78 ± 0.06 and 0.78 ± 0.05 (P = 0.88)). No significant differences were noted in GA at delivery, incidence of meconium-stained amniotic fluid, birth weight, mode of delivery, neonatal gender, 1 and 5 minute Apgar scores, or UA pH and base excess, between study and control patients. Conclusion Fetal cerebral vascular resistance is not affected by the presence of nuchal cord(s) in the third trimester of pregnancy. Copyright  2005 ISUOG. Published by John Wiley & Sons, Ltd.

Objective To assess the feasibility of sonographic depiction of the fetal hard palate and secondarily to create nomograms throughout gestation of its sonographic width, length and area. Methods This was a cross-sectional study of pregnant patients between 15 and 41 weeks' gestation. Inclusion criteria consisted of well-established dates (confirmed by early ultrasound), and singleton, non-anomalous fetuses. Sonographic measurements obtained included biparietal diameter, head circumference, abdominal circumference and femur length. Fetal hard palate measurements included maximum width, maximum length and the calculated area. Tables were prepared depicting the estimated mean ± SD and 5th, 50th and 95th centiles at each gestational week between 15 and 41 weeks. Pearson's correlation coefficient and associated P-values for the relationships between fetal hard palate measurements and other sonographic measurements and coefficients of variation for each of the fetal hard palate measurements were calculated. Results The study included 602 consecutive patients. The mean maternal age was 28.7 ± 6.3 years, with median gravidity of 2 (range, 1–12) and parity 1 (range, 0–8). All attempts at obtaining fetal hard palate ultrasound measurements were successful. Mean fetal hard palate width (cm) = −0.73579345 + 0.11370432 × GA − 0.00083919 × GA2 and SD = −0.017842055 + 0.005142475 × GA, where GA is gestational age in weeks. Mean fetal hard palate length (cm) = −0.82020463 + 0.11767777 × GA − 0.00092801 × GA2 and SD = −0.043064317 + 0.006378869 × GA. Mean fetal hard palate area (cm2) = −2.40090641 + 0.17136556 × GA + 0.00097308 × GA2 and SD = −0.603647741 + 0.040740282 × GA. Sonographic measurements of the fetal hard palate width, length and area correlated significantly and strongly with gestational age (all P < 0.001) and significantly but less strongly with femur length (P = 0.004). Conclusion The fetal hard palate may be depicted sonographically with relative ease between 15 and 41 weeks' gestation and measurements of the fetal hard palate width, length and area correlate well with gestational age, biparietal diameter, abdominal circumference, sonographic estimated fetal weight, and femur length. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Cervical pregnancy is an uncommon ectopic pregnancy that accounts for approximately

We present an unusual case of a primigravida with a viable cervical pregnancy diagnosed by transvaginal ultrasound and magnetic resonance imaging. Staggered conservative therapeutic measures included systemic high-dose Methotrexate with Folinic acid rescue followed by bilateral embolization of the uterine arteries in response to active cervical bleeding despite declining serum beta-human chorionic gonadotropin levels. Continued active cervical bleeding responded to local tamponade with an inflated Foley catheter balloon positioned within the cervical canal. Conservative treatment was successful, with complete resolution of the cervical pregnancy, resumption of normal menstrual cycles, and a normal transvaginal ultrasonographic appearance of the cervical canal, documented 8 weeks after the initial diagnosis. This case and review of the literature support that various staggered conservative hemostatic measures may be used at various points in which bleeding may occur in the conservative management algorithm of cervical pregnancy.

Objective The goal of this study was to evaluate the performance of ThinPrep, a liquid-based cytology preparation technique, in comparison with conventionally prepared Papanicolaou smears in detecting cervical pathology. Methods Forty-seven English-language articles published between January 1990 and September 2002 were identified through Medline and manual searches. After elimination of 5 nonprimary articles, 10 unpaired studies, 5 descriptive articles with insufficient or no data, and 3 articles with data that could not be recast into a consistent format, there remained 24 usable articles. Seventeen articles contained data comparing ThinPrep with conventional cytology for 35,172 patients; and 10 articles compared cytology with histology or other gold standard diagnoses for 21,752 patients. Three of these articles contained both types of comparisons. The standard cytology classification into negative, atypical, low-grade (LGSIL) and high-grade (HGSIL) squamous intraepithelial lesions, and carcinoma was applied; other categorization schemes were recoded as necessary. Concordance estimates, based on five-way and dichotomous (normal/abnormal) classifications, were obtained from the 17 studies containing paired cytology data. Sensitivity and specificity rates were obtained from the 10 studies with paired cytology and histology data. Results The two methods tend to agree in 89 and 92% of cases based on the five-level and dichotomous classifications, respectively. ThinPrep was reported as normal in 93.5% of cases of normal conventional smears. The remaining 6.5% of ThinPrep slides were classified as follows: atypical, 4.55%; LGSIL, 1.56%; HGSIL, 0.36%; invasive cancer, 0.007%. Sensitivity rates, relative to histology, were 68% (conventional) and 76% (ThinPrep), and specificity rates were 79% (conventional) and 86% (ThinPrep). Conclusion ThinPrep tends to be more sensitive and specific than conventional smears in detecting cervical dysplasia. The increased sensitivity of ThinPrep results in increased cytologic diagnosis of cervical atypia, LGSIL, HGSIL, and invasive cervical carcinoma.

Objective To test the null hypothesis that no correlation exists between transvaginal digital examination and the gold standard technique of intrapartum transabdominal ultrasound determination of fetal head engagement, and secondarily to compare the performance of attending physicians and senior residents in depicting fetal head engagement by transvaginal digital examination. Methods Two hundred and twenty-two consecutive patients in labor > 37 weeks' gestation with normal singleton cephalic-presenting fetuses and with either ruptured or intact membranes were included. Of these, 119 were nulliparous and 103 were multiparous. Transvaginal digital examinations were performed by either attending physicians or senior residents and were followed immediately by transverse suprapubic sonographic assessments by a single sonographer. The fetal head was considered engaged on transvaginal digital examination if the leading part of the fetal head was positioned at least at maternal ischial spine station 0, and on transverse suprapubic ultrasound if the fetal biparietal diameter was below the maternal pelvic inlet. Examiners were blinded to each other's findings and the effect of examiner experience on the rate of agreement between the two techniques was assessed. The effect of several other independent variables upon the rate of agreement between the two modalities was also assessed. Results Overall, transvaginal digital examinations were consistent with ultrasound determinations with a raw percent agreement rate of 85.6% (95% confidence interval (CI), 80.8–90.3); κ = 69.5% (95% CI, 59.4–73.9; P < 0.001). When stratified according to parity, the raw percent agreement rate for nulliparous patients was 81.5% (95% CI, 73.4–88.0); κ = 60.7% (95% CI, 45.9–64.1; P < 0.001), and for multiparous patients it was 90.3% (95% CI, 84.1–95.9); κ = 80.4% (95% CI, 63.0–87.5; P < 0.001). Maternal age, gravidity, maternal body mass index, gestational age, cervical dilatation, effacement, membrane status, ischial spine station of the fetal head, fetal head position at ultrasound assessment, birth weight and mode of delivery did not significantly affect rate of agreement. Parity did not affect examination consistency in multiparous patients, but in the whole group increasing parity increased the rate of agreement between modalities. Presence of combined spinal epidural anesthesia significantly increased the rate of agreement in the complete group and among multiparous but not among nulliparous patients. Conclusion These data demonstrate a high rate of agreement (85.6%) between ultrasound determination and transvaginal digital assessment of fetal head engagement. Examiner experience had no effect. These data support the use of intrapartum transabdominal assessment of fetal head engagement. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

The differential diagnosis of reflective intrauterine membranes during pregnancy includes amniotic bands of fetal origin or membranes of combined maternal-fetal origin. While the former have been associated with fetal transverse reduction defects or the lethal amniotic band syndrome, the latter are usually benign and consist of a preexisting uterine septation or synechia around which the fetal membranes fold or become enveloped. We present an unusual case in which a patient was noted at 19 weeks' gestation to have an intrauterine membrane of undetermined origin, appearing to contain a pulsating vessel. Color Doppler imaging and Doppler flow velocimetry clearly depicted a pulse synchronous with the maternal heart rate, defining the membrane as amniotic membranes surrounding a preexisting uterine synechia and not a true amniotic band. The pregnancy was otherwise uneventful and the patient delivered a healthy neonate at elective repeat cesarean at which time the presence of the uterine synechia was confirmed.

Traditionally, oligohydramnios has been implemented as a sign of potential fetal compromise and associated with an increased incidence of adverse perinatal morbidity and mortality. Decreased amniotic fluid volume is especially of concern when it occurs in conjunction with structural fetal anomalies, fetal growth restriction, postdates pregnancies, and maternal disease. Consequently, following ultrasonographic diagnosis of oligohydramnios at term, delivery is routinely advocated even in otherwise uncomplicated pregnancies with an appropriate-for-gestational-age fetus, irrespective of the presence of reassuring fetal evaluation and the absence of maternal disease. Numerous factors complicate the ultrasonographic diagnosis of oligohydramnios. These include a lack of complete detailed understanding of the physiology of the dynamics of oligohydramnios, the transient condition at times of decreased amniotic fluid volume, generally poor performance of ultrasonography in detecting oligohydramnios, an array of different ultrasound diagnostic criteria, and varying ultrasonographic thresholds. In light of the latter and the lack of prospective randomized data, is unclear that the practice of effecting delivery for isolated oligohydramnios at term is justified. This article presents physiologic dynamics of amniotic fluid, factors that may affect amniotic fluid volume, possible pitfalls in the ultrasonographic assessment of amniotic fluid volume, and the clinical significance of oligohydramnios. In addition, the literature regarding perinatal outcome associated with oligohydramnios and current available data supporting expectant noninterventional management of cases complicated by isolated oligohydramnios at term are discussed.

Amniotic fluid (AF) is a biological medium uniquely suited for the study of early exposure of the human fetus to environmental contaminants acquired by the mother before and during pregnancy. Traditional diagnostic applications of AF have focused almost exclusively on the diagnosis of genetic aberrations such as Trisomy-21 and on heritable diseases in high-risk pregnancies. Since more than 50 anthropogenic compounds have been detected in AF, there is considerable potential in utilizing fetal protein biomarkers as indicators of health effects related to prenatal toxic exposure. Here, we focus on preterm birth (PTB) to illustrate opportunities and limitations of using AF as a diagnostic matrix. Representing a pervasive public health challenge worldwide, PTB cannot be managed simply by improving hygiene and broadening access to healthcare. This is illustrated by 15-year increases of PTB in the U.S. from 1989 to 2004. AF is uniquely suited as a matrix for early detection of the association between fetal exposures and PTB due to its fetal origin and the fact that it is sampled from women who are at higher risk of PTB. This critical review shows the occurrence in AF of a number of xenobiotics, including endocrine-disrupting compounds (EDCs), which are known or may reasonably be expected to shorten fetal gestation. It is not yet known whether EDCs, including bisphenol A, phytoestrogens, and polychlorinated biphenyls (PCBs), can affect the expression of proteins considered viable or potential biomarkers for the onset of PTB. As such, the diagnostic value of AF is broad and has not yet been fully explored for prenatal diagnosis of pregnancies at risk from toxic, environmental exposures and for the elucidation of mechanisms underlying important public health challenges including PTB.

Twin gestations are at significant increased risk for adverse perinatal outcome. As a result, although prospective randomized data is lacking, increased fetal surveillance has been advocated for twins. Growth concordance is considered a reassuring sign in twins and conversely, discordancy to possibly reflect a hostile intrauterine environment at least to the smaller twin. Consequently, increased surveillance of discordant twins is commonly practiced. Monochorionic twins are at further risk for type-specific perinatal complications, for example, twin-twin transfusion syndrome. Recently, precise first-trimester depiction of chorionicity has enabled early antepartum stratification of twin gestations according to chorionicity, in comparison with previous later (mid- and third-trimester) ultrasonographic diagnosis of chorionicity. This immediately leads to the question whether antenatal testing of twins should differ according to chorionicity? Review of the literature supports that despite the existence of complications unique to monochorionic twin gestations, dichorionic twins sustain an increased risk of adverse perinatal outcome (such as fetal growth restriction) in comparison with singletons, and that close antenatal fetal surveillance of twins should be performed, irrespective of chorionicity.

Celiac disease (gluten-sensitive enteropathy) may manifest clinically with an array of nongastrointestinal symptoms among which are: dermatitis herpetiformis; dementia; depression; various neurological symptoms; osteoporosis; osteomalacia; dental enamel defects, and anemia of various types. Important data have accumulated in recent years regarding the association between celiac disease, fertility and pregnancy. Many primary care obstetricians and gynecologists and perinatologists are not aware of these important relationships. The aim of this review, utilizing a MEDLINE search from 1966 through March 2000 of the English language, is to describe the possible effects of celiac disease and its treatment upon the reproductive cycle, fertility, pregnancy, and menopause. Review of the literature reveals that patients with untreated celiac disease sustain a significantly delayed menarche, earlier menopause, and an increased prevalence of secondary amenorrhea. Patients with untreated celiac disease incur higher miscarriage rates, increased fetal growth restriction, and lower birth weights. It appears that improvement of celiac disease, as reflected by restoration of small bowel mucosa associated with implementation of a gluten-free diet, may decrease miscarriage rates, improve fetal nutritional support and overall perinatal outcome.

Pseudomyxoma peritonei is an unusual condition more common in females, in which massive amounts of mucinous ascites in conjunction with mucinous peritoneal and omental implants occur. We performed a MEDLINE search of the English-language literature from 1966 to June 2000, utilizing the key words pseudomyxoma peritonei. All case reports, series and studies regarding this condition were reviewed. Cross-referencing was also performed. The etiology and treatment of this condition are currently controversial. Most investigators agree that surgical debulking and appendectomy are adequate initial therapeutic measures. The role of intraperitoneal chemotherapy, radiotherapy or application of mucolytic therapy remains uncertain. Recent molecular genetic studies suggest the appendix as the organ of primary origin of this disease.

Volvulus is an uncommon cause of bowel obstruction during pregnancy. We present an unusual case in which cesarean delivery at 26 weeks of gestation was complicated by volvulus of the small bowel 1 week following delivery. At laparotomy, detorsion of the loop of the terminal ileum sufficed, and bowel resection was not required. We review the literature pertaining to volvulus of the bowel during pregnancy and discuss recent new diagnostic imaging modalities for midgut volvulus, which may assist early noninvasive diagnosis of this condition.

Background Multiple endocrine neoplasia (MEN) type 2a is an autosomal dominant syndrome caused by specific proto-oncogene mutations characterized by medullary carcinoma of the thyroid, pheochromocytoma, and, occasionally, multiglandular parathyroid hyperplasia, which rarely complicates pregnancy. Secondary diabetes rarely has been reported in association with principal endocrinopathies complicating pregnancy. Case A 34-year-old primiparous woman with recently diagnosed gestational diabetes had repeated episodes of dizziness at 30 weeks of gestation, initially attributed to glyburide. Continued episodes of dizziness and later-appearing bouts of severe headache, palpitations, diaphoresis, severe hypertension, and marked tachycardia led to diagnosis and management of MEN type 2a complicating pregnancy. Conclusion Patients with MEN type 2a complicating pregnancy may present with gestational diabetes.

We present an unusual case in which a 36-year-old patient was referred due to increasing upper left quadrant abdominal pain and a possible left adnexal mass at 22 weeks' gestation. Ultrasonography demonstrated a multiseptated cystic mass, with solid components measuring 12 cm in diameter. A thin sonolucency was thought to separate the mass from the uterus and thus the mass was considered consistent with an adnexal mass, possibly a mucinous cystadenoma. A large degenerating leiomyoma could not be ruled out with certainty and magnetic resonance (MR) imaging was performed which depicted a thin band of myometrium encompassing the complex mass and was therefore diagnostic of a degenerating uterine leiomyoma. We discuss the contribution of MR imaging in the noninvasive diagnosis of undetermined solid pelvic masses visualized ultrasonographically.

Hyperemesis gravidarum or pernicious vomiting of pregnancy affects between 0.3% and 2% of all pregnant patients. The objective of this paper is to review current literature pertaining to epidemiology, etiology, symptomatology, complications, treatment, and perinatal outcome of patients with hyperemesis gravidarum. We performed a MEDLINE search of the English literature from 1966 through January 2000 utilizing the keywords: hyperemesis gravidarum, nausea and vomiting, and pregnancy. Current data pertaining to epidemiology, etiology, clinical manifestations, differential diagnosis, complications, various treatment modalities, subsequent perinatal outcome and recent developments are presented. Review of the literature supports that hyperemesis gravidarum is a multifactorial disease in which pregnancy-induced hormonal changes associated with concurrent gastrointestinal dysmotility and possible Helicobacter pylori infection function as contributing factors. Therapeutic key elements are mainly supportive in conjunction with antiemetic medication. It appears perinatal outcome is unaffected.

Placental hemosiderin deposition representing intrauterine bleeding at least 24–48 h before delivery is detected frequently in prematurity. The objective of this study was to assess incidence and site of histologic evidence of intrauterine bleeding in association with fetal growth in prematurity. Placentas of consecutive nonanomalous singleton liveborns delivered 2 weeks were excluded. A single reviewer blinded to clinical data except for gestational age at delivery assessed the presence of decidual hemosiderin. Statistical analysis included ANOVA, and Mann-Whitney U test with p < 0.05 considered significant. The study included 352 patients delivered for principal indication of premature rupture of membranes (PROM) or preterm labor (PTL) and 78 patients delivered for preeclampsia between 1989 and 1994. Mean birth weight percentiles for neonates delivered following PROM/PTL versus preeclampsia were: no decidual hemosiderin 42 ± 25 versus 17.4 ± 25, extraplacental membrane hemosiderin 42 ± 25 versus 9.2 ± 10, placental basal plate hemosiderin 42 ± 25 versus 17 ± 24, and hemosiderin in both sites 27 ± 21 versus 6.4 ± 10 (p = 0.02). Hemosiderin deposition in both placental basal plate and extraplacental decidua is associated with significantly lower mean birth weight percentiles in PROM/PTL at less than 32 weeks of gestation. We postulate that in these patients placental disruption which accompanies decidual bleeding may explain the relatively impaired fetal growth. In preeclampsia, hemosiderin depositions are not associated with further impaired fetal growth.

We present current data pertaining to angiogenesis of the ovary throughout the follicular and luteal phases of the ovarian cycle, in various ovarian pathologic conditions and in benign and neoplastic diseases. MEDLINE, Current Contents, and Index Medicus were searched for studies published between January 1966 and October 1998. All studies that incorporated human and animal models of angiogenesis of the normal ovarian physiologic state and pathologic conditions including both benign and neoplastic ovarian diseases were reviewed. Current literature supports that angiogenesis is an important component of both follicular and luteal phases of the ovarian cycle that correlates well with maturation of secretory endometrium. Angiogenesis also participates in various pathologic processes of the ovary, including follicular cyst formation, polycystic ovary, ovarian hyperstimulation syndrome, and both benign and malignant ovarian neoplasms. In the future a knowledge of specific angiogenic patterns of various pathologic processes may assist in the application of antiangiogenic medications in targeted therapy of benign and neoplastic diseases of the ovary.

First-trimester screening for fetal aneuploidy using nuchal translucency (NT), pregnancy-associated plasma protein A, free or total β-hCG, and maternal age constitutes a very effective screening test for fetal Down syndrome. We describe a case in which a patient presented at 14 weeks' gestation with an acute abdomen 1 week after first-trimester screening (including NT measurement) performed elsewhere, which was negative for trisomies 21 and 18. Sonographic examination revealed an interstitial pregnancy with a singleton fetus with present cardiac activity, which had not been noted 1 week earlier at the time of earlier transabdominal NT measurement. This case indicates that successful acquisition of a NT measurement during first-trimester screening for fetal aneuploidy does not negate the rare possibility of an unusual ectopic pregnancy. © 2008 Wiley Periodicals, Inc. J Clin Ultrasound, 2009

Cases of pelvic or abdominal abscess complicating pregnancy are rare. Noninvasive diagnostic techniques including ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) have enabled early diagnosis of this unusual complication of pregnancy. We describe a patient in whom the diagnosis of a pelvic mass was made by sonography and MRI at 25 weeks' gestation. At laparotomy, a pelvic abscess was partially resected and drained. Two weeks later when the patient again became symptomatic, a recurrent pelvic abscess was detected by CT and treated with intravenous antibiotics and CT-guided transcatheter drainage. The patient's recovery was thereafter uncomplicated and she delivered a healthy male infant by elective repeat cesarean at 38 weeks' gestation. The literature concerning pelvic and abdominal abscesses during pregnancy is reviewed. The potential advantages of imaging-guided, percutaneous transcatheter drainage for the treatment of such patients are emphasized. Target audience Obstetricians & Gynecologists, Family Physicians. Learning objectives After completion of this article, the reader will be able to understand the nonsurgical alternatives for the drainage of intraabdominal abscesses, the possible etiologies of intraabdominal abscess formation in the pregnant population, and the various approaches to percutaneous catheter drainage of intraabdominal abscesses.