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(BQ) Part 2 book Donald school textbook of ultrasound in obstetrics and gynecology presents the following contents: Doppler sonography in obstetrics, postpartum ultrasound, fetal behavior, amniocentesis and fetal blood sampling, amniocentesis and fetal blood sampling, ultrasound and uterine fibroid,...
30 CHAPTER Ultrasound in the Management of the Alloimmunized Pregnancy Daniel W Skupski INTRODUCTION Due to the advent of ultrasound imaging, the diagnosis and treatment of red blood cell (RBC) alloimmunization is arguably the quintessential success story in obstetrics The pathophysiology is well described, the diagnosis is easily and reliably established and life-saving treatment for the fetus and newborn is available both in utero and after delivery with a high degree of success Ultrasound has been used for diagnosis and as an adjunct for the treatment of RBC alloimmunization for several decades, and the applications for ultrasound are continuing to expand This chapter will outline the current uses of ultrasound in the setting of the alloimmunized pregnancy HISTORY Sir Richard Liley began the modern era of fetal therapy with the introduction of amniocentesis for testing of the amniotic fluid for bilirubin levels by spectrophotometry.1 The degree of change in the optical density at a wavelength of 450 nm (delta OD450) of light during spectrophotometry of amniotic fluid correlates with the level of bilirubin in the fluid due to the preferential absorption of light at this wavelength by bilirubin High levels of bilirubin in amniotic fluid correlate with the severity of RBC alloimmunization and have been used to guide therapy Beginning around 1961, treatment for severe RBC alloimmunization consisted of either percutaneous intraperitoneal fetal transfusion (IPT) or early delivery.2 At that time, imaging to guide the needle placement for IPT was in the form of amniography (placement of radio-opaque dye into the amniotic cavity) followed by fluoroscopy, using radiation, to outline the fetus and guide needle placement into the fetal abdominal cavity Real-time ultrasound subsequently replaced amniography as the imaging study of choice Real-time ultrasound allowed the development of percutaneous intravascular blood transfusion to the fetus This first occurred by fetoscopy and later by cordocentesis, also known as funipuncture or percutaneous umbilical blood sampling (PUBS) PUBS is an ultrasound-guided procedure 3,4 Percutaneous umbilical blood sampling allows more accurate diagnosis of fetal anemia and the need for intrauterine therapy, by directly testing the fetal hematocrit Due to improved imaging with ultrasound, this procedure has become technically easier As a result of advances in image quality, intrauterine transfusion (IUT) can now be performed in the early second trimester for the rare cases that present with severe fetal anemia very early in gestation During the decade of the 1990s, the Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses studied numerous blood vessels in an effort to find a way to reliably diagnose severe fetal anemia (that would require invasive treatment) They were successful with the middle cerebral artery and their results were published in the year 2000.5 This has paved the way to a noninvasive method for diagnosing CHAPTER 30 / Ultrasound in the Management of the Alloimmunized Pregnancy 493 TABLE 30.1 Diagnosis of hydrops fetalis* • • • • • • Polyhydramnios Thickened placenta (> cm) Pericardial effusion Ascites Skin edema Pleural effusion *Findings are listed in the order of usual progression of disease Figures 30.1A and B: Ultrasound image of hydrops fetalis (A) The left image is a transverse or axial image of the fetal chest showing bilateral large pleural effusions surrounding the fetal heart The right image is a longitudinal or coronal scan of the fetal thorax (towards the right of the image) and abdomen (towards the left of the image) showing bilateral large pleural effusions above the diaphragm; (B) Axial scan of the fetal head in the same patient showing skin edema (arrows) fetal anemia, which has led to a decrease in morbidity from invasive procedures DIAGNOSIS The identification of antibodies in maternal serum is the key to finding the alloimmunized pregnancy Ultrasound has traditionally been used after a pregnancy is known to have RBC alloimunization in order to identify hydrops fetalis (Figs 30.1A and B) Severe fetal anemia can lead to hydrops fetalis and this is probably produced by a combination of pathophysiologic factors, including hypoalbuminemia and hepatic damage from extramedullary hematopoiesis.6 The fetal hematocrit is usually below 15% when hydrops is present When immune hydrops fetalis is present, IUT is lifesaving, and usually needs to be performed within 1–7 days Hydrops fetalis is present when two or more factors listed in Table 30.1 are present When only one factor is present, this may be an early sign of hydrops, particularly in the alloimmunized pregnancy When fetal anemia becomes severe, there can also be changes in fetal behavior, due to the restriction of oxygen delivery to fetal tissues The fetus may then conserve energy by limiting its movements The biophysical profile is an assessment of the character and frequency of fetal movements along with an assessment of the volume of amniotic fluid The biophysical profile can possibly identify the fetus who is decompensating, but may not be reliable for this purpose The biophysical profile does not distinguish between severe acidemia, severe anemia, advanced fetal sepsis and severe central nervous system anomaly, nor does it determine the cause of the fetal decompensation Ultrasound is commonly used to guide the diagnostic procedure of cordocentesis or PUBS (Figs 30.2A to C) First, ultrasound is used to identify the umbilical cord insertion into the placenta, then a 20 or 22 gauge needle is placed percutaneously through the maternal abdomen into the fetal umbilical vein at the level of the placental cord insertion An alternative site is the fetal intrahepatic portion of the umbilical vein, which may be chosen if the placenta is posterior and the position of the fetus limits accessibility to the placental cord insertion site The placental cord insertion is generally chosen because the cord is anchored at this point, allowing the needle to easily puncture the cord.7 Free loops of umbilical cord have rarely been used as the access point to the umbilical vein because their mobility limits the success of puncture The vein is chosen because it has a larger caliber and usually allows a shorter procedure time It is also thought that puncture of an arterial vessel is more likely to produce fetal bradycardia 494 Section / Obstetrics Noninvasive Diagnosis Figures 30.2A to C: Percutaneous umbilical blood sampling or cordocentesis for intrauterine fetal transfusion (A) Ultrasound image of a needle being placed through the maternal abdominal wall and placenta into the umbilical vein at the placental cord insertion in a pregnancy with an anterior placental attachment; (B) High resolution image of the placental cord insertion using color Doppler; (C) High resolution image of the needle tip in the umbilical vein (color Doppler turned off) During the past two decades many fetal vessels and morphologic findings have been evaluated for ultrasound or Doppler findings that would allow a specific diagnosis of severe fetal anemia prior to the development of hydrops fetalis An excellent review of this experience is available The optimal time for diagnosis of severe anemia is prior to the development of hydrops fetalis because the mortality increases once hydrops has occurred A group of investigators working consistently during the decade of the 1990s has now identified that the fetal middle cerebral artery peak systolic velocity (MCA-PSV) reliably predicts fetal anemia and can be performed by sonographers consistently with technical accuracy.5,10-13 The viscosity of blood is inversely correlated with the speed of blood flow in vessels Assuming the same pumping force is applied, the lower the viscosity of blood in vessels, the higher the velocity When fetal anemia becomes severe, the viscosity of blood is markedly decreased, and this leads to a markedly increased peak systolic velocity The angle of incidence at which the ultrasound beam intersects the blood flowing in a vessel affects the results of many Doppler measurements Due to this limitation, most Doppler indices include angle correction as a feature of the software that performs the calculations For optimal accuracy, i.e low intraobserver and interobserver variability—the measurement of peak systolic velocity of blood in a vessel requires that no angle correction be performed.10 With a 0° angle of incidence no angle correction is needed and the measurement of peak systolic velocity is then very accurate The specific technique for performing MCA-PSV measurements includes magnifying the image on the screen, using color Doppler to visualize the middle cerebral artery of the fetus and adjusting the transducer on the maternal abdomen so that the angle of incidence of the beam to the artery is 0°, i.e the direction of blood flow in the vessel should be aimed directly at the transducer or directly away from the transducer (Fig 30.3) Measurements should be taken when there is an absence of marked fetal body and breathing movements Several measurements should be obtained at each visit The highest MCA-PSV should be reported and used for management decisions The Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses has reported the results of a large number of patients with fetuses at risk for anemia who have undergone fetal MCA-PSV testing.5,12 In their first report, they studied 110 consecutive pregnant women carrying 111 fetuses at risk for fetal anemia due to RBC alloimmunization evaluated CHAPTER 30 / Ultrasound in the Management of the Alloimmunized Pregnancy Figure 30.3: Power and pulsed wave Doppler measurement of the peak systolic velocity of the fetal middle cerebral artery (MCA) The peak systolic velocity (PS) of 34.54 centimeter per second is seen in the box in the upper right Note the orientation of the MCA is as close to 0° as possible to that of the ultrasound beam between 15 and 36 weeks of gestation.5 They performed MCA-PSV measurements at the time of initial referral and every two weeks thereafter, including immediately prior to cordocentesis Since hemoglobin concentration in fetuses increases with gestational age, they developed nomograms for hemoglobin concentration from 265 fetuses undergoing cordocentesis for other reasons (suspicion of fetal infection, alloimmune thrombocytopenia, immune thrombocytopenia purpura and chromosomal anomalies) who did not have anemia The expected values for MCA-PSV were based on nomograms produced previously 10 The results from cordocentesis showed that 41 of 111 fetuses at risk for anemia did not have anemia, 35 had mild anemia, had moderate anemia and 31 had severe anemia Of the 31 fetuses with severe anemia, 12 had hydrops fetalis The sensitivity of MCA-PSV in detecting moderate or severe anemia was 100% (35/35) and the 95% confidence intervals were 86–100% Receiveroperator characteristic curves for the MCA-PSV showed that a level of 1.5 multiples of the median (MOM) or greater allowed a sensitivity of 100% while only producing a false-positive rate of 12% (4/35) They concluded that, in fetuses at risk of anemia due to RBC alloimmunization, moderate and severe anemia can be reliably detected by noninvasive Doppler assessment using the middle cerebral artery peak systolic velocity In a follow-up prospective multicenter trial with intent-to-treat, MCA-PSV was found to be highly predictive of moderate-to-severe anemia at delivery, with a sensitivity of 88%, specificity of 87%, positive 495 predictive value of 53% and negative predictive value of 98%.13 The diagnosis of severe anemia was missed in one fetus, but the final outcome was good They concluded that MCA-PSV will minimize fetal complications associated with invasive testing in pregnancies affected by RBC alloimmunization and recommended a Doppler testing within an interval of seven days.13 The same investigators also assessed the ability of MCA-PSV in determining severe anemia longitudinally in 34 fetuses, where measurements were performed serially They calculated the slope of the MCA-PSV in each fetus over time and determined the average rate of change as a function of gestational age in three groups of fetuses: normal, mildly anemic and severely anemic The estimated average slope increased significantly in the severely anemic fetuses This demonstrated that the MCA-PSV can be used to follow fetuses at risk for severe anemia over the course of the pregnancy.12 The current status of MCA-PSV as a reliable method for the noninvasive determination of fetal anemia has also been confirmed by meta-analysis.14 This study showed that the likelihood ratio for a positive test was 8.45 and for a negative test was 0.02 These results are consistent with both clinical and statistical significance In a prospective multicenter study, including 164 women with alloimmunized pregnancies, fetal MCAPSV measurements were demonstrated to be superior to delta OD450 in amniotic fluid for the prediction of severe fetal anemia.15 These women had Rh(D), Rh(c), Rh(E) and Fy(a) antibodies, had antibody titers >1:64 and antigen positive fetuses When clinical findings necessitated invasive assessment in this study, fetal MCA-PSV was performed first, followed by the amniocentesis Cordocentesis was performed if one or both tests suggested severe fetal anemia (MCA-PSV above 1.5 MOM or Liley upper zone II) Seventy-four fetuses were diagnosed as severely anemic, defined as a hemoglobin five standard deviations below the mean for gestational age Fetal MCA-PSV was significantly more sensitive than amniotic fluid delta OD 450 measurements using the Liley curve (88% versus 76%, difference in sensitivity 12%, 95% CI 0.3–24.0), but was not more specific (82% versus 77%) MANAGEMENT Ultrasound has progressed from a useful adjunct to an indispensable diagnostic tool in the evaluation and treatment of the alloimmunized pregnancy A management scheme that is significantly less invasive than previous schemes is now possible The author’s 496 Section / Obstetrics algorithm for management is shown in Flow chart 30.1 This management scheme includes the primary use of fetal MCA-PSV measurements rather than amniocentesis as the preferred choice for monitoring for severe fetal anemia There are times when the fetal MCA-PSV measurement may not be reliable and resort to amniocentesis or cordocentesis may be necessary Still, there are significantly fewer invasive procedures for these women as a whole than in years past, providing for less procedural complications and less likelihood of iatrogenic premature delivery Deoxyribonucleic acid (DNA) testing for the Rhesus D (RhD) locus is a highly reliable diagnostic test and with its use those fetuses who are truly at risk are able to be identified DNA testing for the RhD locus allows us to separate the fetuses who are antigen negative from antigen positive.16 This can occur whenever fetal DNA can be obtained at any time in gestation and is irrespective of the paternal zygosity status The RhD DNA testing by polymerase chain reaction (PCR) is reliable even if paternity is unknown Fetal tissue can be obtained by amniocentesis or chorionic villus sampling (CVS) in early gestation and further invasive procedures can be avoided in those fetuses who are antigen negative and are thus not at risk for severe anemia.16 For fathers who are heterozygous for the offending antigen, this includes 50% of fetuses Ultrasound guidance is an essential component of the diagnostic procedures of amniocentesis and CVS When the woman has no prior pregnancy history of severe fetal anemia and the fetus is antigen positive, the patient can be followed with serial ultrasound to detect hydrops fetalis and an MCA-PSV measurement performed every one or two weeks beginning at 18 weeks of gestation to detect severe fetal anemia If the MCA-PSV is greater than 1.5 MOM for the gestational age at which it is performed, this indicates a severe fetal anemia and is an indication for cordocentesis and possibly IUT If hydrops fetalis is identified, cordocentesis for IUT would also be chosen Management can be tailored based on prior pregnancy history for those fetuses that are antigen positive Invasive testing in a subsequent pregnancy begins before the time in gestation when the fetus was Flow chart 30.1: Management of the alloimmunized pregnancy CHAPTER 30 / Ultrasound in the Management of the Alloimmunized Pregnancy deemed to be affected in a prior pregnancy For example, if amniocentesis showed delta OD450 in Liley zone at 28 weeks of gestation (or cordocentesis showed severe fetal anemia) in one pregnancy, then invasive testing would be recommended at 20–26 weeks of gestation in the next pregnancy in previous schemes of management Using the MCA-PSV, earlier testing would not be required (because all patients would begin testing at 18 weeks of gestation) unless an earlier pregnancy was affected prior to 18 weeks An excellent review of the current state of treatment for RBC alloimmunization is available.17 ALLOIMMUNE THROMBOCYTOPENIA Fetal and neonatal alloimmune thrombocytopenia is the platelet corollary to RBC alloimmunization The natural history of the disease shows that each subsequent pregnancy is generally more severely affected, including antenatal intracranial hemorrhage and fetal demise.18 Lifesaving fetal treatment is available in the form of intravenous immune globulin (IVIG) given to the mother on a weekly or twice weekly basis, which is believed to act in part by limiting the placental transfer of antiplatelet IgG antibody that attaches to fetal platelets.19-21 Antiplatelet IgG that is transferred from maternal plasma to the fetus is thought to coat fetal platelets and enhance the rapid elimination of fetal platelets by the fetal reticuloendothelial system The ultrasound guided procedure of cordocentesis is used to diagnose the most severely affected cases Cordocentesis allows fetal blood to be obtained so that a severely low fetal platelet count can be discovered and prenatal treatment can be instituted Review articles of the diagnosis and treatment of alloimmune thrombocytopenia are available.22,23 SUMMARY From its beginnings as a research tool to its current indispensable status as both a diagnostic tool and an adjunct to therapy, ultrasound is a cornerstone in the fight against alloimmunization Ultrasound has advanced our knowledge of the pathophysiology and the fetal effects of disease and our ability to manage the alloimmunized pregnancy The Doppler MCA-PSV measurement is a major advance in our ability to diagnose fetal anemia and thus manage the alloimmunized pregnancy Advances in ultrasound imaging quality and in our knowledge of the uses of ultrasound in the near future should further refine our ability to diagnose and treat the alloimmunized pregnancy 497 REFERENCES Liley AW Liquor amnii analysis in the management of pregnancy complicated by rhesus immunization Am J Obstet Gynecol 1961;82:1359-66 Liley AW Intrauterine transfusion of foetus in haemolytic disease Br Med J 1963;2(5365):1107-13 Rodeck CH, Kemp JR, Holman CA, et al Direct intravascular fetal blood transfusion by fetoscopy in severe thesus isoimmunization Lancet 1981;1(8221):625-7 Rodeck CH, Nicolaides KH, Warsof SL, et al The management of severe rhesus isoimmunization by fetoscopic intravascular transfusions Am J Obstet Gynecol 1984; 150(6):769-74 Mari G, Deter RL, Carpenter RL, et al Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red cell alloimmunization for the Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses N Engl J Med 2000;342(1):9-14 Bowman JM Hemolytic disease (erythroblastosis fetalis) In: Creasy RK, Resnik R (Eds) Maternal-Fetal Medicine: Principles and Practice Philadelphia: WB Saunders Company;1994 p 719 Grannum PA, Copel JA, Plaxe SC, et al In utero exchange transfusion by direct intravascular injection in severe erythroblastosis fetalis N Engl J Med 1986;314(22):1431-4 Whitecar PW, Moise KJ Sonographic methods to detect fetal anemia in red blood cell alloimmunization Obstet Gynecol Survey 2000;55(4):240-50 Schumacher B, Moise KJ Fetal transfusion for red blood cell alloimmunization in pregnancy Obstet Gynecol 1996;88(1):137-50 10 Mari G, Adrignolo A, Abuhamad AZ, et al Diagnosis of fetal anemia with Doppler ultrasound in the pregnancy complicated by maternal blood group immunization Ultrasound Obstet Gynecol 1995;5(6):400-5 11 Mari G, Rahman F, Ologsson P, et al Increase of fetal hematocrit decreases the middle cerebral artery peak systolic velocity in pregnancies complicated by rhesus alloimmunization J Matern Fetal Med 1997;6(4):206-8 12 Detti L, Mari G, Akiyama M, et al Longitudinal assessment of the middle cerebral artery peak systolic velocity in healthy fetuses and in fetuses at risk for anemia Am J Obstet Gynecol 2002;187(4):937-9 13 Zimmerman R, Carpenter RJ, Durig P, et al Longitudinal measurement of peak systolic velocity in the fetal middle cerebral artery for monitoring pregnancies complicated by red cell alloimmunisation: a prospective multicentre trial with intention-to-treat BJOG 2002;109(7):746-52 14 Divakaran TG, Waugh J, Clark TJ, et al Noninvasive techniques to detect fetal anemia due to red blood cell alloimmunization: a systematic review Obstet Gynecol 2001;98(3):509-17 15 Oepkes D, Seaward PG, Vandenbussche FP, et al Doppler ultrasonography versus amniocentesis to predict fetal anemia N Engl J Med 2006;355(2):156-64 16 Bennett PR, Le Van Kim C, Colin Y, et al Prenatal determination of fetal RhD type by DNA amplification N Engl J Med 1993;329(9):607-10 498 Section / Obstetrics 17 Moise KJ Management of rhesus alloimmunization in pregnancy Obstet Gynecol 2002;100(3):600-11 18 Bussel JB, Zabusky MR, Berkowitz RL, et al Fetal alloimmune thrombocytopenia N Engl J Med 1997;337(1):226 19 Lynch L, Bussel JB, McFarland JG, et al Antenatal treatment of alloimmune thrombocytopenia Obstet Gynecol 1992;80(1):67-71 20 Bussel JB, Berkowitz RL, Lynch L, et al Antenatal management of alloimmune thrombocytopenia with intravenous gamma-globulin: a randomized trial of the addition of low-dose steroid to intravenous gammaglobulin Am J Obstet Gynecol 1996;174(5):1414-23 21 Urbaniak SJ, Duncan JI, Armstrong-Fisher SS, et al Transfer of anti-D antibodies across the isolated perfused human placental lobule and inhibition by high-dose intravenous immunoglobulin: a possible mechanism of action Br J Haematol 1997;96(1):186-93 22 Skupski DW, Bussel JB Alloimmune thrombocytopenia Clin Obstet Gynecol 1999;42(2):335-48 23 Bussel J Diagnosis and management of the fetus and neonate with alloimmune thrombocytopenia J Thromb Haemost 2009;7 Suppl 1:253-7 31 CHAPTER Doppler Sonography in Obstetrics A Kubilay Ertan, H Alper Tanriverdi INTRODUCTION Doppler sonographic applications in pregnancy are the widely accepted functional methods of evaluating fetal wellbeing Flow velocity waveforms provide important information from the early stages of pregnancy to term As applications proliferate, awareness of the complexity of fetal and placental circulations, in normal pregnancy and in sequential responses to compromise, has also grown.1 One of the main aims of routine antenatal care is to identify the “at risk” fetus in order to apply clinical interventions which could result in reduced perinatal morbidity and mortality Doppler ultrasound is a noninvasive technique whereby the movement of blood is studied by detecting the change in frequency of reflected sound Doppler ultrasound has been used in obstetrics since 1977 to study the fetoplacental (umbilical) circulation,2 and since the 1980s to study the uteroplacental (uterine) circulation3 and fetal circulation.4 Recently, this method became an important tool for qualifying pregnancies in risk Information obtained with Doppler sonography helps obstetricians managing patients in situations like pregnancies complicated by intrauterine growth restriction (IUGR), Rhesus alloimmunization, multiple pregnancies and anamnestic risk factors Examination of the uteroplacental and fetomaternal circulation by Doppler sonography in the early second trimester helps predicting pregnancy complications like preeclampsia, IUGR and perinatal death.5-13 This chapter aims to introduce Doppler sonographic examinations in modern obstetrics Doppler blood flow velocity waveforms (FVWs) of the fetal arterial side (umbilical arteries, descending aorta and middle cerebral arteries) and maternal side (uterine arteries) are discussed and nomograms for routine obstetric practice are presented THE SAFETY OF DOPPLER ULTRASOUND IN OBSTETRICS The data available suggests that diagnostic ultrasound has no adverse effects on embryogenesis or fetal growth In addition, ultrasonographic scanning has no long-term effects on cognitive function or change visual or hearing functions According to the available clinical trials, there is a weak association between exposure to ultrasonography and non-right handedness in boys (odds ratio 1.26; 95% CI, 1.03–1.54).14 However, although B and M mode scans are safe during pregnancy, color, power and pulsed Doppler procedures should be performed with caution, especially in the early stages of pregnancy, due to possible thermal effects Studies concerned with the safety of ultrasound included mostly exposures before 1995, when the acoustic potency of the equipment used was lower than in modern machines Over the years, there has been a continuous trend of increasing acoustic output, and the findings of the previous studies necessarily apply to currently used equipment Because of weak regulation of ultrasound equipment output, fetal exposure using current equipment can be almost eight times greater than that used previously, regardless 500 Section / Obstetrics of whether gray-scale imaging, the three-dimensional technique, color Doppler or duplex Doppler is employed A short acquisition time of any kind of diagnostic ultrasonic wave may decrease exposure and thus unknown effects on fetal development.15 In particular, the use of pulsed Doppler involves the use of higher intensities compared to diagnostic ultrasound, and hence may cause significant tissue heating and thermal effects However, these thermal effects depend on the presence of a tissue/air interface and may therefore not be clinically significant in obstetric ultrasound examinations.16 The principle known as ALARA (as low as reasonably achievable) is generally supported and encourages the balance between the necessary medical information, minimal settings and exam time.17 In a randomized controlled prospective study, considering the long-term effect of ultrasound examinations on childhood outcome up to years of age, it was shown that exposure to multiple prenatal ultrasound examinations from 18 weeks’ gestation onwards might be associated with a small effect on fetal growth, but is followed in childhood by growth and measures of developmental outcome similar to those in children who had received a single prenatal scan.18 DEPENDENCY OF DOPPLER FLOW VELOCITY WAVEFORMS ON GESTATIONAL AGE The amount of perfusion in trophoblastic tissue is related to gestational age For this reason, in interpreting the Doppler sonographic findings, gestational age must be taken into account That is, nomograms for Doppler sonographic measurements should be standardized according to gestational age In the routine use of ultrasound in practice, the accepted time for starting Doppler sonographic examinations is the beginning of the second trimester This is the right time that allows modifications in antenatal care in a high risk pregnancy For specific conditions, earlier timing of measurements may be considered.19 The main objective in constituting fetomaternal Doppler sonographic nomograms is to improve perinatal outcome in high risk pregnancies Curves presented below depict normal fetal and maternal Doppler sonographic values, and can be used in routine practice Indices Blood flow velocity in the fetal circulating system depends on the type of vessel: The arteries always have a pulsatile pattern, whereas veins have either a pulsatile or continuous pattern Figure 31.1: Scheme of the Doppler curve (I) S= systolic, D= diastolic, C= temporal average of maximum frequency Calculation formulas of the main Doppler sonographic indices (II) Analysis of Doppler sonographic FVWs quantitatively, is more difficult than analyzing qualitatively Qualitative analysis also overcomes erroneous measurements in small vessels There are plenty of indices for qualitative analysis Following are the most frequently used indices: • Systolic/Diastolic ratio (S/D ratio, Stuart 1980) • Resistance index (RI, Pourcelot 1974) • Pulsatility index (PI, Gosling and King 1977) In analyzing sonographic results and calculating indices, following characters are used: S = Temporal peak of maximum frequency D = End-diastolic maximum frequency C = Temporal average of maximum frequency, Fmean I = Instantaneous spatial average frequency E = Temporal average of spatial average frequency Calculations of formulas are as follows (Fig 31.1): S/D ratio = S/D RI = (S–D)/S PI = (S–D)/C While calculating PI values, in some sonographic devices, E values are used instead of C values As a result PI values increase slightly The above presented indices overcome also a very serious problem involved with the angle between the ultrasound beam and the direction of blood flow (insonation angle) These indices are relatively angle independent and are therefore easily applied in clinical practice In practice, none of the indices is superior to the other20-22 and any index may be used Although the S/D ratio is easily calculated, RI is the easiest to interpret Resistance index values approach to zero if the resistance decreases and approach to one if resistance increases If end-diastolic flow is absent, PI is the only index making evaluation of blood flow possible, because CHAPTER 31 / Doppler Sonography in Obstetrics in this situation S/D will equal to infinite and RI to one The PI is more complex because it requires the calculation of the mean velocity, but modern Doppler sonographic devices provide those values in real time Doppler sonographic nomograms are used for the differentiation of normal and abnormal blood FVWs, which helps to determine pregnancies at risk By taking threshold values of pathologic pregnancies into consideration, nomograms are capable to differentiate between normal and abnormal The nomograms are presented for meeting this target.23 While confronting with these nomograms, it must always kept in mind that the values on these nomograms should not be taken as mathematical equations, and that limitations of sensitivity and specificity exist Using Nomograms in Practice Just like the defense mechanism of peripheral vasoconstriction in an adult in the face of hemorrhagic shock, the “brain sparing” mechanism (brain-sparing effect) becomes active in a fetus with hypoxia or chronic placental insufficiency As a result of the brain sparing effect, resistance either in the umbilical artery (UA) and fetal descending aorta (FDA) increases As a consequence Doppler indices related to these vessels increase The end-diastolic blood flow increases in middle cerebral arteries (MCA) by the same effect Doppler indices for this vessel decreases consequently Some points should be considered while using Doppler sonographic nomograms: • Among the measurements performed on the UA and FDA, values between 90–95th percentiles should be considered as borderline and repeat follow-ups should be planned Values exceeding the 95th percentile are considered abnormal • Doppler values between 5–10th percentiles in MCA should be considered as borderline and repeat follow-ups should be planned Values below the 5th percentile are considered abnormal • Measurements taken after 24 weeks’ gestation from uterine arteries are more valuable The early diastolic notching, and values exceeding the 95th percentile are considered as abnormal One point to remember is that notching predicts an increased risk of preeclampsia CHANGES IN DOPPLER SONOGRAPHIC RESULTS DURING THE COURSE OF PREGNANCY AND COMPLICATED PREGNANCIES During the course of pregnancy and in some specific pregnancy complications, Doppler sono- 501 graphic results of fetomaternal vessels display changing values Umbilical Artery (UA) It has been shown in a longitudinal observational study that Doppler ultrasound of the UA is more helpful than other tests of fetal wellbeing (e.g heart rate variability and biophysical profile score) in distinguishing between the normal small fetus and the “sick” small fetus.24 However, its exact role in optimizing management, particularly timing of delivery, remains unclear, and is currently being investigated by many study groups The optimal timing of delivery in pregnancies complicated by highly pathological Doppler flow findings is still an issue to be resolved To resolve this question and to improve the perinatal morbidity and mortality some multicenter clinical trials 25 have been undertaken Gestational age, Doppler waveforms, antenatal testing, and maternal status should all be taken into consideration to guide optimal timing of delivery to minimize extreme prematurity, but also to prevent intrauterine injury, in the case of the compromised fetus Blood flow velocity in the UA increases with the advancing gestation As a result impedance to blood flow continuously decreases due to increasing arterial blood flow in the systole and diastole End-diastolic velocity is often absent in the first trimester2,26 and the diastolic component increases with advancing gestation27 (Fig 31.2) With advancing gestational age, end-diastolic flow becomes evident during the whole heart cycle (Fig 31.3), proven with previous longitudinal studies of Fogarty et al22 and Hünecke et al,28 as with many cross-sectional studies.27,29 Figure 31.2: Absent end-diastolic flow of the umbilical artery in the first trimester (physiologic) with pulsations of the umbilical vein (physiologic) CHAPTER 58 / USG Role in Perinatal Infection Figure 58.4: Echogenic bowel 1007 Figure 58.6: Placentomegaly titer within weeks since the IgM could persist in the circulation for more than 18 months from last infection.23 Differentiating between primary or secondary infection is somewhat important for assessing the possibility of fetal infection as mentioned earlier The CMV IgG avidity test is very useful in this domain.24 Intrauterine infection diagnosis could be achieved through amniocentesis and isolation of the CMV DNA by PCR with a sensitivity of 80–99% of cases.17 It should be noted that it takes 5–7 weeks after fetal infection for viral replication in the fetal kidneys to be present in sufficient quantity to be secreted into amniotic fluid, also the PCR testing is unreliable prior to the 21st weeks of pregnancy This means that amniocentesis for CMV detected by PCR should not be performed before the 21st weeks and with an elapse of at least weeks from the time of maternal infection.19 Figure 58.5: Hydrops e-bowel Treatment of CMV Infection uncommon less than 10% in utero or at birth Among the ultrasound markers for CMV infection that could be detected are cranial calcification periventricular in position without shadowing, ventriculomegaly, echogenic bowel (Figs 58.4 and 58.5), enlarged liver and spleen, focal calcification in the liver and mild ascitis, severe IUGR Placentomegaly (Fig 58.6) is noted in 32% of the time Those cases showing cerebral manifestations and/or severe IUGR are more prone to develop neurological sequel.22,23 The mere detection of positive IgM and IgG is not indicative of active infection unless we obtain a rising There is currently no approved treatment for congenital infection Gangciclovir being effective treatment for CMV however not safe in the first trimester.22 Valaciclovir is showing some promise for use however with limited research till now.25 Hyperimmunoglobulin appears to be an effective drug for fetal however also with limited data.22 Toxoplasma Mode of Infection It is caused by the protozoon, Toxoplasma gondii The definitive host is the cat and the intermediate hosts 1008 Section / Gynecology Treatment Spiramycin can decrease the risk of congenital toxoplasmosis by around one half It is taken as 1g every hourly and is continued until delivery.30 This drug does not cross the placenta, so in the evidence of fetal infection by amniocentesis and PCR, treatment should be in favor of other drugs that are effective and also cross the placenta.30 This include both Pyrimethamine and Sulfadiazine Different regimens are used however in all of them folic acid is added as both of them are folic acid antagonist Examples are: Pyrimethamine 50 mg/day + Sulfadiazine g tid + folinic acid 10–25 mg/day for weeks alternating with weeks of Spiramycin g tid This regimen is continued until term.30,31 Parvovirus B19 Infection Figure 58.7: Cranial calcification include humans, numerous mammals and birds which acquire the infection from the oocysts contained in cat feces and thus seronegatives are urged to avoid contact with cats, wash fruits and vegetables thoroughly and avoid raw meat.26 Transmission It is caused by the human Parvovirus B19 which belongs to the Parvoviruses group a single DNA strand.32 The viruses affect the function of the hematopoietic organs through the infection and lysis of erythropoid cells The disease is very mild for the mother and carries a 33% placental transmission rate following maternal seroconversion at any stage of pregnancy The virus can cause severe destruction of erythroid progenitor cells in the fetus with the risk of developing fetal anemia, hydrops and intrauterine death.32 The rate of mother to fetus transmission depends on the gestational age and the time of the initial infection It is around 15%, 30%, 60–70%, in the first, second and third trimesters respectively However, the reverse is the situation for the severity of infection, being highest in first trimester and almost nil in the third trimester.27 Transmission Ultrasound Signs The hallmark of this infection is fetal hydrops which may be severe in very low hemoglobin levels It accounts for 10–15% of nonimmune fetal hydrops NIHF.33,34 The main ultrasound sign of prenatal toxoplasmosis infection is ventriculomegaly, intracranial calcification (Fig 58.7) Choroidoretinitis is among the sequelae detected postnatal Other ultrasound markers include hepatosplenomegaly, ascitis.15 Testing If the serologic testing shows that the woman has contracted toxoplasmosis during pregnancy by a positive IgG and IgM with a rising titer, detecting T gondii in the amniotic fluid by PCR through amniocentesis is the preferred methods for assessing fetal infection with a sensitivity more than 80% and specificity of 96%.28,29 It would lead to fetal anemia in 7–17% of affected cases It is not associated with a clinically significant risk of malformations.32 Ultrasound Signs Testing Nonimmune hydrops should call for a Parvovirus B19 IgG and IgM antibody testing in the maternal serum In 80% of the cases, the virus can be detected in the fetal blood by PCR In case of NIHF the evaluation of middle cerebral artery peak systolic velocity is an important tool to diagnose and follow-up fetal anemia.35,36 This should be followed by cordocentesis and intrauterine blood transfusion which is the only way for fetal survival, more than 80% of the fetuses transfused in utero will survive CHAPTER 58 / USG Role in Perinatal Infection 1009 MANAGEMENT Exposure Before 20 Weeks If the mother is not immune: I globuline 1000 gm IM may be given If she develops chicken pox, council her for the possibilities of fetal infection and follow-up by serial USG Exposure After 20 Weeks Figure 58.8: Liver calcification Varicella Zoster DNA virus of the Herpes family responsible for chicken pox (varicella), the primary infection and Herpes Zoster shingles, a reactivation of the virus occurring at any age but with an increasing incidence in adulthood transmission via droplet infection and infection is followed by long lasting immunity Both maternal and fetal infection is important and serious Pregnancy increases the risk of disease associated complications particularly in late pregnancy Pneumonia occurs in up to 10% of cases and could be so severe that it necessitates mechanical ventilation.37 Fetal varicella syndrome occurs when the fetus is infected during maternal viremia in the first 20 weeks of gestation The risk of fetal varicella syndrome is estimated to be 0.4% in the first 12 weeks of pregnancy, 2% between 13–20 weeks of gestation, the syndrome does not occur if maternal infection occurs after 20 weeks.37 Prenatal diagnosis of fetal varicella syndrome depend on serial USG examination weeks or later after primary infection among the signs are polyhydramnios, microcephaly, liver calcification (Fig 58.8), NIHF, limb hypoplasia Varicella embryopathy is the term used for infants contracted the infection intrauterine.37 It comprises cutaneous scars, denuded skin, limb hypoplasia, muscle atrophy and rudimentary digits, other more frequent abnormalities are microcephaly, intracranial calcification cortical atrophy, cataract, chorioretinitis, micro-ophthalmia and psychomotor retardation There is no fetal infection in these cases, however the mother may develop some complications mainly Pneumonitis, thus if she is presented within 24 hours of chicken pox rash She may be given oral acyclovir 800 mg times daily for days to reduce the severity and duration of illness If presented after 24 hours, the acyclovir is of no effect and just follow-up the disease progression.38,39 In Herpes Zoster, the fetus is unaffected by maternal Herpes Zoster unless mother is immunosuppressed Rubella Mode of Infection It is caused by a small RNA togavirus, the rubella virus Transmission Direct contact with infected droplets If the infection is contracted in the first weeks of gestation, two-thirds of the fetuses will develop a rubella syndrome Infections in later weeks are associated with lower risks, 25% between and weeks, 20% between 10–12 weeks and 10% between 13–17 weeks.40 Ultrasound Signs The anomaly typically found in rubella embryopathy is ventricular septal defect (VSD) or tetralogy of Fallot Additional signs include growth retardation and microcephaly The triad of cataract, cardiac anomalies and deafness (Gregg syndrome) is a classic embryopathy caused by the infection.15 Testing A normal ultrasound scan cannot exclude fetal rubella infection, thus in cases of primary rubella infection, it is possible to detect the virus in chorionic villi or amniotic fluid Cordocentesis has reasonable accuracy but should not be performed earlier than 22 weeks since the IgM production may still be too low before 21 weeks A good strategy in earlier cases is to start with CVS or 1010 Section / Gynecology amniocentesis and if negative, confirm the result by cordocentesis at 22 weeks.41 CONCLUSION • Ultrasound markers of a congenital infection include echogenic bowel, hepatosplenomegaly, NIHF, cranial anomalies mainly hydrocephalus and cranial calcifications and early symmetrical IUGR • Maternal screen for TORCH and TORCH-like infections is recommended in these cases • Serial ultrasound should be performed every two weeks in pregnancies at risk for congenital infection as in case of exposure to infection or maternal seroconversion • Amniocentesis is considered the standard invasive test for the diagnosis of most intrauterine infection where isolation of the virus is done by PCR with a sensitivity now approaching 100% • Intrauterine infection are not a cause for recurrent pregnancy loss, so TORCH is not indicated in these cases REFERENCES Simposon JL, Mills JL, Kim H, et al Infections processes: an infrequent cause of first trimester spontaneous abortions Hum Reprod 1996;11(3):668-72 Jauniaux E, Gavril P, Nickolaides KH Ultrasongraphic assessment of early pregnancy In: Jurkovic D,Jauniaux E (Eds) Ultrasound and Early pregnancy Carnforth UK:Parthenon publishing; 1995 pp.53-64 Iskaros J, Jauniaux E, Rodeck C Outcome of non immune hydrops fetalis diagnosed during the first half of pregnancy Obstet Gynecol 1997;90:321-5 McCoy MC, Katz VL, Gould N, et al Non Immune hydrops after 20 weeks gestation, review of 10 years experience with suggestions for management Obstet Gynecol 1995;85:57882 Weiner CP, Grose CF, Naides SJ Diagnosis of fetal infection in a patient with an ultrasongraphically detected abnormality but a negative clinical history Am J Obstet Gynecol 1993;168:6-11 Kilby M, Hodgett S Perinatal viral infections cause of intrauterine growth restriction In: Kingdom J, Baker P (Eds) Intrauterine Growth Restriction: Aetiology and Management, London:SpringerVerlag; 2000 pp 29-49 Holliman RE Clinical sequelae of chronic maternal toxoplasmosis Rev Med Microbiol 1994;5:47-55 Benoist G, Salomon L, Mohlo M, et al Cytomegalovirus related fetal brain lesions: comparison between targeted ultrasound examination and magnetic resonance imaging Ultrasound Obstet Gynecol 2008;32(7):900-5 Hall SM Congenital toxoplasmosis Br Med J 1992; 305(6848):291-7 10 Ranucci Weiss D, Uerpairojkit B, Bowles N, et al Intrauterine adenovirus infection associated with non immune hydrops Prenat Diagn 1998;18(2):182-5 11 Lambot MA, Noel JC, PenyMO, et al Fetal parvovirus B19 infection associated with myocardial necrosis Prenat Diagn 1998;18:182-5 12 Parilla BV, Tamura RK, Ginsberg NA Association of parvovirus infection with isolated fetal effusions Am J Perinatol 1997;14(6):357-8 13 Muller F, Dommergues M, Aubry MC, et al Hyperechogenic fetal bowel: an ultrasonographioc marker for adverse fetal and neonatal outcome Am J Obstet Gynecol 1995;173(2):508-13 14 Mac Gregor SN, Trmura R, Sabbagha R, et al Isolated Hyperechoic Fetal Bowel: Significance and implications for management Am J Obstet Gynecol 1995;173(4):1254-8 15 Yaron Y, Hassan S, Geva E, et al Evaluation of fetal echogenic bowel in the second trimester Fetal Diagn Ther 1999;14(3):176-80 16 Degani S Sonographic finding in fetal viral infection: A systematic review Obstet Gynecol Surv 2006;61(5):329-36 17 Jauniaux E A comparison of Chorionic villus sampling and amniocenetsis for prenatal diagnosis in early pregnancy In: Grudzinskas JG,Ward RHT (Eds) Screening for Down Syndrome in the First Trimester London: RCOG press; 1997 pp 259-69 18 Guerra B, Lazzarotto T, Quarta S, et al Prenatal diagnosis of symptomatic congenital cytomegalovirus infection Am J Obstet Gynecol 2000;183(2):476-82 19 Nigro G, Mazzocco M, Anceschi M, et al Prenatal diagnosis of fetal cytomegalovirus infection after primary or recurrent maternal infection Obstet Gynecol 1999;94(6):909-14 20 Malm G, Engman ML Congenital cytomegalovirus infections Semin Fetal Neonatal Med 2007;12(3):154-59 21 Stagno S, Pass R, Cloud G Primary cytomegalovirus infection in pregnancy Incidence, transmission to fetus, and clinical outcome JAMA 1986;256(14):1904-8 22 Nigro G Maternal fetal cytomegalovirus infection: From diagnosis to therapy J matern Fetal Neonatal Med 2009; 22(2):169-74 23 Omoy A, Diav-Citrin O Fetal effects of primary and secondary cytomegalovirus infection in pregnancy Reprod Toxicol 2006;21(4):399-409 24 Evaluation of the new architect cytomegalovirus immunoglobulin M (IgM), IgG and IgG avidity assays J Clin Microbiol 2009;47(6):1695-9 25 Jacquemard F, Yamamoto M, Costa J, et al Maternal administration of valaciclovir in symptomatic intrauterine cytomegalovirus infection Br J Obstet Gynaecol 2007; 114(9):1113-21 26 Joynson DHM, Payne R Screening for toxoplasmosis in pregnancy Lancet 1988;2(8614):795-6 27 Gilbert R, Gras L European multicentre study on congenital toxoplasmosis Effect of timing and type of treatment on the risk of mother to child transmission of Toxoplasma gondii Br J Obstet Gynaecol 2003;110(2):112-20 28 Gras L, Gilbert RE, Wallon M, et al Duration of the IgM response in women acquiring Toxoplasma gondii during pregnancy: implications for clinical practice and crosssectional incidence studies Epidemiol Infect 2004;132(3): 541–8 CHAPTER 58 / USG Role in Perinatal Infection 29 Foulon W, Pinon JM, Stray-Pedersen B, et al Prenatal diagnosis of congenital toxoplasmosis: multicenter evaluation of different diagnostic parameters Am J Obstet Gynecol 1999;181(4):843-7 30 Wallon M, Liou C, Garner P, et al Congenital toxoplasmosis: systematic review of evidence of efficacy of treatment in pregnancy Br Med J 1999;318(7197):1511–4 31 Foulon W, Villena I, Stray-Pedersen B, et al Treatment of toxoplasmosis during pregnancy: a multicenter study of impact on fetal transmission and children sequelae at age year Am J Obstet Gynecol 1999:180(2 Pt 1):410-5 32 Hedrick J The effects of human parvovirus B19 and cytomegalovirus during pregnancy J Perinat Neonatal Nurs 1996;10(2):30–9 33 Chisaka H, Morita E, Yaegashi N, et al Parvovirus B19 and the pathogenesis of anaemia Rev Med Virol 2003; 13:347–59 34 Al Khan A, Caliguri A, Apuzio J Parvovirus B19 infection during pregnancy Infect Dis Obstet Gynecol 2003;11(3): 175-9 1011 35 Cosmi E, Mari G, Chiaie LD, et al Noninvasive diagnosis by Doppler ultrasonography of fetal anemia resulting from parvovirus infection Am J Obstet Gynecol 2002;187(5): 1290–3 36 Hernandez-Andrade E, Scheler M, Dezerga V, et al Fetal Middle cerebral artery peak systolic velocity in the investigation of non immune hydrops Ultrasound Obstet Gynecol 2004;23(5):442-5 37 Pretorius DH, Hayward I, Jones Kl, et al Sonographic evaluation of pregnancies with maternal varicella infection J Ultrasound Med 1992;11(9):459-63 38 AL Levy M, Schick B, et al Outcome after maternal varicella infection in the first 20 weeks of pregnancy N Engl J Med 1994;330(13):901-5 39 Smego RA, Asperilla MO Use of acyclovir for varicella pneumonia during pregnancy Obstet Gynecol 1991;78: 1112-6 40 Banatvala J, Brown DWG Rubella Lancet 2004;363(9415): 1127-37 41 Sever JL, South MA, Shaver KA Delayed Manifestations of Congenital Rubella Rev Infect Dis 1985;7:(Supp 1) S164-9 INDEX A Abdomen 37, 59, 205, 210, 211, 606 Abdominal circumference 37, 216 insertion of umbilical cord 207 myomectomy 796, 797 pain 58 pregnancy 143 thoracic appearance 40 Abnormal biochemical markers 58 bone structure 292 development of fetal neck 277 facial expression 244 profile 292 fetal activity 489 first-trimester dual marker test 482 flow in umbilical vein 510 flow velocity waveform in uterine artery in third trimester 514 flow velocity waveforms of ductus venosus 512 inferior vena cava 511 middle cerebral artery in third trimester 508 umbilical artery in third trimester 503 head shape 292 pregnancy associated plasma protein 482 results from CVS/amniocentesis 482 serum alpha-fetoprotein 38 triple test 482 uterine bleeding 794 vaginal bleeding 113 yolk sac 482 Abortion 800 Abruptio placentae 38, 503 Acardius acephalus 577 Achondrogenesis 292, 293, 406 Achondroplasia 292, 405 Acquired brain abnormalities in utero 266 Acrania with cervical spina bifida 549 Acromelia 293 Acute pelvic inflammatory disease 833 pelvic pain 942 with negative pregnancy test 943 with positive pregnancy test 950 polyhydramnios 297 salpingitis 944 salpingo-oophoritis 980 Adenocarcinoma 838 Adenomyoma 978 Adenomyomatous polyps 970 Adenomyosis 774, 853, 883, 959, 977 Adnexal mass 950 torsion 947 tumors 810 Adrenocorticotropic hormone 86 Adriamycin 166 Adult uterus 760 Agenesis of corpus callosum 249, 255, 258 septum pellucidum 249 Agnathia with cleft lip 624 Alcohol abuse 47, 503 Alloimmune thrombocytopenia 497 Alobar holoprosencephaly 256, 257, 575 Alteration of facial expression of fetus 731 Amelia 295 Amenorrhea 774, 856 Amniocentesis 38, 58, 149, 602, 671, 705, 714 Amnion 121 Amnio-peritoneal membrane 365 Amnioreduction 684 Amniotic and chorionic membranes 570 band 248, 411, 485 fluid 29, 37, 226 abnormalities 58 volume 39 septostomy 684 Amputation of endometrium 973 Anembryonic pregnancy 117 Anemia 503 Anencephaly in middle gestation 250 Aneurysm of right aortic valsalva sinus 344 Angiogenesis of corpus luteum 768 Angle of insonation 32 Aniridia 272 Anonymous artery 582 Antenatal neurological screening test 662 Anterior abdominal wall 39 defects 362 cerebral arteries 258 fontanelle 546 hernias 302 knee flexion 423 posterior diameter of renal pelvis 217 wall fibroid and pregnancy 800 Antibiotic therapy 835 Antidiuretic hormone 71 Antley-Bixler syndrome 265 Antral follicle count 888, 892 AO arch 329 Aorta 19 Aortic arch 205, 329 valve 328 Apert syndrome 242, 265, 625 Apodia 295 Aqueductal stenosis 247 Arachnoid cyst 263, 264 Arania 250 Arcuate arteries 760, 771 uterus 881, 895 Arhinia 256 Arterioarterial anastomoses 474 Arteriovenous placental anastomoses 683 Arthrogryposis 265 multiplex congenita 297 Ascites 493 Asherman’s syndrome 856, 895 Assessment of fetal facial expression 752 levator ani reactivity 996 myometrial invasion 807 Assisted reproduction techniques 92 Atrial contraction 185 width measurement 243, 246 Atrioventricular septal 350 valves 338, 349, 356 AV valves insertion 328 opening 328 1014 Donald School Textbook of Ultrasound in Obstetrics and Gynecology Axial scan of fetal head 606 mouth 202 section of fetal brain 248 thick slice 236 B Basal body temperature 161 Basic anatomy of fetal brain 234 Beckwith-Wiedemann syndrome 437 Beginning of opening of eyelids 738 Benign tumors of fallopian tube 836 Bicornuate uterus 38, 850, 882, 967 with pregnancy 565 Bilateral cleft lip 626 cleft of maxillary bone 553 congenital cataract with microphthalmia 553 coronal suture 264 hydronephrosis 633 parts of eyebrows 734 peromelia 295 renal agenesia 379 talipes equinovarus 417 umbilical arteries 556 Biophysical monitoring of pregnancy 559 Biparietal diameter 37, 40, 199, 215 Bladder 18, 37, 59, 208, 210 exstrophy in first trimester 556 Blastocyst 542 Blighted ovum 117 Bochdalec hernia 302, 630 Body-stalk anomaly 725, 726 Bone length 292 parameters 292 Bowel disorders 369 obstruction 371 Bowing of femur 402 tibiae 407 Brachiocephalic vessels 205 Brachycephaly 265 Brachydactylia 295 Brain 37, 210, 549 anomalies 624 basilar arteries 545 edema 509 paring effect 67 tumors 266, 268 Branchial cyst/fistula 285 Breast abscess 535 Bronchopulmonary sequestration 305 Bull’s horn-like appearance 257 C Calcaneous angulation 417 valgus deformity 419 Callosomarginal artery 258 Calm and tranquil expression of fetus 740 expression of fetus 741 Calvarium 39 Camptodactylia 295 Camptomelic dysplasia 293, 294 Carbimazole 280 Cardiac anomaly 292 axis 328 crux 328 cycle 185 disease 503 Doppler parameters 227 outflow tracts 40 size 328 Cardiorespiratory diseases 503 Cardiothoracic lesions 1005 Caudal neural tube formation 249 Causes of fetal goiter 280 Cavum pellucidum 40 septi pellucidi 59, 201, 210, 211, 561, 606 Celocentesis 677 Central cord insertion 441 hernia 302 nervous system 241, 549 Cephalocele 248, 549 Cerebellar vermis 201 Cerebellum 59, 210, 211, 216, 240, 254, 486 Cerebral hemorrhage 271 hypoplasia 247 ischemia 271 palsy 243, 658, 664, 666 white matter hypoplasia 249 Cerebrospinal fluid 238 Cervical cancer 809 chondrocutaneous branchial remnants 285 hemangioma 285 myoma 723 pregnancy 139, 141 spine 59, 210 teratoma 283 Cervix 762 Cesarean delivery 38 section 532 rate 673, 708 Champagne-cork thorax 292 Chemotherapy 165 of choriocarcinoma 166 Chiari malformation 253 Choanal atresia 265 Choledocal cysts 373, 374 Chorioangioma 503 Choriocarcinoma 157-161, 166, 169, 170, 448, 534 metastases 159 Chorion frondosum 697 Chorionic villus sampling 57, 149, 674, 675, 716, 920 Choroid plexus 59, 201, 236, 238, 243, 247, 486, 561 cysts 266 Chromosomal defect 297 Chromosome abnormalities 272 Chronic hypertension 38 inflammation of endometrium 973 pain 949 pelvic inflammatory disease 834 pain 950 renal disease 38 salpingitis 944 tests 225 tubal pregnancy 136 Cingulate sulcus and gyrus 258 Circle of Willis 507, 545 Circumvallate placentas 441 Cisterna magna 37, 39, 59, 200, 210, 211, 253, 486 Classical tubo-ovarian mass 979 Classification of facial patterns 752 lissencephaly 260 movement patterns 651 Cleft foot with toe dysplasia 637 lip 33, 242, 602, 745 and palate 625 Clinodactyly 295 Cloaca exstrophy 387 Cloverleaf skull 404 Club foot 297 Cogwheel sign 834, 944 Collagen vascular disease 503 Color Doppler Hy-Co-Sy 906 rendering volume 318 Combined scoring system for ovarian endometrioma 949 Comet sign 107 Common carotid arteries 545 Complete agenesis of corpus callosum 257 Index bidimensional echocardiography 206 circumvallate placenta 441 hydatidiform mole 157, 161, 169 in situ in uterus 158 mole in triplet pregnancy 163 of twin 163 placenta previa 448 Complex adnexal mass 831, 833, 944, 950 congenital heart defect 347 cystic lesion 945 Concurrent intrauterine pregnancy 132 Congenital abnormalities 299 anomalies 847 of fetal thorax 306 central nervous system anomalies 248 cystic adenomatoid malformation 305, 631 lung lesions 308 diaphragmatic hernia 305, 630, 686, 687 heart diseases 310, 311 infection 1003 knee luxation 423 nonimmune hyperthyroidism 281 patellar luxation 423 structural abnormalities 38 uterine malformations 534 Conjoined twins 548 Conservative management of ectopic pregnancy 920 Constriction band in low extremity 411 Contiguous gene syndromes 272 Contours of both eyelids 731 Contralateral normal arm and hand 412 ovary 983 upper extremity 411 Cord insertion 37 Cordocentesis for intrauterine fetal transfusion 494 Cornelia De Lange syndrome 307 Cornual angle 965 ectopic pregnancy 139 pregnancy 138-140 Coronal scan 561 of lips and nostrils 202 section of kidneys 207 uterus 19 suture 546 thick slice of premature brain 236 Corpus callosum 201, 258, 262, 593, 594, 637 luteum 765, 766, 768, 858, 891 angiogenesis 945 cysts 952 hemorrhagic cyst 945 neoangiogenesis 768 Corticotropin releasing hormone 86 Cranial calcification 1008 lesions 1004 sutures 645, 662 Craniofacial bony structure 235 Craniorachischisis 549 Craniosynostosis 244, 264 Cranium 549 bifidum 249 occultum 249 Crossing of great arteries 100 328 Crouzon syndrome 265 Crown-rump length 108, 121, 126, 175, 177, 213 Cubital diaphysis 394 Culdocentesis 919 Cumulus oophorus 891 Cyclophosphamide 166 Cyclopia 256 Cystic adenomatoid malformation 303, 304 dermoid tumor 811 hygroma 278, 581, 724 renal dysplasia 380 solid ovarian tumor 814 villus 165 Cytomegalovirus 241, 305, 1006 infection 241 Cytotrophoblast 111 D Dandy-Walker cyst 262 malformation 260-262 syndrome 248 variant 260-262 Dangling choroids plexus 246 Deformable calvaria 292 Degenerating leiomyomas 945 fibroid 946 Degree of bowing 292 Demineralized fetal skull 400 Dermoid tumor 285 Descending aorta 204 fetal aorta PI nomogram 506 S/D ratio nomogram 506 Detection of bone fractures 292 Determination of fetal renal function 389 1015 Development of cranial bones 235 gestational sac 544 human embryos 541 placenta 63 Diabetes mellitus 664 Diabetic macrosomia 722 Diaphragmatic eventration 727 hernia 301, 302, 306, 368 herniation 726, 727 Dichorionic twins 468 Didelphic uterus 852, 882 Didelphys uterus 966 Diffuse hyperechogenicity of abdominal cavity 373 Discordance in fetal size 471 of fetal growth 474 Discordant umbilical arteries 428 Disseminated intravascular coagulation 141 Distinct hydrosalpinx enveloping globular ovary 981 Dolichocephaly 264 Dorsal sac 256 Double bubble sign 370 Down syndrome 187 Drainage of pelvic abscesses 918 Ductal arch 329, 343 Ductus arteriosus 324, 354 venosus 183-185, 226, 511, 512, 579, 622, 632 flowmetry 473 Duodenal atresia or stenosis 370 Duplication of cervix and vagina 853 Dysgenesis of corpus callosum 258 Dysgenetic hydrocephalus 246 Dysmorphic hand 424 E Early fetal circulation 111 color Doppler 111 pregnancy failure and vaginal bleeding 113 loss 120, 1003 stage of Dandy-Walker malformation 262 Eccentric cord insertion 441 Echogenic bowel 373, 1007 cystic lesions 984 endometrium 527, 530 intracardiac focus 484 mass 268, 528, 530 in small bowel 484 ovary 979 1016 Donald School Textbook of Ultrasound in Obstetrics and Gynecology Ectopic gestational sac 134, 135, 953 liver 632 pregnancy 38, 58, 120, 131, 132, 136, 144, 951-953 Ectrodactylism 295, 296 Ectromelia 295 Edwards syndrome 272 Electric shocks 60 Electrical scalpel 24 Embryo and yolk sac 108 transfer 38, 57 Embryonic bradycardia 482 cardiac activity 136 heart rate 121, 125 period 562 Empty uterine cavity 138 Encephalocele 250, 628 Encephalocystocele 249 Encephalomeningocele 240, 249 Enchondral ossification 401 Encircling corpus luteum 768 Endocrine disorders 981 Endometrial cancer 796, 803, 805-807, 971 carcinoma 777, 779, 971 diseases 794 Doppler 98 echogenicity 96 factors of infertility 872 fluid collections 972 hyperplasia 775, 776, 779, 795, 805 polyp 772, 779, 851, 854, 875, 895, 904, 968 receptivity 973 thickness 95, 132, 794, 805845 vessels 762 volume 95, 101, 804, 805 Endometriosis 885, 948 Endometriotic cyst 887 Endometritis 830, 855, 959 Endometrium 872, 973 in infertile women 875 under hormone replacement therapy 936 Endopelvic fascia 987, 997, 998 Enlarged foramen of Monro 247 Epilepsy 243 Epithelioid trophoblastic tumor 160, 168 Esophageal atresia 308, 369, 370 Esophagus 301 Estimating fetal weight 217 Evaluation of ductus venosus 185 fetal growth 38, 58 fetal well-being 58 flow across tricuspid valve 183 intracranial translucency 190 outflow tracts 319 ovarian reserve 888 uterine artery blood flow using Doppler 191 uterus 39, 58 Exocoelomic membrane 111 Exophthalmos 242, 244, 625 Expulsion of tongue 736 External orbital diameters 37 parasagittal scan 201 Extraembryonic mesoderm 542 Extreme hyperdorsiflexion 550 Extremely short upper limb 398 Eyelids 542 F Facial anomalies 624 bone 235 contours of facial muscle 730 expression in fetus with unilateral cleft lip 747 of fetus with arthrogryposis 746 Fallopian tube 763, 893, 896, 944, 979 carcinoma 838 Fan-like scanning 12 Fatal osteochondrodysplasias 293 Female genitalia 208 Femoral diaphysis 395 focal deficiency in newborn 413 Femur and humerus articulations 613 length 40, 216, 292 measurement 216 Fetal abdomen 487, 729 adrenal gland 378 adrenocorticotropic hormone 68 akinesia deformation sequence 421 alcohol syndrome 272 anatomic survey 59, 279 anatomy 39, 59 anomalies 723 arm with elbow pterygium 409 biometry 487 biparietal diameter 41 bladder 78 blood sampling 676, 709, 717 brain 726 cardiac activity 59 function 314 screening 314 cardiovascular system 69, 315 central nervous system 79, 233, 234 clubfoot 554 craniofacial expression 272 skeletal structure 235 death 38, 58 descending aorta 505, 507 deterioration 225 echocardiography 279, 312, 472 face 650, 735 and foot 244 and left forearm 290 in fetus with bilateral cleft lip 745 foot postaxial polydactyly 420 gastrointestinal system 72 goiter 279 growth and metabolism 67 hand 737 syndactyly 421 heart 59, 70, 486 in 3D and 4D 316 rate 174, 228 heartbeat 38 karyotyping 279 kidney 78 legs 290 lung and liver 75 musculoskeletal abnormalities 393 neck 734 normality 40 orbits and face 486 ovarian cyst 16, 20 tumor 724, 725 pelvis 208 period 568 periventricular leukomalacia 271 pleural effusions 305, 687 pyelectasis 484 reduction 918 respiratory system 74 skeleton 17, 289, 393, 487 skull 404 spine 486 status 279 therapy 680 thorax 397, 486 oblique section 403 tone 38 tongue 643 tumors 316 umbilical cord insertion 39 unit 107 urinary system 76 venous circulation 509 weight estimation 59 yawning 739 Fetoscopic endoluminal tracheal occlusion 687 Fetus in third trimester of gestation 736 Fetus with anencephaly 745 bilateral cleft lip 745 labiopalatoschisi 746 macroglossia 746, 747 Index osteochondrosis dysplasia 745 thanatophoric dysplasia 744 trisomy-18 744 unilateral cleft lip 745 Fibroid 976 elastoscans 792 polyps 970 Fibula 37 Finger movements 645, 646 First trimester measurements 213 of pregnancy 562 screening for fetal anomalies 188 preeclampsia 190 ultrasonography 49 Fisher exact test 119 Fixed human embryos 541 Flow index 94, 95 Focal endometrial lesions 968 Follicle-stimulating hormone 101 Follicular maturation 976 Folliculogenesis 818 Foramen magnum 253 ovale 320, 328 Fraser cryptophthalmos syndrome 308 syndrome 308 Free fluid in cul-de-sac 136 surface scanning 12 Frontal and parietal bones 235 holoprosencephaly 577 suture 546 Frontalis muscle 742 Frontomaxillary angle 181 facial angle 181 Frontonasal dysplasia 612 Fryns syndrome 307 Fukuyama syndrome 260 Functional ovarian cysts 979 Functions of placenta 67 Fundal height 38 measurement 222 muscular septum 967 Fundus corpus 119 Funneling of bladder neck 1000 urethra 1000 G Gallbladder 206 Gastrointestinal lesions 1005 Gastroschisis 362, 364 Gel infusion sonohysterography 895 Genetic disorders 272 hydrocephalus 637 Genital tract bleeding 143 Genitalia 37, 211 Gestation fetus with right aortic arch 324 Gestational age 57, 58, 153 choriocarcinoma 160, 165 diabetes 503 sac 121, 213 trophoblastic disease 157, 161, 446 neoplasm 796 Glass body rendering volume 318 Goiter 283 Goitrogens 280, 281 Goldenhar syndrome 285 Graaf follicle 564 Gray scale appearance of umbilical cord 486 Great arteries 329 Guthmann’s image 721 Gyral abnormalities 258 H Half Fourier acquisition single shot turbo spin echo 725 Hand and foot deformities 415 Hand-to-face movements 646 Hard(E) syndrome 260 Head 210, 587 and brain 199 and face 210 and neck 59 circumference 40, 37, 215 size 292 Heart 19, 211 volume 318 Hemangioma 283, 285 Hemimelia 295 Hemivertebra 611, 629 Hemorrhagic cyst 767, 945 of ovary 767 ovarian cyst 845, 943 Hepatic masses 374 portion of umbilical vein 185 vein 205 Hernial sac 555 Heterogeneous uterus 778 Heterotopias 258 Hexadactyly 296 High echogenic yolk sac 548 Hindfoot 416 Holoprosencephaly 248, 255 Holt-Oram syndrome 296 1017 Homogeneous echogenicity 949 Homozygous achondroplasia 293 Honemeyer’s case 167 Hormone replacement therapy 93 Huge omphalocele 632 tumor 267 Human chorionic somatomammotropin 69 placental lactogen 160 Hy-Co-Sy procedure 903 requirements 903 Hydatidiform mole 38, 58, 157, 163, 447 Hydrocephalus 244, 248, 626 Hydronephrotic kidney 384 Hydropic fetus 398 Wharton’s jelly in syndromic fetus 427 Hydrops E-bowel 1007 fetalis 493 hepatosplenomegaly 1005 splenomegaly hepatomegaly 1006 Hygroma 277 and fetal hydrops 575 Hyperechogenic endometrium 830 Hyperstimulated ovary 859 Hypertension 145 129 12 666 Hypochondrogenesis 293 Hypoechoic cystic structure 363 Hypomineralization 292 Hypoplasia of bone 292 bony thorax 292 long bones of limbs 295 vermis 262 Hypoplastic cubitus and ulna 410 left heart syndrome 349 nasal bone 174, 551 thorax 397, 402, 403 vermis of cerebellum 262 Hypovolemic shock 954 Hysterectomy 797 Hysterosalpingo-contrastsalpingography 896 Hysteroscopic myomectomy 796 Hysteroscopy 794 Hysterosonography 848 I Iliac artery 873 In vitro fertilization 38, 92 Incompetent cervix 58 Incomplete abortion 114 1018 Donald School Textbook of Ultrasound in Obstetrics and Gynecology and complete spontaneous abortion 114 Increased intracranial pressure 246 Induction of labor 38 Infantile polycystic renal dysplasia 381 Inferior vena cava 205, 226, 510, 609, 616 Infertility 949 Insertion of umbilical cord into abdominal wall 363 Insula 561 Interhemispheric cyst 263 Internal carotid arteries 545 iliac vein 31 Interstitial fibroid 978 pregnancy 138 Intertwin membrane folding 474 Interventional fetal cardiology 689 Interventricular hemorrhage 267 septum 320, 323 Intervillous blood flow 64 Intestinal hypoperistalsis syndrome 386 Intra-abdominal pregnancy 141 vessels 316 Intra-amniotic infections 659 Intracavitary fluid 830 Intracerebral peripheral vessels 238 vessels 316 Intracranial cavity volume 237 hemorrhage 270 translucency 190, 582 tumor 267 Intrahepatic tract of umbilical vein 206 Intramural fibroid 781 uterine fibroid 785 Intraovarian resistance index 867 Intrauterine contraceptive device localization 38 device 28, 57, 130, 972 in uterine cavity 972 gestational sac 132 growth restriction 154, 220, 502, 503, 659, 664, 666, 1004 hematomas 118 infection 1004 insemination 100 pregnancy 57, 142 synechiae 774 transfusion 38 tumor 159, 167 Intraventricular hemorrhage 267, 270 Invasive hydatidiform mole 157, 158, 161, 164 mole 165, 170 Ipsilateral corpus luteum 134-136 Irregular blood flow 124 synostosis 265 Isoechoic myometrial lesion 448 Isolated anteflexion of head 643 eye blinking 645 Isolated hand movement 646 head anteflexion 642, 662 limb movement 643 retroflexion of head 643 ventriculomegaly 248 J Jarcho-Levin syndrome 407 Jaw bone 584 Jejunal atresia 372 Johanson-Blizzard syndrome 272 K Kidney 59, 210 biopsy 686 Kleihauer-Betke test 305 Klippel-Trenaunay-Weber syndrome 285 Kurjak’s antenatal neurological test 645, 646 Kyphosis 253, 611 L Labia majora 208 Lacunae 167 Lambdoid suture 264 Laminae 203 Langer-Giedion syndrome 272 Laparoscopic chromopertubation 901 myomectomy 796, 797 Large ectopic pregnancy 953 endometrial polyp 876 fibroids 800 myelomeningocele 252 omphalocele containing liver 365 para-ovarian cyst 987 teratoma 284 umbilical cord 427 ventricular septum defect 350 yolk sac 548 Laser therapy 685 Lateral cerebral ventricles 59, 210 ventricles 211 Lean umbilical cord 426 Left and right portal veins 39 Leiomyoma 780, 953, 876, 946 Leiomyomata 38 Leiomyomatosis 503 Leiomyosarcoma 783 Lethal pterygium syndrome 635 Levator ani 987, 996, 997 Level of kidneys and umbilicus 40 stomach 40 Limb 37, 208, 210 anomalies 292 body-wall complex 548, 555 malformations 291 Liquor amnii 485 Lissencephaly 249, 259, 260 Liver biopsy 686 calcification 1009 Lobster claw 295 Location of tumor 267 Loss of zona pellucida 542 Low birth weight 220 resistance index 952 Lower limb 208 limbs tibial bowing 402 part of abdomen 207 Lumbar spine 59, 210 Lumbosacral myelomeningocele 252 Lung sequestration 306 vessels 316 Luteal phase of menstrual cycle 762 Luteinized unruptured follicle syndrome 864 Lymphangiomas 283 M Macrocrania 403, 404 Macrosomia 154, 437 Macrosomic fetus 722 Main pulmonary artery 354 Male genitalia 208 Malignant ovarian tumor 813 tumors of fallopian tube 837 Malpositioned calcaneous valgus foot 419 fetal foot 416, 421 hand 418 foot 416 hands 417 Management of alloimmunized pregnancy 496 pregnancy 303 Mandibular hypoplasia 589 Manual removal of placenta 38 Marginal cord insertion 441 placenta previa 448, 449 Index Martius image 721 Mastoid cells 277 Maternal and fetal screening tests 489 cervical myoma 723 diabetes mellitus 482 fever 666 ingestion of antithyroid drugs 281 ovarian tumor 723 phenylketonuria 272 tumors 722 uterine unit 107 Maxillary hypoplasia 265 McCune-Albright syndrome 280, 281 Mean ovarian diameter/size 889 sac diameter 213 Measurement of crown-rump length 483 endometrial volume 94 endometrium 974 intrauterine temperature 720 nuchal translucency in first trimester 483 Meconium peritonitis 372, 473 Medial longitudinal fasciculus 80 Medical complications of pregnancy 38 Medulla oblongata 178, 180, 181, 190 Meningocele 249, 252 Menorrhagia 795, 855 Menstrual age 57 cycle 761, 766 Mesenchymal dysplasia 437 Mesenteric cyst 374 Mesoblastic nephroma 389 Mesomelia 292, 293 Metastatic mole 161 Methimazole 280 Method of delivery 38 Metopic suture 264 Microcephaly 260, 272 Micrognathia 552 Microlissencephaly 260 Micromelia 292, 293, 397, 398 Micromelic limbs 403 Microretrognathia 409 Middle cerebral artery 67, 226, 305, 495, 507, 508, 545, 666 PI nomogram 508 RI nomogram 508 S/D ratio nomogram 508 Midfacial hypoplasia 265 Midline falx 59, 210 Midsagittal scan of brain 201 Migration disorder 258, 259 Mild hydronephrosis 633 ventriculomegaly and micrognathia 245 Miller-Dieker syndrome 260, 272 Missed abortion 115, 951 Mixed Muellerian tumor 838 solid-cystic tumor 285 Monochorionic pregnancy 470 Monochorionicity 460 Monolateral cleft-lip and cleft-palate 602 Monozygosity phenomenon 461 Morgagni hernia 302 Motochordal canal 542 Mottled gray scale appearance 884 Mucinous cystadenocarcinoma 985 Müllerian anomalies 879, 962 Multicystic dysplastic kidney 634 renal dysplasia 381, 383 Multifetal pregnancies 153 Multilocular hydrosalpinx 979 Multiplanar display of right lower limb 289 technique 324 Multiple and cerebral palsy 475 gestation 38, 58, 505 hemivertebrae 422 hepatic calcifications 374 intrauterine fractures 422 lacunae 167 porencephaly 248 pregnancy 111, 701 synostosis 265 Muscle biopsy 686 eye-brain disease 260 Myelocystocele 252 Myelomeningocele 241, 248, 252-254 of aborted fetus 253 with kyphosis 628 Myeloschisis 252, 254 Myocardiac contractility 328 Myocardial performance index 227 Myomas and malignant potential after menopause 932 Myomectomy 795 Myometrial invasion 778 layer of uterus 775 vascularity 534 Myometrium 158 N Narrow thorax 293 Nasal aplasia 242 bone 179-181, 235, 483, 546, 583 and fetal aneuploidy 180 evaluation 180 1019 Neonatal death/stillbirth 47 intensive care unit 42 intraventricular hemorrhage 504 Neoplastic ovarian masses 983 Neural tube and limbs 606 Neuronal migration 249 Neurulating human embryo 543 Newborn and prepubertal uterus 760 Nomenclature for limb abnormalities 295 Non-bowel cystic masses 373 Nonfunctioning pulmonary parenchyma 307 Nongestational choriocarcinoma 157, 160, 166 Nonimmune hydrops fetalis 1004 Nonmultilayered endometrium 96 Nontrophoblastic placental tumors 446 Normal appearance of heart and lungs 301 brain 236, 547 corpus luteum 867 early pregnancy 106 enchondral ossification line 400 feet 609 fetal 3D spine 400 brain 240 foot 419 fetus 19 intrauterine pregnancy 113, 950 medullary veins 238 vessels 623 nuchal translucency measurement 215 puerperium 521 uterine cavity 771, 909 uterus 770, 846 Norman-Roberts syndrome 260 Nuchal cord 746 fold 216, 483 skin 486 skinfold 37 translucency 50, 179, 214, 473, 555, 579, 632 O Observation of fetal face 642 Obstructive cystic renal dysplasia 382 Occipitofrontal diameter 215 Occult dysraphic states 249 Oligoamniotic sac 482 Oligodactylia 295 Oligohydramnios 38, 47, 482 Omental cyst 373 Omphalocele 144, 365, 555, 574, 577 1020 Donald School Textbook of Ultrasound in Obstetrics and Gynecology Opening of fetal mouth 741 mouth and movements of eyebrows 732 Ossification of calvaria 292 Osteochondrodysplasias 292, 397, 408 Osteogenesis imperfecta 292-294, 400, 404, 405 Ovarian cancer 812, 813, 815 causes of infertility 856 cycle 16, 763, 917 cyst 811 cystic tumor 812 endometrioma 948 endometriosis 886 factor in infertility 888 follicle 38 hyperstimulation 983 malignancy in postmenopause 928 multilocular cyst with solid components 811 parenchyma 833 pregnancy 142 stroma 862 stromal blood flow 890 tumors 723 vein thrombosis 949 volume 889 Ovaries 763 Ovulation 764, 890 Ovulatory and anovulatory cycles 844 P Pachygyria 249 Pallister-Killian syndrome 306 Parallel-plane display of fetal heart 15 Para-ovarian cysts 987 Parietolateral part of unilateral cerebrum 270 Part of fetal face, fetal nose and lips 650 Partial absence of limb 295 adnexal torsion 947 hydatidiform mole 157, 158, 161, 164, 169 placenta previa 448 syndactyly 265 Parvovirus B19 infection 1008 Patau syndrome 272 Patellar anterior luxation 423 Pelvic angiography 165 bones 292 congestion syndrome 949, 950 endometriosis 887 infection 868 inflammatory conglomerate 836 disease 130, 829, 837, 944 mass 58 pain 57, 58 peritoneum 979 Pelvis 18 Percutaneous umbilical blood sampling 494 Perigestational hemorrhage 119 Peripheral vascular system in 3D 315 Periphery of adenomyotic lesions 775 endometrium 771 Permanent diastolic flow 124 Peroneal diaphysis 395 Persistent cloaca 387 signs 583 trophoblastic disease 157, 160, 161, 166, 170 Pes equinovarus 292 Pfeiffer syndrome 244, 265 Phocomelia 295, 410 Pierre Robin sequence 624 syndrome 245 Placenta 23, 37, 63, 727 accreta 442, 533 and umbilical cord 611 increta 443, 533 percreta 533, 727, 728 previa 38, 58, 448, 449, 503 Placental abruption 58, 953, 954 bleeding 666 cysts 503 disease 436 infarction 503 insufficiency 47 location 447 septation 412 site trophoblastic tumor 157, 160, 161, 166, 170 texture 438 trophotropism 440 Plasma protein 174 Polycystic ovarian syndrome 861, 892 ovary 862, 893 renal dysplasia 380, 381 Polydactyly 292, 295, 419, 554, 636 Polyhydramnios 38, 47, 482, 493, 666 Polymicrogyria 249 Polypoid endometrial lesions 974 Pontine tegmentum 82 Portion of cervix and cul-de-sac 28 Position of myoma 565 umbilical cord 616 Positive pregnancy test 118, 136 Possible causes of fibroids 789 Postaxial polydactyly of hand 420 left hand 420 Posterior coronal scan 592 cranial fossa 570, 606 fossa 216 plagiocephaly 264 Postmenopausal atrophy 998 bleeding 805 endometrial thickness 934 endometrium 933-935 intrauterine fluid collection 935 ovary 926, 930 palpable ovary syndrome 928 state 762 uterus 931 Postnatal hand appearance 636 Postpartum endometritis 529 hemorrhage 800 urinary retention 535 Pouch of Douglas 831 Prader-Willi syndrome 272 Precordial veins 226 Pre-embryonic period 562 Pregnancy test 144 Premature cranial bones 235 delivery 38 labor 47 ovarian failure 983 Preovulatory cumulus oophorus 764 follicle 763 Primary amenorrhea 966 fallopian tube carcinoma 838, 840 Prominent calcaneous 419 Proteinuria 38 Proximal femoral focal deficiency 410, 413 part of maxilla and eyes 595 Prune-Belly syndrome 556 Pseudopapillomatous protrusion 833 Pubocervical ligament 987, 997 Puerperal mastitis 535 Pulmonary artery 15, 37, 205, 325, 582, 609, 616 atresia 353 hypoplasia 292 valve 328 veins 204, 582 Pulsatility index of uterine arteries 93 Pulse repetition frequencies 31 R Radial arteries 771 Radiohumeral synostosis 265 Regular enchondral ossification line 401 Renal agenesia 379 Index and urinary abnormalities 628 tract anomalies 390 arteries 379 disease 503 tumors 389 vessels 316 Resistance index 949 Retained placental tissue 526 Retroflexion of head 652 Retroplacental hematoma 445 Retroverted uterus 524 Rhizomelia 292, 293, 406 Right diaphragmatic hernia 368 ventricle outflow tract 206 Ring of fire 768 Rubella 305, 1009 Rudimentary mouth 277 S Sacral spine 59, 210 Sarcoma 282 Scaphocephaly 264 Scapula and iliac wings 203 Schizencephaly 249, 258, 260 Schlesinger veins 623 Sclerosis tuberose 325 Seckel syndrome 272 Secondary amenorrhea 973 hydrocephalus 246 palate 598, 604 Secretory endometrium 96 Segmental spinal dysgenesis 630 Semilobar holoprosencephaly 256 Septate cystic hygroma 575 uterus 849, 880, 904 Septo-optic dysplasia 249 Septum pellucidum 270 Serous cystadenocarcinoma 986 Severe adenomyosis 775 diabetes mellitus 38 fetal scoliosis 418 hydrocephalus 246 kyphosis 252 platyspondyly 403 scoliosis 550 vertebral scoliosis 629 Short rib polydactyly syndrome 293, 295 umbilical cord 629 Simple hydrocephalus 246 ovarian cyst 918, 947 Simpson-Golabi-Behmel syndrome 307 Single needle and free-hand technique 696 shot fast spin echo 726 umbilical arteries 429 Sirenomelia 295 Situs solitus 341 visceral 328 Skin biopsy 686 edema 493 Skull 37, 210 Sleeping expression of fetus 734 Slip and fall injuries 60 Smith-Lemli-Opitz syndrome 272 Smphysis pubis 994 Snow-storm pattern 162 Solid ovarian lesions 984 Speckle reduction system 321 Sphenoid bone 591 Sphenoidal fontanelle 546 Spin technique 324 Spina bifida 241, 251, 253 aperta 249 occulta 253 Spinal canal 203 column 110, 292 cord 159, 251, 544 Spine 37, 59, 202, 210, 211 Spleen 487 Split hand 295 and split-foot malformation 410 Spondylothoracic dysplasia 407 Spontaneous abortion 123, 950 Standard fetal measurements 37 gray scale 300 Stimulated ovary 889 Stomach in thoracal cavity 302 Stromal echogenicity 893 ovarian tissue 766 Subarachnoid space 246, 247 Subcapsular cyst in hydronephrotic kidney 383 Subchorionic hematoma 120, 954 Subendometrial myometrial waves 762 Subependymal pseudocysts 268 veins 623 Submucosal fibroid 782, 783, 796 leiomyomas 851 Submucous fibroids 794 and polyps 968 myoma 795, 808 small myoma distorting uterine cavity 878 1021 Subplacental myometrium 442 Subseptate uterus 963, 964, 967 Subserosal fibroid 783, 784 uterine fibroid 781 Supercoiled cord 431 Superior and inferior vena cava 206 sagittal sinus 238 vena cava 205 Suprasellar arachnoid cyst 264 Swiss cheese appearance 444 appearance of myometrium 775 Sylvian fissure 622 Symphysis pubis 993, 994, 996 Syndactyly 421, 554, 636 Synechial bands in endometrium 973 Syphilis 305 Systemic disease 165 T Talipes clubfoot 295 equinovarus 419 deformity 417 foot 416 Temporal ambiguity 32 Teratoma 282, 283 Termination of pregnancy 38 Tetralogy of Fallot 346, 352 Thanatophoric dysplasia 292-294, 401-403, 636 Theca lutein cysts 158, 165 Therapy of trophoblastic diseases 169 Thermal index Thick heterogeneous endometrium 777 lobulated endometrium 971 Thickened placenta 493 Thoracic spine 59, 210 Thoracolumbar vertebra 630 Thorax 211 Threatened abortion 113 Thrombophilia 664 Thyroglossal cyst/fistula 285 Thyroid hemiagenesis 280, 281 hormone production 280 stimulating hormone 279 immunoglobulin 280 tumors 280 Thyrotropin-binding inhibitory immunoglobulin 280 Tibial diaphysis 398, 408 Tongue and maxillary bone 598 expulsion 643, 646 1022 Donald School Textbook of Ultrasound in Obstetrics and Gynecology Tortuous and dilated pelvic venous plexuses 950 structure of spinal cord 253 Total cranial sutures 264 ovarian volume 893 ventricular volume 237 Toxoplasma 1007 Toxoplasmosis 305 Tracheoesophageal atresia 308 Transabdominal embryoscopy 679 fetoscopy 679 ultrasound 131 Transcerebellar scan 200 Transcervical embryoscopy 679 Transorbitary scan 200 Transplacental infection 659 Transverse cerebellar diameter 200 Treatment of CMV infection 1007 Tricuspid atresia 350 valve 174, 183 regurgitation 182 Trigonocephaly 264 Triplet pregnancy 112 Trophoblast 158 cell invasion 65 Trophoblastic diseases 157 tumor 168 T-sign in monochorionic twins 112 Tubal abortion 134 arteries 833 cause of infertility 834, 867 ectopic pregnancy 135, 136 factor of infertility 894 mucosa 831 mucosal fold 834 ostia 959 patency 910 walls 831835 Tubercular synechial bands 973 Tubo-ovarian abscess 831, 835, 944 Turner syndrome 278 Twin pregnancy 163 reversed arterial perfusion syndrome 577 Twin-to-twin transfusion syndrome 111, 175, 470, 471, 683 Types of fibroids 790 limb malformations 288 Typical banana sign 254 face of achondroplasia 592 lemon sign 254 U Umbilical artery 66, 225, 501-503, 505, 574, 609 pulsatility index 502 resistance index 502 cord 39, 486, 728 and placenta 315 angioarchitecture 430 cyst 578 insertion and intact abdominal wall 211 insertion site into fetal abdomen 59, 210 vessel number 59, 210 hernia 109, 110, 629 ring 433 vein 19, 72, 226, 501, 509, 510, 622 Unicornuate uterus 853, 965 Unilateral cleft lips 746 cleft palate 553 coronal suture 264 lambdoid suture 264 Unilocular ovarian cysts in postmenopause 928 Upper limb 208 lip 210 mediastinum 324 Ureterocele 385 Urethra obstruction 387 Urethral valve stenosis 633 Urinary bladder 39, 993, 994 exstrophy 387, 389 tract abnormality 556 Uterine anomalies 503 arteries PI nomogram 515 RI nomogram 514 S/D ratio nomogram 514 arteriovenous lesions 533 artery 65, 190, 225, 525, 844 blood flow 191 origin 873 causes of infertility 843 cervical cancer 809 cervix 455 Doppler 93, 97 fibroid 781, 785, 791, 801 and pregnancy 799 embolization 797, 798 fundal leiomyoma distorting uterine cavity 878 fundus 849 leiomyomas and sarcomas 808 vein 31 wall 790 Uterus 759 and fallopian tubes 901 arcuatus 534 didelphys 38, 965 Uvula 596 V Vaginal abortion 60 bleeding 38, 47, 58, 60, 118, 165 Valsalva maneuver 995 Valve of ureter 385 Valvular aortic stenosis 350 Varicella zoster 1009 Vascular chorioangioma 446 Vascularity in adenomyoma 978 Vascularization flow index 94, 95, 101 index 94, 95, 101 mapping of fibroid 799 Vein of Galen aneurysm 265 Velamentous insertion of cord 441 Venous blood flow 124 Ventricular septal defect 324 systole 183 Vertebra and spinal cord 549, 626 Vertebral scoliosis 629 Vesicoamniotic shunt operation 557 Vesicoureteral reflux 385 Vital trophoblast 144 Vocal rotational method 804 W Walker-Warburg syndrome 260 Wall of urinary bladder 444, 1000 White blood cell count 944 Willis circle 594 Wilms tumor 389 syndrome 272 Wolf-Hirschhorn syndrome 272 Wrinkling of brows or face 748 X X-linked hydrocephalus 242, 260 Y Yolk sac 121, 547 lies 570 vascularity 122 Z Z-scores 355 ... Straightening of trunk 20 51-53 (Week 8) 18 -22 Upper limbs longer and bent at elbow 21 53-54 22 -24 Hands and feet turned inward 22 54-56 23 -28 Eyelids, external ears 23 56-60 27 -31 Rounded head, body and. .. mass on day in 51% of normal cases, in 21 % on day 14 and in 6% on day 21 He questioned ultrasound finding of an echogenic mass in uterine cavity as a sign of RPT However, the definition of an echogenic... ultrasound finding associated with RPT is an echogenic mass8,34-35,55,57-68 (Figs 32. 9A to C, 32. 10A and B, 32. 11A and B, 32. 12A, 32. 13A to C and 32. 14A) In contrast, Edwards et al.15 found in