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Aim: Although an absent or reversed a-wave in ductus venosus (DV-RAV) is reported to be the terminal finding of fetal growth restriction (FGR), we have seen DV-RAV that disappears within a short span of time in some FGR cases with a hypercoiled cord. The purpose of this study was to investigate the relationship between hypercoiled cord and reversible DV-RAV in FGR., Methods: This was a retrospective study of 499 FGR cases, including 14 with DV-RAV. Transabdominal amnioinfusion (AI) was performed when oligohydramnios was severe (maximum vertical pocket <2 cm) and/or variable deceleration was detected. DV-RAV that disappeared quickly was defined as 'temporary DV-RAV'. DV-RAV that continued until delivery or fetal death (FD) was defined as 'persistent DV-RAV'. A hypercoiled cord was defined as one with an umbilical coiling index >0.6 antenatally or >0.3 postnatally. Clinical characteristics and clinical courses of the two types of DV-RAV were compared., Results: DV-RAV disappeared after AI in all five cases in which temporary DV-RAV was identified. The incidence of a hypercoiled cord was significantly higher among temporary DV-RAV cases (100%) than among persistent DV-RAV cases (14.3%; P = 0.015). The time from detection of DV-RAV to delivery or FD was significantly longer among temporary DV-RAV cases (4.5 weeks) than among persistent DV-RAV cases (0.7 weeks; P = 0.027)., Conclusion: Temporary DV-RAV is suspected to be related to the combination of a hypercoiled cord and oligohydramnios. DV-RAV may not be always be a terminal finding in FGR with a hypercoiled cord., (© 2018 Japan Society of Obstetrics and Gynecology.)

We performed a dual-gate Doppler examination for a twin reversed arterial perfusion (TRAP) sequence in a monochorionic-triamniotic triplet pregnancy at 16 weeks of gestation and were able to identify the pump twin by arterial pulse rate synchronicity. We performed radiofrequency ablation to coagulate blood flow in the acardius at 16 weeks of gestation without any postoperative complication. At 29 weeks of gestation, we performed a cesarean section due to preterm rupture of the membranes and the patient delivered 1167/1237-g female neonates and a macerated acardius. Examination of the placenta revealed two thickened vessels from the pump twin to the acardius, which had been prenatally identified by dual-gate Doppler. This new technology launches the new field of noninvasive fetal identification for triplet TRAP sequence.

Objective: To clarify whether distinguishing between the uterine isthmus and cervix can improve the accuracy of diagnosing placenta previa at term., Methods: A multicenter prospective observational study was conducted among pregnant women with suspected placenta previa at 20-24 weeks' gestation. Subjects were divided into the open isthmus group and closed isthmus group. The accuracy of diagnosing placenta previa at term was compared between the 2 groups., Results: We screened 9,341 patients, and 53 (0.6%) met the inclusion criteria. Nineteen cases with an open isthmus and 34 with a closed isthmus were followed. The accuracy for diagnosing placenta previa or a low-lying placenta at term was 94.7% in the open isthmus group and 26.5% in the closed isthmus group (p < 0.001). Elective or emergency Cesarean section was required in 100% of cases in the open isthmus group and 20.6% in the closed isthmus group (p < 0.001)., Conclusion: A high prediction rate of placenta previa was obtained by using transvaginal ultrasound at 20-24 weeks' gestation after the isthmus opened by carefully distinguishing between the cervix and isthmus., (© 2016 S. Karger AG, Basel.)

Cesarean scar pregnancy is one of the rare types of ectopic pregnancy. Ultrasonography enables early diagnosis and the successful preservation of the uterus. However, the correct diagnosis of cesarean scar pregnancy can be difficult in some cases. We describe a case of cesarean scar pregnancy that was initially misdiagnosed on the basis of current ultrasonographic criteria. Ultrasonographic images at 9 weeks' gestation demonstrated no gestational sac but did show a bulging mass in uterine wall with irregularly shaped hypoechoic areas, which resembled the lacunae in placenta previa. Color Doppler imaging demonstrated that the lacunae-like areas were richly perfused. Cesarean scar pregnancy was finally diagnosed with magnetic resonance imaging, which showed a lack of myometrium in the lower anterior uterine wall with placental invasion. Histological examination of the uterus after hysterectomy revealed the direct invasion of trophoblasts into the mural zone which had resulted in a deficit of myometrium at the previous cesarean scar. A mass in the myometrium with richly perfused lacunae-like areas should be considered as one of the important ultrasonographic findings indicating cesarean scar pregnancy.

Objectives: Uterine contractions (UC) in twin pregnancy are often experienced, yet the effects of UC in twin-twin transfusion syndrome (TTTS) remain to be clarified. The recipient heart preload condition and the effects of UC were evaluated and the final objective was to clarify the effects of tocolysis., Methods: Firstly, the preload indexes (PLIs) and cardiothoracic area ratios (CTARs) were analyzed on both fetuses of 10 TTTS cases, aged from 14 to 28 gestational weeks in stage III/IV cases for evaluating the preload condition. Then, the PLIs in the presence and absence of UC in the recipient fetuses were determined to evaluate the difference., Results: The PLIs of the recipient and the donor fetuses were 0.78 +/- 0.34 (n = 163) and 0.35 +/- 0.13 (n = 71) respectively. The CTARs were 30.2 +/- 6.1 (n = 62) and 23.4 +/- 5.4 (n = 62) respectively. The PLIs in the absence and presence of UC in the recipient fetuses were 0.69 +/- 0.29 and 0.99 +/- 0.38 (n = 35). All above comparisons showed highly significant differences (p < 0.0001)., Conclusion: The recipient fetuses have signs of cardiac dilatation and a high-preload condition. UC transiently further raises high-preload conditions of the recipient fetus. Thus, tocolysis may be necessary for management in cases of early-onset severe TTTS., (Copyright (c) 2004 John Wiley & Sons, Ltd.)

Objective: To characterize serial findings of the middle cerebral artery (MCA) and umbilical artery (UA) flow patterns, their relationship to each other, and neonatal outcomes in growth-restricted fetuses., Methods: Serial pulsatility indices (PIs) from MCA and UA Doppler waveforms were measured in 41 growth-restricted fetuses until Cesarean delivery. We found three patterns, as follows: phase 1 (n = 27), UA PI < MCA PI (no brain-sparing effect); phase 2 (n = 11), UA PI > MCA PI (brain-sparing effect); phase 3 (n = 3), both PIs elevated with the absence of end-diastolic flow or presence of reverse end-diastolic flow, which was designated as the 'breakdown of the brain-sparing effect'. Umbilical cord blood gas data at delivery were compared between each group., Results: Age at delivery and body weights were significantly different for each phase. The mean body weights in all phases were significantly diminished from Japanese standard body weights, indicating growth restriction. The phase 3 pH and base excess were significantly different from those of the other two phases., Conclusions: Growth-restricted fetuses which suffered from the state of breakdown of the brain-sparing effect were delivered early with severe growth restriction and mild metabolic acidosis. The change from decreased to increased MCA PI along with increasing UA PI may predict a severely growth-restricted infant.

Nonimmune hydrops fetalis can be associated with many fetal conditions. A fetal blood sample obtained from ultrasound-guided cordocentesis can offer vital information about the underlying cause of the nonimmune hydrops fetalis, and perinatal management can be planned accordingly. We attempted to evaluate a case of nonimmune hydrops fetalis conveying poor perinatal outcome through serial fetal blood sampling. Although we could establish no apparent reason for this acute case, fetal blood sampling in addition to ultrasonographic screening can play a key role in the management of the 'perplexing' nonimmune hydrops fetalis.