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The umbilical cord is crucially important feto-maternal unit, though very simple in structure while containing two arteries and one vein; it modulates blood flow conveyance between the fetus and placenta. Umbilical cord characteristics, such as cord length and thickness, number of vessels and their diameters, amount of Wharton's jelly, type of placental insertion, coiling and blood flow patterns are recognized contributors that may reveal increased risk for possible antenatal and perinatal complications. However, during the “routine” fetal anatomical survey, only the number of umbilical cord vessels is recorded in majority of antenatal centers. Thereafter, umbilical cord is rarely analyzed, except for umbilical artery blood flow patterns that are mainly used to further assess well-being of growth-restricted fetuses. At present time, it appears prudent to exercise more detailed umbilical cord analysis, including but not limited to vessel number, coiling patterns and cord thickness, during the fetal...

This study considers whether admission to the hospital of a patient diagnosed with a short cervix delayed delivery, prevented preterm delivery, and/or decreased the rate of change in the cervical length (CL) on follow-up measurements. The design was a retrospective cohort study of women carrying singleton pregnancies with cervical lengths

Objective To evaluate whether a relationship exists between the antenatal umbilical coiling index (UCI) and umbilical cord Doppler flow characteristics. Methods During the fetal anatomical survey in 200 consecutive pregnant patients at 18–23 weeks' gestation, we recorded umbilical coiling patterns and blood flow characteristics. The antenatal UCI, calculated as a reciprocal value of the distance between a pair of umbilical cord coils, was compared with Doppler parameters including umbilical vein blood flow volume (in mL/min/kg), and mean resistance index (RI) and peak systolic velocity (PSV in cm/s) averaged from both umbilical arteries. Results A total of 154 patients met the inclusion criteria of singleton pregnancy and having adequate sonographic umbilical cord images, Doppler flow indices, and all demographic, antenatal and labor data. The mean antenatal UCI was 0.40, with 10th and 90th centiles of 0.20 and 0.60, respectively. The mean ± SD umbilical artery RI and PSV and umbilical vein blood flow volume were 0.74 ± 0.07, 25.1 ± 6.4 cm/s, and 264 ± 106 mL/min/kg, respectively. All Doppler variables correlated significantly with antenatal UCI, with lower RI and higher PSV and umbilical vein blood flow volume values being associated with higher antenatal UCI (P = 0.016, P < 0.001, and P = 0.032, respectively). However, when stratified by antenatal UCI into hyper- (above 90th centile), normo- (10th–90th centile), and hypocoiled (below 10th centile) umbilical cord groups, a significant difference was observed for PSV only (P = 0.016). Conclusion It appears that umbilical cord coiling modulates noticeably blood flow through the umbilical cord. We speculate that more prominent umbilical coiling (higher antenatal UCI values) has a protective effect on blood flow in terms of decreased arterial resistance and higher blood flow velocities, as well as increased venous blood flow. However, due to lack of significant differences between Doppler characteristics when stratified by antenatal UCI into hypo-, normo-, and hypercoiled groups, the clinical implications of this observation are uncertain. Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.

Objective The clinical application of first-trimester aneuploidy screening remains controversial in the United States. The aim of our study was to evaluate the performance of maternal age, fetal nuchal translucency measurements, pregnancy-associated plasma protein A, and free beta-human chorionic gonadotrophin used in aneuploidy screening in a single institution outside of a clinical trial. Study design Four thousand eight hundred eighty three patients underwent first-trimester aneuploidy screening at 11 to 13 6/7 weeks of gestation (fetal crown-rump length 45 mm to 84 mm) at our institution between January 2003 and September 2004. Measurement of nuchal translucency was performed according to the Fetal Medicine Foundation standards and was included in the overall risk assessment performed by NTD Laboratories. Measurement of pregnancy-associated plasma protein A and free beta-human chorionic gonadotrophin on maternal dried whole blood samples was conducted by NTD Laboratories and was reported as gestational-specific multiples of the median adjusted for ethnicity. Risk adjustment for trisomy 21 and trisomy 18 was done with a standard algorithm using maternal age, serum biochemistry, and nuchal translucency. Only singleton gestations (N = 4615) were included in the analysis. Results The median maternal age was 33.0 years (interquartile range 31.0 to 36.0) and the median crown-rump length was 61.2 mm (interquartile range 55.7 to 67.2) at the time of screening. There were a total of 22 fetuses diagnosed with trisomy 21 and 8 with trisomy 18. The detection rates for trisomy 21 for a 5% false-positive rate and 1% false-positive rate were 90.9% (20 of 22) and 77.3% (17 of 22), respectively. Similarly, the detection rates for trisomy 18 at a 5% false-positive rate and a 1% false-positive rate were 100% (8 of 8) and 100% (8 of 8), respectively. Conclusion Non-investigational use of first-trimester aneuploidy screening for trisomy 21 and trisomy 18 can replicate results from investigational trials.

Objective The purpose of this study was to evaluate the antenatal umbilical cord coiling index obtained during the fetal anatomic survey in the second trimester as a predictor of adverse pregnancy outcome. Study design Four hundred twenty-five consecutive women who had a fetal anatomic survey between 18 to 23 weeks of gestation were evaluated for umbilical cord coiling. The antenatal umbilical cord coiling index was calculated as a reciprocal value of the distance between a pair of coils (antenatal umbilical cord coiling index = 1/distance in cm) and was correlated with the following adverse pregnancy outcomes: (1) small for gestational age, (2) mode of delivery, (3) presence of meconium-stained amniotic fluid, (4) presence of nonreassuring fetal status in labor, and (5) Apgar scores at 1 and 5 minutes. Results A total of 294 patients had adequate ultrasound images and all antenatal and labor data to meet the study inclusion criteria. Abnormal coiling was associated significantly with small for gestational age neonates at birth ( P = .043) and nonreassuring fetal status in labor ( P = .007). Nine of 58 neonates (15.5%) with abnormal umbilical coiling were small for gestational age infants compared with 15 of 236 small for gestational age neonates (6.4%) who had normal cord coiling. A nonreassuring fetal status in labor was observed in 25.7% of fetuses (15/58 fetuses) with abnormal umbilical coiling compared with 11.0% of fetuses (26/236 fetuses) with normal cord coiling. In contrast, no statistical difference for Apgar scores at 1 and 5 minutes or higher prevalence of interventional deliveries and meconium-stained amniotic fluid in labor between the groups with normal and abnormal umbilical cord coiling was observed. Conclusion Abnormal umbilical cord coiling that is detected at the fetal ultrasound anatomic survey in the second trimester is associated with a higher prevalence of small for gestational age neonates and nonreassuring fetal status in labor. This observation can be used potentially as a predictor of adverse antenatal or perinatal events in future studies.

To evaluate interval fetal growth and compare the incidence of small-for-gestational age (SGA) newborns between fetuses with an isolated single umbilical artery and those with a 3-vessel umbilical cord.A retrospective, case-controlled study in which 84 singleton pregnancies with an isolated single umbilical artery were compared with 3-vessel umbilical cord fetuses as the control group.There was no statistical difference between the groups in maternal demographic data, except for ethnicity and neonatal outcomes, respectively. The mean newborn birth weight was similar between the isolated single umbilical artery and the control groups, 3,268 +/- 596 g and 3,274 +/- 627 g, respectively. The prevalence of SGA newborns was 7.1% (6 of 84) in the isolated single umbilical artery group and 4.8% (4 of 84) in the control group. An ultrasound examination demonstrated fetal growth restriction in 50% of cases (3 of 6) in the isolated single umbilical artery group and in 25% of subjects (1 of 4) in the control group, respectively.Fetuses with an isolated single umbilical artery are at similar risk for SGA compared with fetuses with 3-vessel umbilical cords. It appears that antepartum serial ultrasound examination does not provide more information for interval fetal growth assessment in fetuses with an isolated single umbilical artery.

The purpose of this study was to evaluate the sonographic accuracy to determine the umbilical coiling index (UCI) during the routine fetal anatomic survey in the second trimester.In 300 consecutive women with singleton pregnancies and absence of gross fetal anomalies who had a routine second-trimester fetal anatomic survey, a distance between 2 pairs of coils was measured from the longitudinal images of the umbilical cord, and the antenatal UCI (aUCI) was calculated. The aUCI was compared with true UCI results obtained after birth.Two hundred thirty-six patients had adequate sonographic umbilical cord images, and all required demographic, antenatal, and labor data collection to meet the inclusion criteria. A statistically significant correlation between aUCI and true UCI was found (P.0001; r = 0.643). The mean aUCI was 0.402 (80% confidence interval, 0.382), and the true UCI at birth was 0.203 (80% confidence interval, 0.176). The sonographic evaluation showed 12.3% and 8.9% of hypocoiled and hypercoiled cords, whereas evaluation at birth found 10.6% and 8.1% hypocoiled and hypercoiled umbilical cords, respectively. The sensitivity values of sonography to predict hypocoiling and hypercoiling at birth were 78.9% and 25.4%, respectively.A sonographic evaluation of umbilical cord coiling in the second trimester correlates with the true UCI at birth, although the sensitivity in predicting coiling patterns as hypocoiled and hypercoiled cords is less accurate. A difference between the aUCI and matched UCI at birth could be explained by a sonographic error in the sampling of different umbilical cord segments with discordant coiling patterns or the possibility of a dynamically evolving UCI with advancing gestational age.

Objective. The relationship between amniotic fluid volume and gestational age has been described previously. The association of body weight and urine output has been observed in human neonates. Our goal was to assess the correlation of the amniotic fluid index (AFI) with estimated fetal weight (EFW) in the third trimester. Methods. We conducted a retrospective observational study on 426 pregnant women with singleton gestations who were referred to our unit for sonographic evaluation in the third trimester. The AFI, EFW, and EFW percentile corrected for gestational age were evaluated. The sonographic examinations were stratified into 3 gestational age categories: 28 through 33.9 weeks, 34 through 37.9 weeks, and 38 weeks and later. Maternal and fetal outcome variables were collected from medical records. Linear regression, Mann-Whitney U, and Kruskal-Wallis tests were used for statistical analysis. Results. There was no significant relationship between the AFI and EFW in the entire group of patients (R = 0.08; P = .096). There was a significant relationship between the AFI and EFW after 38 weeks' gestation (R = 0.30; P = .003). In addition, in female fetuses the EFW percentile correlated with higher AFI values at all gestational ages (R = 0.31; P

Objective To evaluate and compare umbilical cord thickness of aneuploid fetuses with umbilical cord diameter nomograms generated from euploid fetuses between 14 and 23 weeks' gestational age. Methods A retrospective study was conducted in which 56 fetuses and neonates had diagnoses of abnormal karyotypes, of which 46 fetuses had numerical chromosomal abnormalities. Among these cases, 26 subjects with adequate umbilical cord sonographic images were included in the study. The umbilical cord thickness was measured and plotted against the umbilical cord diameter nomogram that was generated from previously published data. Results From 26 evaluated fetuses and neonates, in 14 subjects (53.8%), the umbilical cord thickness was greater than the 95th percentile for gestational age. A thick umbilical cord was observed in 57.8% of fetuses with trisomy 21 and 50% of subjects with trisomy 18 and monosomy 45,XO. One fetus with trisomy 2 had umbilical cord thickness within the normal range. The largest number of aneuploid fetuses with thick umbilical cords (87.5%) was observed between 16 and 17 gestational weeks. Conclusion Aneuploid fetuses have thicker umbilical cords than euploid fetuses. The umbilical cord thickness can be related to an increased amount of Wharton jelly. Because of the smaller number of thick umbilical cords in aneuploid subjects at later gestational ages, we speculate that abnormal cord thickness has a natural tendency toward its own resolution with the advancement of gestational age.

Objective. Ultrasonographic imaging is considered an objective means for fetal weight estimation. The goals of this study were to determine the accuracy of ultrasonographic estimates of fetal weight performed by residents in training and to ascertain how rapidly the residents gained proficiency in this regard. Methods. A total of 300 ultrasonographic estimates of fetal weight and corresponding birth weight were collected and stratified into 4 groups by the level of residents' experience, from level 1 (inexperienced, with

Objective: To compare resistance to blood flow between two umbilical arteries at the same cord site during the second half of pregnancy. Methods: We evaluated 80 patients with singleton pregnancies cross-sectionally at gestational ages ranging from 20–40 weeks’ gestation. Resistance to blood flow was measured separately by means of systolic-diastolic ratio (S/D) for both umbilical arteries of each subject at the same site of transverse cord section. The higher mean value of the one umbilical artery was designated S/Dmax, whereas the lower mean value of the other paired umbilical artery was designated S/Dmin. The percent difference between the two values was calculated for each pair of measurements. Then these data were stratified by gestational age. Results: The overall mean (± standard deviation [SD]) S/Dmax was significantly different from S/Dmin (2.62 ± 0.58 versus 2.27 ± 0.40, respectively P < .001). The mean (± SD) calculated percent difference of 14.9 ± 10.4% ranged in a downward trend over the course of late pregnancy from 29.2 ± 17.1% in the 20–28 weeks’ gestational age group to 10.4 ± 6.1% among those at term (37–40 weeks); the slope of this trend was −1.32 ± 8.55% per week, a statistically significant trend (P < .001). There was a more than 20% difference in more than one quarter (29%) of the 80 pairs of umbilical arteries we studied. Cases with these large differences were concentrated mostly among those with earlier gestational ages: At term, only 8.6% showed this difference in flow resistance measurements. Conclusion: The resistance to blood flow in one umbilical artery often differs considerably from that in the other. The difference, which equalizes gradually as pregnancy advances, perhaps as a result of functional maturation of the Hyrtl anastomosis between the vessels, may have clinical importance for identification and evaluation of the potentially jeopardized fetuses, either as an early marker of fetal hypoxia or in interpretating fetal status.

Objective To study if a repeat cervical length (CL) measurement in the patient already diagnosed with a short cervix has any additional value in the prediction of preterm delivery. Study design This was a retrospective study of singleton pregnancies with cervical lengths 1–25 mm at a gestational age of 16–28 weeks seen in our institution between 2002 and 2005. Patients who were managed expectantly and had a follow-up CL measurement within 3 weeks were included. Delivery data were obtained from the patients' computerized medical records. Results Sixty-eight patients met the inclusion criteria. 37% of the patients had a shorter CL on the second measurement. These patients delivered at an earlier gestational age (36 + 4 vs. 38 + 2 weeks, P = 0.031) and were more likely to deliver at < 37 weeks (60% vs. 26%, P = 0.009). The change in the CL correlated with earlier gestational age at delivery and delivery at < 37 weeks. Conclusion In patients diagnosed with a short cervix, follow-up CL measurement is a strong predictor of preterm delivery. Greater change in the CL correlates with an earlier gestational age at delivery. In the patient diagnosed with a short cervix, a repeat measurement of CL gives additional predictive value. Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.

To reduce the mortality from ovarian cancer various studies by transvaginal color Doppler (TVCD) sonography and serum CA-125 tumor marker, alone or in combination, have been performed. Relatively poor specificities of CA-125 and transvaginal conventional sonography can be improved with the use of TVCD. Furthermore, high specificity can be achieved on screening asymptomatic postmenopausal women by combining serum CA-125 measurement with TVCD. Combining tests should not necessarily increase the overall cost of screening because of the expected decrease in the number of unnecessary surgical interventions. Until the results of large, prospective studies are available, the efficacy of potential tests for screening of ovarian cancer will remain unproven and they should not be used to screen apparently healthy women outside of scientific interest.

Transvaginal color Doppler ultrasonography was used to study 131 normal early pregnancies, 30 molar pregnancies, 20 threatened abortions, two blighted ova, and five pregnancies with intramural myoma. Four separate parts of the maternal circulation were studied: uterine, arcuate, radial, and spiral arteries. There was statistical difference in the RI and PI among uterine, arcuate, radial, and spiral arteries (P < 0.001) in all observed groups of patients except those with intramural myoma. When the same part of the maternal circulation was compared among different groups of patients, the following results reached statistical significance: uterine artery in normal and molar pregnancy (P < 0.001); arcuate artery in normal and molar pregnancy (P < 0.001); radial artery in normal and molar pregnancy (P < 0.001) and in normal pregnancy and threatened abortion (P < 0.01); spiral artery in normal and molar pregnancy (P < 0.001), in normal pregnancy and threatened abortion (P < 0.01), and in molar pregnancy and threatened abortion (P < 0.01). The standard values of blood flow are different in normal and in some cases of abnormal early pregnancy (molar pregnancy, threatened abortion).

Transvaginal color Doppler was used to investigate blood flow in the fetomaternal circulation of 60 women with threatened abortion and 90 women with normal intrauterine pregnancy. The obtained Doppler sonograms were analyzed and the resistance index (RI) was calculated in the maternal circulation, while in the fetal circulation the pulsatility index (PI) was used. There was no significant difference in the RI values of the maternal circulation between women with normal pregnancies and pregnancies complicated by bleeding, but with normal pregnancy outcome (p0.05). No differences in RI values of the uterine, arcuate and radial arteries were found between pregnancies with threatened abortion and normal pregnancy outcome and women with abnormal outcome (p0.05). In 9 of 21 women with visible retrochorionic hematoma, the RI of the spiral arteries was higher on the hematoma side in comparison to the opposite side (p0.01). This could be a consequence of the mechanical compression caused by the hematoma. In 3 of 4 cases of missed abortion, the RI of the spiral arteries was lower in comparison to the control group. Such findings could be caused by the vasodilatating products of inflammation which probably exist in such areas. There was no significant difference in terms of the PI of fetal blood vessels between normal pregnancy and threatened abortions with normal outcome, as well as between threatened abortions with normal outcome and subsequent abortions of live fetuses (p0.05).

The objective of the study was assessment of the adnexal tumor vascularization with transvaginal color and pulsed Doppler sonography. Vessel location, its arrangement, and pulsed Doppler waveform characteristics were used to distinguish benign from malignant vascularity. The study was designed as a retrospective one in which sonographic and personal records of 254 women were investigated. The significance between ultrasonic results was analyzed by difference between group means and pooled estimate of variance. Results showed that peripheral and pericystical location with single vessel displayed and resistance index above 0.40 were highly associated with benign ovarian lesions. Blood vessels located in the centar, septum, and papillary projection of the tumor with diffuse dispersed vascular arrangement and resistance index below 0.41 were highly correlated with malignancy. There were no statistically significant differences in blood flow velocities observed at different vascular locations and vessel arrangement between benign and malignant ovarian masses. In conclusion, in addition to resistance index analysis of blood flow, vascular arrangement and location are important for accurate discrimination of benign from malignant ovarian lesions.

A total of 18 cases with ovarian carcinoma stage I (15 stage Ia and three stage Ib) were studied retrospectively to evaluate the efficiency of transvaginal color Doppler sonography in detecting the disease in its early stages. Four asymptomatic women (two cases with morphologically normal ovaries, and two with simple unilocular cysts) were found during the screening program. These cases would have been missed without the use of transvaginal color Doppler sonography. One ovary with stage Ia, and another ovary in a case with stage Ib ovarian cancer were missed. These data show the ability of transvaginal color Doppler sonography to detect ovarian cancer as early as stage I even in asymptomatic women as well as in the morphologically normal ovary. Copyright © 1993 International Society of Ultrasound in Obstetrics and Gynecology

Transvaginal color Doppler investigation of the uteroplacental circulation was performed on 108 pregnant women with normal intrauterine pregnancy. Decline of resistance index (RI) and pulsatility index (PI) and increase of peak systolic velocity (Ps velocity) were found in all segments of the uteroplacental circulation with advancing gestational age. There was a decrease of RI and PI from the uterine artery through its branches: arcuate, radial and spiral arteries. Ps velocities decreased from the uterine, through the arcuate, to the radial arteries, but Ps velocities in the spiral arteries were higher than those in the radial arteries. According to our results RI seems to be more precise in the assessment of the uteroplacental than the PI.

Transvaginal color Doppler has enabled precise investigation of feto-maternal circulation in early pregnancy. Decrease of peripheral impedance, as well as increase of blood flow velocity was found in all segments of the uteroplacental circulation with gestational age. The same finding was observed in umbilical artery, fetal aorta and intracranial blood vessels. A significant decrease of vascular impedance in cerebral blood vessels exists earlier than in fetal aorta or umbilical artery which could be explained by the establishment of cerebral autoregulation mechanisms which ensure adequate oxygen and glucose supply to embryonic brain. There was no significant difference for RI values of luteal blood flow from the 6th to the 12th gestational week. No difference was found between RI values of luteal blood flow in normal and ectopic pregnancy. In threatened, incomplete and missed abortions RI of luteal blood flow was significantly higher in comparison with normal pregnancy. It seems that in the group of patients with threatened abortion, follow up of the luteal flow might give some prognostic value. No difference in peripheral impedance and blood flow velocity of the uteroplacental blood vessels was found between women with normal pregnancies and women with threatened abortions and normal pregnancy outcome. There was no significant difference in terms of RI and PSV in uteroplacental blood vessels between women with threatened abortion and normal pregnancy outcome and women with threatened abortion whose pregnancy terminated with complete abortion and blighted ovum. In 46% of 21 women with visible retrochorionic hematoma RI in spiral arteries was higher and PSV was lower on the side of the hematoma. These values could be explained by compression of the wall of the spiral arteries caused by hematoma. In missed abortion the mean RI value of the uterine artery was lower than the mean value in normal pregnancy, but was not in spiral arteries. Some authors reported RI values in cases of missed abortions around and above the cutoff point value of 0.63. In blighted ovum RI in uterine and spiral arteries was lower in comparison to normal pregnancy, but in the other studies this was not the case. Increased blood flow in radial arteries in patients with pregnancy associated with uterine myomata could be explained by higher levels of estriol hormone metabolized in the placenta. Transvaginal color Doppler could be helpful in diagnosis and differentiation of the different forms of a gestational trophoblastic disease. It seems that this technique is a good substitute for pelvic angiography.(ABSTRACT TRUNCATED AT 400 WORDS)

Objective We sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI). Study Design After implementing training for maternity staff, the incidence of OBPI was compared between pretraining and posttraining periods using both univariate and multivariate analyses in deliveries complicated by shoulder dystocia. Results The overall incidence of OBPI in vaginal deliveries decreased from 0.40% pretraining to 0.14% posttraining ( P .01). OBPI after shoulder dystocia dropped from 30% to 10.67% posttraining ( P .01). Maternal body mass index ( P .01) and neonatal weight ( P = .02) decreased and head-to-body delivery interval increased in the posttraining period ( P = .03). Only shoulder dystocia training remained associated with reduced OBPI ( P = .02) after logistic regression analysis. OBPI remained less in the posttraining period ( P = .01), even after excluding all neonates with birthweights >2 SD above the mean. Conclusion Shoulder dystocia training was associated with a lower incidence of OBPI and the incidence of OBPI in births complicated by shoulder dystocia.

Transvaginal color and pulsed Doppler sonography was performed on 106 singleton pregnant women; 75 had clinically normal pregnancies, and the remaining 31 patients had complicated pregnancies with vaginal bleeding. The gestational ages ranged from the 7th to 18th menstrual weeks. The aim of the study was to establish the earliest gestational age at which intracranial blood flow could be detected, in particular in the middle cerebral artery. The intracranial circulation becomes visible at the 8th week of gestation (7 weeks and 3 days). The end-diastolic component of blood flow is inconstantly present from the 11th to the 13th gestational week, and is always detected thereafter. A significant decrease in the pulsatility index (p 0.05). Results suggest that Doppler studies of middle cerebral arteries in early pregnancy are unlikely to be of value in identifying fetal hemodynamic disorders in the early stages of spontaneous abortion. Copyright © 1992 International Society of Ultrasound in Obstetrics and Gynecology

Transvaginal color Doppler offers the potential to study uteroplacental circulation in early normal pregnancies and pregnancies associated with intrautine fibroids. A total of 62 patients (30 early pregnancies complicated by myoma and 32 normal pregnancies representing the control group) whose gestational age ranged from the 6th to the 14th week were examined. The equipment used was an Aloka color Doppler SSD-680 with 5.0 MHz curve-linear transvaginal transducer. The main uterine, radial and spiral arteries were identified in all patients. Peak systolic velocity and resistance index were measured and automatically calculated. Statistical analysis used was Student t-test. This study documents a physiological decrease in impedance in the uteroplacental circulation in pregnancy associated with fibroids, while the blood velocity of the radial arteries showed a significant increase between the 10th and 14th week of gestation.

We studied changes in the width of the symphysis pubis in 32 women examined serially by ultrasound during labor. Measurements were made at the superior border of the symphysis and at its narrowest breadth in the latent phase, the active phase, and the second stage of labor. There was a significant increase in the width of the symphysis between the first and second stages of labor at both measured levels. Widening was observed in 94% at the superior symphyseal breadth and in 59% at the narrowest. Of those cases in which the width of the symphysis increased, there was a large spectrum of change, ranging from 9 to 98% of the original width at the narrowest measurement site and from 2 to 139% at the superior breadth. There was a strong inverse correlation between maternal age and the degree of symphyseal widening in nulliparas, but not in multiparas. We conclude that labor is associated with a substantial widening of the symphysis pubis in most, but not all women.

To assess the relationship between discordant umbilical arterial size and resultant blood flow parameters and determine the impact of discordance on fetal outcome.This is a descriptive, cross-sectional study of 200 patients with a singleton gestation, who underwent a fetal anatomy survey between 18 to 23 weeks of gestation, with documented umbilical cord morphological patterns and blood flow characteristics. Umbilical vessel diameters and Doppler parameters (umbilical vein blood flow volume, mean resistance index, and peak-systolic velocity) were analyzed for discordance. Discordances encountered were examined for their possible association with perinatal outcome.We had adequate ultrasound umbilical cord images, Doppler flow parameters, and all necessary demographic data for 154 patients. Umbilical artery discordance averaged 13.1% and was significantly correlated with both the expected and the true percent of difference in resistance index values (RI, P0.001). In 12 patients (7.8%), a significant discordance of more than 29.5%, or 95th percentile, was observed between the two umbilical artery diameters. However, in these cases no associated adverse perinatal outcome or significant placental pathology was noted. There was no significant difference between patients discordant or concordant umbilical artery in terms of maternal, labor, and neonatal data.The magnitude of umbilical arteries' luminal discordance directly influences the corresponding blood flow parameters. In our sample of patients, the presence of discordant-in-size umbilical arteries was not associated with umbilical cord or placental abnormalities.

Objective The purpose of this study was to evaluate the impact of spontaneous reduction in multifetal pregnancy on first-trimester maternal serum biochemistry. Study design We evaluated first-trimester pregnancy associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin levels in singleton euploid pregnancies. Biochemical values in pregnancies with evidence of spontaneous reduction were compared to other singleton pregnancies. Mann-Whitney U , Student t test, Fisher exact test, and logistic regression analysis were used for statistical comparison. Results There were 41 cases (0.9%) of spontaneous reduction. Though spontaneous reduction was not associated with different levels of either analyte, reduction within 4 weeks was associated with higher levels of both PAPP-A (1.79 vs 1.18; P = .002) and free β-hCG (1.28 vs 0.96; P = .03) compared with other pregnancies. Spontaneous reduction was associated with a higher frequency of PAPP-A >95th %ile (17.1 vs 4.7%; P = .003) and free β-hCG >95th %ile (17.1% vs 5.0%; P = .004). Logistic regression identified independent associations between spontaneous reduction and both high PAPP-A and high free β-hCG. Conclusion Recent spontaneous reduction is associated with higher values of PAPP-A and free β-hCG. These differences have the potential to affect risk assessment for fetal aneuploidy.

OBJECTIVE The purpose of this study was to evaluate a relationship between the umbilical cord thickness and cord coiling patterns during the fetal sonographic anatomic survey in the second trimester of pregnancy. METHODS This was a prospective study of 470 patients with singleton pregnancies who had a fetal anatomic survey with recorded umbilical coiling patterns between 18 and 23 weeks' gestation. The umbilical cord thickness was assessed as an umbilical diameter at the level of the fetal abdominal cord insertion and compared with the antenatal umbilical coiling index (aUCI), calculated as a reciprocal value of the distance between a pair of umbilical cord coils. RESULTS Three hundred twenty-one patients had adequate sonographic umbilical cord images and maternal demographic, antenatal, and labor data to meet inclusion criteria. The mean aUCI was 0.41 with 10th and 90th percentiles of 0.21 and 0.60, respectively. A total of 10.6% (34/321) and 9.3% (30/321) of patients were categorized as having hypocoiled and hypercoiled umbilical cords, respectively. The mean cord diameter +/- SD was 9.48 +/- 0.97 mm (range 7.0-12.5 mm). There was no statistically significant correlation between aUCI and umbilical cord thickness (P = .1164). CONCLUSIONS An aUCI, or umbilical coiling pattern, does not correlate with umbilical cord thickness. It appears that a lesser amount of the umbilical supportive tissue, mainly Wharton jelly, is not related to an increased umbilical cord coiling pattern.

An isolated fetal ascites is a rare ultrasonographic finding. It is commonly diagnosed in association with fetal genitourinary or gastrointestinal conditions, mainly bowel obstruction. We present the sonographic features and neonatal outcome of a fetus with a large bowel obstruction, perforation and subsequent development of meconium peritonitis, prenatally diagnosed as isolated fetal ascites. A colonic atresia should be also included in the differential diagnosis of isolated fetal ascites.

To establish an umbilical cord thickness nomogram from anatomy ultrasound scans performed between 18 and 23 weeks of gestational age in singleton pregnancies, and compare it to two previously published nomograms.In this retrospective cohort study of 1107 patients, a total of 650 singleton pregnancies were included. The umbilical cord diameter measurements were performed at the level of fetal abdominal wall insertion, and were correlated with gestational age (GA) and estimated fetal weight (EFW). Statistical analysis with non-parametric polynomial least squares regression analysis was performed.A statistically significant correlation between umbilical cord diameter and GA (P0001, r=0.399, 95% CI 0.331 to 0.464), and EFW (P0001, r=0.420, 95% CI 0.353-0.483) was observed. A nomogram of umbilical cord thickness according to GA (y), and EFW (y'), was generated from the following equations:y=-51.30+5.367*x-0.1165*x(2) and y'=6.917+0.007233*x, respectively.Our nomogram is in agreement with one of the previously published nomograms that also measured umbilical cord diameter at the level of the fetal abdominal umbilical cord insertion. Therefore, we recommend umbilical cord thickness to be measured in close proximity to the fetal abdominal wall, but no further than 0.5 cm away from the wall insertion.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are life-threatening dermatologic disorders that are more common in the setting of a compromised immune system. We present the case of a pregnant patient with known human immunodeficiency virus (HIV) infection who presented with Stevens-Johnson syndrome after treatment with antibiotics for a urinary tract infection. CASE: A young woman at 33 4/7 weeks of gestation with known HIV infection presented to the emergency room with a chief complaint of rash, fever, blisters, and lower abdominal pain. Her symptoms were present for 2 days after ingestion of nitrofurantoin, prescribed for a urinary tract infection. She was diagnosed with preterm labor and possibly Stevens-Johnson syndrome. Due to active labor, HIV, and vaginal stenosis, a primary cesarean was performed. A skin biopsy performed at the time of admission confirmed the diagnosis of a drug-induced dermatosis (erythema multiforme), evidenced by subepidermal bullae, hemorrhage, and acantolated, dyskeratotic eosinophilic cells. CONCLUSION: Stevens-Johnson syndrome and toxic epidermal necrolysis represent a spectrum of disease that has been long associated with multiple drugs, recently including many antiretroviral medications. It also seems that the incidence of these conditions is increased in immunocompromised patients. We speculate that the combination of HIV and pregnancy in addition to antibiotic treatment, such as with nitrofurantoin, may induce Stevens-Johnson syndrome in patients with severely altered immune systems.

OBJECTIVE: Intrinsically poor maternal adaptation to pregnancy and dysregulated processes have been postulated to occur as a consequence of an immune response to the feto-placental unit as "foreign" material. The aim of our study was to compare placental pathology and pregnancy outcomes of in vitro fertilization (IVF) pregnancies conceived by donor oocytes with those conceived by non-donor oocytes. STUDY DESIGN: We conducted a retrospective, case-control study on 91 placentas from IVF pregnancies (36 from donor oocytes and 55 from non-donor cycles). All placentas were examined by a single pathologist for signs indicative of an immune response, including chronic villitis, chronic deciduitis, increased perivillous fibrin, ischemic change/infarction, decidual vasculopathy, increased syncytial knots, intervillous thrombi, and retroplacental hematomas. RESULTS: Placentas from donor cycles were significantly more likely to demonstrate certain pathologic findings: chronic villitis (P

We present a patient with a placenta previa in which we failed to manage conservatively with methotrexate and uterine embolization. The patient was diagnosed in the second trimester as having a possible placenta previa-increta,and underwent a repeat classical cesarean delivery at 32 weeks of gestation due to significant antepartum vaginal bleeding. Following abdominal closure,the uterine vessels were embolized with the Gel-Foam by interventional radiology. The placenta previa was left in-situ and patient was discharged home in stable condition in five days. The patient reported on the 44th postoperative day with heavy vaginal bleeding. A total abdominal hysterectomy was performed due to an unstable patient's hemodynamic condition in association with fluid resuscitation and multiple blood transfusions. The pathologic findings revealed a 675 g uterus with placenta previa-percreta with extension of chorionic villi to the serosal layer. Our case demonstrates a need for careful selection of patients with placenta previa and suspected accreta/increta/percreta that would be suitable candidates for conservative medical management. Patients who opt for conservative medical management should be informed about the possibility of catastrophic bleeding associated with a retained placenta, that would ultimately require blood transfusions and hysterectomy.

Objective To assess the intra- and interobserver reproducibility of ultrasound measurements of fetal biometric parameters. Methods We assessed the intraobserver and the interobserver agreement in measurements of fetal biparietal diameter (BPD), abdominal circumference (AC), head circumference (HC) and femur length (FL) on 122 singleton pregnancies. Patients were each examined twice by the first sonographer to determine the intraobserver reliability of measurements of fetal biometry. Subsequently, during the same ultrasound examination, a second blinded sonographer measured fetal biometric parameters to assess interobserver reliability. The consensus between and among observers was analyzed using the intraclass correlation coefficient (intra-CC) and interclass correlation coefficient (inter-CC) and the reliability coefficients (RC, α) for the four biometric measurements. A value > 0.75 was considered a reliable consensus for the intra-CC and inter-CC. A Bland and Altman plot was also created for the fetal biometric parameters to assess the repeatability of the measurements. Results Reliable consensus was observed for both the intra-CC and inter-CC and RC for all four biometric parameters. The intra-CC with the 95% CI and RC for the BPD, AC, HC and FL were as follows: 0.996 (0.995, 0.997), α 0.998; 0.994 (0.992, 0.996), α 0.997; 0.996 (0.994, 0.997), α 0.998; and 0.994 (0.992, 0.996), α 0.997, respectively. Similarly, the inter-CC with the 95% CI and RC for the same parameters were as follows: 0.995 (0.993, 0.997), α 0.998; 0.980 (0.971, 0.990), α 0.990; 0.994 (0.992, 0.996), α 0.997; and 0.990 (0.985,0.993), α 0.995, respectively. The Bland and Altman plots demonstrated a high degree of repeatability of BPD, AC, HC, and FL measurements. Conclusion Our results demonstrate that the intra- and interobserver reproducibility of ultrasound measurements of fetal biometry are highly reliable. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Ultrasonographic demonstration of bowel peristalsis within the fetal scrotum has been described as a pathognomonic sign of inguinoscrotal bowel herniation. We present the sonographic features and neonatal outcome of a fetus with a scrotal mass seen at 34 weeks of gestation in a twin pregnancy. This mass was diagnosed postnatally as a non-reducible inguinoscrotal hernia, in which bowel peristalsis had not been observed by real-time ultrasound in utero.

A new device in assessment of cervical consistency by means of resistance to electrical current was compared to observations made by traditional clinical assessment of the cervix. The cervix of 50 specimens obtained consecutively at a series of total abdominal hysterectomies done for benign disease was evaluated for cervical consistency first by palpation preoperatively and then by the new device, using 5 prototypes, after the specimen was removed. Obtained results showed that intra-observer error for all five prototypes averaged 1.28 +/- 2.5% (mean +/- standard deviation), whereas inter-observer error was 8.44 +/- 7.9%. Stratified by clinical cervical consistency as soft, moderate and firm, there was a statistically significant difference in the resistance to electrical current (f = 29.0, r2 = 0.19, p < 0.0001). Resistance to electrical current was highest for firm cervices, less for those of moderate consistency, and least for soft ones (21.8 +/- 2.73, 19.6 +/- 2.91 and 15.6 +/- 4.09 ohms, respectively). In conclusion, measurements of cervical resistance obtained objectively by a new device reliably correlated with traditional clinical assessment of cervical consistency.

Objective To compare color and pulsed Doppler sonography with gray-scale ultrasound imaging and serum CA 125 levels in establishing accurate preoperative diagnoses of adnexal masses. Methods Medical records of 109 patients referred with preexisting adnexal lesions were reviewed retrospectively by comparing preoperative ultrasonic data (gray-scale imaging and color and pulsed Doppler findings) with serum CA 125 levels. Results Eighty-three masses were removed surgically, confirming seven malignancies and 76 benign tumors, and 26 masses were followed; 15 regressed and 11 persisted. Color and pulsed Doppler sonography showed the highest sensitivity, followed by gray-scale imaging, whereas serum CA 125 levels revealed the highest specificity in distinguishing malignant from benign adnexal tumors. All three methods had high negative predictive values (96–100%), whereas only serum CA 125 had a positive predictive value greater than 50%. Conclusion Color and pulsed Doppler sonography, which demonstrate a tumor angiogenic activity, are as accurate as gray-scale imaging in the assessment of adnexal lesions. Together with serum CA 125 marker levels, they produce high negative predictive values, providing reassurance that an adnexal mass is benign.

Objective To determine blood flow characteristics of ovarian and uterine arteries in patients with endocrinologically and clinically confirmed polycystic ovary disease (PCOD) in comparison with blood flow parameters observed in patients with spontaneous ovulatory cycles. Design Controlled clinical study. Setting Patients from Infertility Service in a tertiary care institution. Patients Forty patients with confirmed PCOD and 50 control patients in various phases of spontaneous menstrual cycles. Main Outcome Measure Using transvaginal color Doppler sonography to determine ovarian morphology, ovarian blood vessel visualization rates, and ovarian and uterine arteries blood flow parameters (resistance index, pulsatility index, and maximal peak velocity). These parameters were correlated with serum hormone levels. Results Polycystic ovaries showed typical vascular pattern: increased stromal vascularity, a positive correlation between increased blood velocities and serum LH levels, and a trend toward lower resistance index and pulsatility index values, whereas uterine arteries revealed significantly increased resistance index and pulsatility index values. Conclusions The observed specific intraovarian and uterine vascular pattern in PCOD patients may provide additional data for conventional endocrinologic and ultrasonic diagnostic methods for PCOD.

We investigated the development of intracranial vascularization in the human fetus, with particular emphasis on the choroid plexus. The fetal brain was visualized in 102 patients with healthy pregnancies between 9 and 16 weeks' gestation. Imaging was done transvaginally except in the pregnancies of longer duration with unfavorable fetal positions. Color flow imaging was used to identify vessels in the cranium and within the choroid plexus. Pulsed Doppler signals were obtained from an internal carotid-middle cerebral artery and from a choroid plexus vessel. The pulsatility index was calculated from the Doppler spectral envelope. A major cerebral vessel could be seen at 9 weeks' gestation. Choroid plexus vessels were first seen at 10 weeks 3 days. Visualization rates ranged from 35 to 75% for plexus vessels, and 65 to 100% for cerebral vessels. Visualization of choroid plexus vessels was maximal at 13 weeks. The pulsatility index for the cerebral arteries at this gestational period averaged 2.6 +/- 0.6. The result for the choroid plexus was 1.66 +/- 0.5. (P < 0.001). Visualization of the vessels of the choroid plexus increases and decreases as the gland develops and shrinks. This developmental period also is the time of active neurogenesis.

Several screening procedures have been proposed to detect ovarian and endometrial cancer. However, none of them is sensitive and specific enough to be used in population-based screening programs. During our 5 year long study, 5013 asymptomatic women (44% premenopausal and 56% postmenopausal women) were scanned by transvaginal color and pulsed Doppler ultrasonography in an attempt to detect malignancy. These women had 404 adnexal cysts; 70 had resolved spontaneously on follow-up scans and 18 persisted. Another 316 sonographically benign cysts are still in the procedure of follow-up second scans. Of 5013 women, four women had stage I ovarian carcinoma and six had stage I endometrial carcinoma. There was one false-positive case encountered with an endometrioma. Only 14 women were subjected to major operative intervention; others underwent minor procedures based on the benign scan findings. No medical or surgical complications were reported. Transvaginal color Doppler ultrasonography, a noninvasive procedure, can detect ovarian and endometrial carcinoma in asymptomatic women and may be used as a screening procedure for these diseases.

This study was conducted to evaluate the role of transvaginal color Doppler ultrasonography in detecting endometrial carcinoma in postmenopausal women and in evaluating the depth of myometrial invasion and tumor staging.A group of 750 postmenopausal women were examined by transvaginal color Doppler ultrasonography 1 day before the planned hysterectomy. Histopathologic and blood flow characteristics were evaluated. Analysis of variance was used to test the significance among the subgroups.Thirty-five women had endometrial carcinoma; 32 (91.4%) cases were detected by transvaginal color Doppler ultrasonography. Visualization of abnormal blood flow within the endometrium was 100% in the diagnosed cases with resistance index near or0.40, which constituted a statistically significant difference compared with that of endometrial hyperplasia. No flow was detected in normal, atrophic, and in 92% of cases with hyperplastic endometria. The color Doppler ultrasonography depicted 18 of 19 histologically proved cases of myometrial invasion. Three asymptomatic cases were discovered on the basis of morphologic and blood flow patterns.Transvaginal color Doppler ultrasonography can depict endometrial carcinoma, even in asymptomatic women, determine the depth of myometrial invasion, and help in tumor staging.

A cross-sectional transvaginal color and pulsed Doppler study was performed on 95 normal singleton pregnancies to establish blood flow characteristics of maternal and placental components of circulation. During the pregnancy, vascular impedance to blood flow decreases from the main uterine artery to the spiral arteries in the maternal component of uteroplacental circulation. In the placental component of circulation, vascular impedance decreases from the umbilical artery to the fetal arteries within placenta-intraplacental arterioles. At the same time, in both components of uteroplacental circulation, an increase of blood flow velocity with gestational aging was observed. There was no significant drop of vascular impedance of blood flow or increase of blood flow velocity around the 12th or 14th gestational week, which should prove the hypothesis of ‘opening’ of spiral arteries which have tips plugged with trophoblast tissue.