The latest medical research on Radiology
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Performance of middle cerebral artery peak systolic velocity for the prediction of fetal anemia in untransfused and transfused fetuses: a diagnostic test accuracy meta-analysis.Ultrasound in Obstetrics and Gynecology
To evaluate the performance of Doppler studies using the middle cerebral artery peak systolic velocity (MCA-PSV) for the prediction of moderate-severe fetal anemia, in untransfused and transfused fetuses.
A systematic search was performed to identify relevant observational studies evaluating the performance of MCA-PSV using a 1.5 MoM threshold for the prediction of fetal anemia reported in the 2008-2018 period. The reference standard was the diagnosis of fetal anemia by blood sampling. A hierarchical summary receiver-operating characteristic curve (hSROC) was constructed using random effects modeling. Subgroup and meta-regression analyses according to the number of previous transfusions, were performed.
A total of 12 studies and 696 fetuses were included. The area under the curve (AUC) for moderate-severe anemia was 83%. Pooled sensitivity, specificity, positive and negative likelihood ratios were 79% (70%-85%), 73% (62%-82%), 3.0 (2.22-4.01), and 0.29 (0.21-0.38), respectively. If only untransfused fetuses are considered, prediction improves achieving an 87% AUC, 86% (75%-93%) sensitivity, and 71% (49%-87%) specificity. A decline in sensitivity is observed (estimate -0.055; 95% CI: -0.107 to -0.003; p=0.039) as more transfusions are required.
A moderate accuracy in the prediction of fetal anemia (86% sensitivity and 71% specificity) is demonstrated by Doppler assessment of MCA-PSV in untransfused fetuses that decline with an increasing number of intrauterine transfusions. This article is protected by copyright. All rights reserved.
The effect of morphological types of extrauterine ectopic pregnancies on the accuracy of pre-operative ultrasound diagnosis.Ultrasound in Obstetrics and Gynecology
The aim of this study was to assess the overall accuracy of the transvaginal ultrasound scan (TVS) diagnosis of all types of extrauterine ectopic pregnancy (EUEP) in a large group of women who were managed surgically. We also examined the positive predictive value (PPV) of the different ultrasound morphological types of EUEP, using visual confirmation of ectopic pregnancy on surgery as the reference standard.
We performed a retrospective observational study of all pregnant women who underwent emergency surgery following ultrasound diagnosis of EUEP in a single Early Pregnancy Unit between January 2009 and December 2017. The pre-operative TVS findings were recorded including the exact location and morphological type (defined on ultrasound criteria, as type I-V) of EUEP. The TVS findings were compared with the operative and histological findings.
A total of 26401 women presented with early pregnancy complications during the study period, including 1241 (4.7%, 95% CI 4.5-5.0) women who were diagnosed with an EUEP. Surgery was performed in 721 cases (58.1%, 95% CI 55.3-60.8) out of which 710 (98.5%, 95%CI 97.6% to 99.4%) had been diagnosed with an EUEP on a preoperative TVS. The remaining 11 women had severe pain and significant haemoperitoneum and were managed surgically on clinical grounds as an emergency, without an ectopic pregnancy having been identified on ultrasound scan. At laparoscopy the diagnosis of EUEP was confirmed in 706/710 (99.4%, 95% CI 98.6-99.8) of women with positive ultrasound diagnosis and in all 11 women with presumed ultrasound diagnosis of EUEP. The PPV of pre-operative ultrasound for the diagnosis of EUEP was 99.4% (95% CI 98.6-99.8) with a sensitivity of 98.5% (95% CI 97.3-99.1). There was no statistically significant difference in the accuracy of pre-operative ultrasound diagnosis for the five morphological types of EUEP (p=0.76).
The accuracy of pre-operative ultrasound diagnosis of EUEP is high. The morphological type of EUEP on TVS had no significant effect on the accuracy of pre-operative diagnosis. This article is protected by copyright. All rights reserved.
Late stage Cesareans cause recurrent, early preterm birth: how to tackle this problem?Ultrasound in Obstetrics and Gynecology
Preterm deliveries have multiple aetiologies and management is dependent on cause. Recent studies have shown that caesarean sections performed late...
Imaging of gynecological disease: clinical and ultrasound characteristics of serous cystadenofibromas in the adnexa.Ultrasound in Obstetrics and Gynecology
To describe the clinical and ultrasound characteristics of serous cystadenofibromas in the adnexa.
This is a retrospective study. From the International ovarian tumor analysis (IOTA) database we identified patients with a histological diagnosis of serous cystadenofibroma, who had undergone preoperative ultrasound examination by an experienced ultrasound examiner between 1999 and 2012. In the IOTA database containing prospectively collected data, the tumors were described using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. In addition, three authors reviewed, first independently and then together, ultrasound images of serous cystadenofibromas and described them using pattern recognition.
We identified 233 women with a histological diagnosis of serous cystadenofibroma. In the IOTA database, most (67.4%) were described as containing solid components (157/233) but 19.3% (45/233) were described as multilocular cysts and 13.3% (31/233) as unilocular cysts. Papillary projections were described in 52.4% (122/233) of the cystadenofibromas. In 79.5% (97/122) of the cysts with papillary projections color Doppler signals were absent in the papillary projections. Most cystadenofibromas (83.7%, 195/233) manifested no or minimal color Doppler signals. On retrospective analysis of 201 ultrasound images of serous cystadenofibromas using pattern recognition we identified 10 major types of ultrasound appearance. The most common pattern was a unilocular solid cyst with one or more papillary projections (25.9%, 52/201). The second most common pattern was a multilocular solid mass with small solid component(s) but no papillary projections (19.4%, 39/201). The third and fourth most common patterns were multilocular cyst (16.9%, 34/201) and unilocular cyst (11.9%, 24/201). Using pattern recognition, shadowing was identified in 39.8% (80/201) of the tumors, and microcystic appearance of the papillary projections was observed in 35 (39.8%) of the 88 tumors containing papillary projections.
The ultrasound features of serous cystadenofibromas vary. The most common pattern is a unilocular solid cyst with one or more papillary projections with absent color Doppler signals. Most serous cystadenofibromas are poorly vascularized on color Doppler and many manifest acoustic shadowing. This article is protected by copyright. All rights reserved.
Fetal costello syndrome: a description of the phenotype of HRAS exon 1 mutations.Ultrasound in Obstetrics and Gynecology
This is a description of similar prenatal ultrasound findings in five cases of fetal Costello syndrome from 3 countries. We suggest that Costello s...
Maternal and neonatal complications of fetal macrosomia.Ultrasound in Obstetrics and Gynecology
To estimate risks of maternal and neonatal complications in pregnancies with macrosomia.
This was a retrospective cohort study undertaken at a large maternity unit in United Kingdom between January 2009-December 2016. We compared the incidence of complications in pregnancies with macrosomia, defined by birthweight (BW)>4,000 g and severe macrosomia with BW>4,500 g, to those in pregnancies with normal BW 2,500-4,000 g. Regression analysis was undertaken to determine odds ratios (OR) [95% confidence interval (CI)] for pregnancy complications in macrosomic compared to normal BW group.
The study population of 35,548 pregnancies included 4,522 (12.7%) with macrosomia, 643 (1.8%) with severe macrosomia and 31,026 (87.3%) with normal BW. In macrosomia group, adjusted OR was 3.07 (95%CI:1.64,2.01) for cesarean section for failure to progress, 2.40 (95%CI:1.95,2.96) for post-partum haemorrhage, 2.29 (95%CI:1.86,2.82) for sphincter injury, 10.37 (95%CI:8.57,12.55) for shoulder dystocia, 28.48 (95%CI:8.94,90.67) for brachial plexus injury, 32.33 (95%CI:3.76,278.15) for birth fractures and 4.40 (95%CI:2.20,8.82) for hypoxic-ischemic encephalopathy. The respective values for severe macrosomia were 4.32 (95%CI:3.05,6.13), 2.93 (95%CI:1.93,4.44), 3.12 (95%CI:1.92,5.08), 28.74 (95%CI:20.75,39.79), 73.92 (95%CI:15.05,363.16), 87.17 (95%CI:7.72,984.96) and 13.77 (95%CI: 5.16,36.75).
Macrosomia is associated with serious adverse perinatal outcomes. This study provides accurate estimates of risks to aid in pregnancy management. This article is protected by copyright. All rights reserved.
Maternal and neonatal complications of fetal macrosomia: a systematic review and meta-analysis.Ultrasound in Obstetrics and Gynecology
To determine accurate estimates of maternal and neonatal risks of fetal macrosomia by undertaking a systematic review and meta-analysis METHODS: A search of MEDLINE, EMBASE, CINHAL and The Cochrane Library was performed to review relevant citations reporting maternal and neonatal complications of pregnancies with macrosomia with birthweight (BW) >4,000g and >4,500g. We selected prospective and retrospective cohort and population studies that provided data regarding both, cases and controls. Meta-analysis using random effects model was used to estimate weighted pooled estimates of summary statistics (odds ratio (OR) [95% confidence intervals (CI)]). Heterogeneity between studies was estimated using Cochrane's Q, I2 statistic and Funnel plots.
There were 16 studies reporting data on maternal and neonatal complications of macrosomia. In pregnancies with macrosomia with BW > 4,000g, there is an increased risk of maternal complications such as emergency cesarean section, post-partum hemorrhage and obstetric anal sphincter injury with OR (95%CI) of 1.82 (1.68-1.98), 1.98 (1.69-2.30) and 1.82 (1.62-2.03), respectively. The corresponding values for BW >4,500 g were 2.52 (2.26-2.77), 3.14 (2.13-4.65) and 2.56 (1.97-3.32), respectively. Similarly, there was an increased risks of neonatal complications such as shoulder dystocia, obstetric brachial plexus injury and birth fractures with OR (95%CI) of 8.60 (6.35-11.66), 11.03 (7.06-17.23), and 6.43 (3.67-11.28), respectively. The corresponding values for BW >4,500 g were 15.24 (11.31-20.55), 19.87 (12.19-32.40), and 8.16 (2.75-24.23), respectively.
Macrosomia is associated with serious maternal and neonatal adverse outcomes. This study provides accurate estimates of these risks that can be used for decisions on pregnancy management. This article is protected by copyright. All rights reserved.
Is prenatal identification of small-for-gestational-age fetuses useful?Ultrasound in Obstetrics and Gynecology
To assess whether prenatal identification of small-for-gestational-age (SGA) fetuses would reduce the rates of the primary composite outcome of 'stillbirths and neonatal complications', and secondary outcomes of stillbirth and low 5-min Apgar score.
This historical cohort study was conducted with women who had singleton delivery (≥ 32 weeks), in 247 French maternity units. Medical terminations of pregnancy, infants with malformations, and women with missing delivery data were excluded. Among the infants born SGA (<5th percentile), we compared those who had been identified as such in utero (i.e. "exposed group") (n=5,093) with those who had not (i.e. "non-exposed group") (n=19,853). The main endpoint was a composite variable defined as stillbirth or death in the delivery room, or transfer to a neonatal intensive care unit (NCIU). The secondary outcomes were stillbirth and 5-min Apgar score.
Mean birthweight in the cohort was 2449.1 ± 368.3 g. The adjusted Relative Risk (aRR) for the main composite outcome was 1.29 (95%CI: 1.21-1.38) in the group identified prenatally as SGA compared with non-identified SGA fetuses (39.5% vs. 13.5%). In the subgroups, i.e. ≥37-<40 weeks and ≥40 weeks, prenatal identification of SGA fetuses improved this main outcome. The stillbirth rate was reduced for fetuses with prenatal suspicion of SGA (aRR=0.47; 95%CI: 0.27-0.79). The 5-min. Apgar score did not differ between the 2 groups. The a posteriori study power with α=0.05 was 99%.
Among children born SGA, prenatal identification did not improve, globally, fetal and neonatal issues; however, it reduced stillbirth. This article is protected by copyright. All rights reserved.
A new sonographic marker of borderline ovarian tumors: the microcystic pattern of papillary projections and solid components.Ultrasound in Obstetrics and Gynecology
Accurate diagnosis of borderline ovarian tumors (BOTs) is important to ensure timely and appropriate management, especially in women desiring to preserve fertility. Transvaginal ultrasound (TVUS) is considered the best modality to diagnose adnexal tumors. Sonographic features of BOTs described in the literature include septa, solid components, mural nodules (papillae) and blood vessels within these structures. However, there is no single signature that differentiates BOTs from other adnexal masses. We have identified a microcystic pattern on ultrasound of BOTs. The objective of our study was to evaluate the utility of a new sonographic pattern to describe a novel, yet typical, microcystic pattern of papillary projections, solid components and/or septa as a new ultrasound marker of BOTs and present their histologic confirmation.
In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who underwent pre-operative transvaginal ultrasound (TVUS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations associated with solid components, papillary projections, and/or septa. Case-matched histopathologic slides of each BOT were examined for the presence of the above-described microcystic features identified on TVUS. To confirm that the microcystic TVUS pattern is unique to BOTs, we randomly selected 20 cases of epithelial cancer and 20 cases of benign cystadenomas from our ultrasound and surgical database. These were also reviewed by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to learn if the above described microcystic tissue pattern was previously described.
Sixty-seven cases with pre-operative ultrasound that had surgically confirmed BOT on pathologic examination were included in the final analysis. Median age at surgery was 39.8 years. Average size of the BOTs was 60.7mm. Of the 67 BOTs, 47 (70.14%) were serous, 15 (22.38%) were mucinous, and 5 (7.46%) were seromucinous. Sixty (89.7%) of 67 BOTs demonstrated the microcystic pattern in the papillary projections, solid components and/or septa. On ultrasound imaging, 46 of the 47 (97.9%) serous type BOTs had a microcystic pattern compared to 11 of the 15 (73.3%) mucinous and 3 of the 5 (60.0%) seromucinous BOTs. On microscopic evaluation, 60 (89.7%) of 67 samples had characteristic 1-3-mm fluid-filled cysts like those seen on transvaginal ultrasound. Only 7 cases revealed discrepancies between the sonographic and histologic identification of a microcystic pattern. The cystadenomas (we submitted 4 of the 20 pairs we studied for comparison for this article) were mostly unilocular and/or multilocular and largely avascular. None of the 20 cystadenomas or 20 epithelial ovarian malignancies case-matched to histology displayed microcystic characteristics on ultrasound. On review of 23 published articles in the English medical literature containing 163 sonographic pictures of BOT, no description of the microcystic tissue pattern was found.
In conclusion, we report a novel sonographic marker of BOTs termed "microcystic pattern" of their papillary projections, solid components and/or septa. This was seen in the majority of both the serous and the mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of both benign entities and malignancies, the microcystic appearance appears to be unique to BOTs. No such or similar description was previously provided. We feel utilization of this new marker will help to correctly identify BOTs, discriminating them from ovarian cancers and benign ovarian pathologies, and ensure their appropriate clinical and surgical management. This article is protected by copyright. All rights reserved.
Fetal heart rate variability with hypoxemia in an instrumented sheep model.Ultrasound in Obstetrics and Gynecology
We examined the effect of hypoxemia on fetal heart rate variability using the instrumented fetal sheep model.
In this prospective study, 19 pregnant sheep were instrumented under general anesthesia at a mean gestational age of 127 days. After a 5-day recovery, hypoxaemia was induced by attaching the mother to a re-breathing circuit. Hypoxemia was further extended till 120 minutes, following which it was reversed till matenal and fetal pO2 returned back to baseline. The heart rate recordings at baseline, hypoxemia of 30 and 120 minutes, and recovery were analysed to calculate short term variation (STV) in 16 epochs of 3.75sec each, every minute. Phase rectified signal averaging (window length L= 10, time T= 2 and Scale S=T) was used to calculate acceleration capacity (AC) and deceleration capacity (DC).
At baseline, mean (SD) fetal pO2 was 2.90±0.38 kPa. Acute hypoxaemia was associated with a significant reduction in mean pO2 at 30 (1.60±0.37 kPa) and 120 (1.50±0.16 kPa) minutes. Mean (SD) fetal pO2 at recovery was 2.80±0.32 kPa. The median STV, AC and DC were 1.307 msec (IQR: 0.515 to 2.508), 1.295 (IQR: 0.990 to 2.685) BPM and 1.197 (IQR: 0.850 to 1.836) BPM respectively, at baseline. With 30-minute hypoxaemia, the values were 1.323 (IQR 0.753 to 2.744) msecs, 1.696 (IQR: 1.310 to 3.013) BPM & 1.584 (IQR 1.217 to 4.132) BPM. With 120-minute hypoxaemia, the values were 1.760 (IQR: 0.928 - 4.656) msecs, 3.098 (IQR: 1.530 - 5.163) BPM & 3.054 (IQR: 1.508 - 4.522) BPM. At recovery they changed to 0.962 (IQR: 0.703 - 1.154) msecs, 1.228 (IQR: 1.071 - 2.234) BPM & 1.086 (IQR: 0.873 - 1.568) BPM respectively. Hypoxemia for 30 and 120 minutes were associated with a significant increase in the DC compared to baseline (p = 0.014 & 0.017 respectively). The changes in STV and AC were not significant.
Acute hypoxaemia is associated with a significant increase in the deceleration capacity of the fetal heart rate. This article is protected by copyright. All rights reserved.
The role of additional pathology on head growth patterns in fetuses with congenital heart defects.Ultrasound in Obstetrics and Gynecology
Neurodevelopmental delay is frequently encountered in children with congenital heart defects (CHD). Fetuses with major CHD show a smaller head circumference (HC), irrespective of altered cerebral flow or brain oxygenation. This cohort study compares head growth in isolated to non-isolated CHD cases to evaluate the effect of additional pathology on head size.
All prenatally diagnosed CHD cases were selected from our regional PRECOR registry (2002-2014). Cases with multiple pregnancy, diabetes, severe structural brain anomalies or functional CHD were excluded. Subjects were allocated to the isolated group or assigned to one of the three non-isolated groups: genetic syndromes, extra-cardiac malformations or placental pathology. CHD types were also clusted according to their effect on aortic flow and saturation. Mean HC z-scores at 20 weeks and increase or decrease (Δ) of z-scores over the course of pregnancy were compared between isolated and non-isolated subjects, using mixed-linear regression models.
We included 916 prenatally diagnosed CHD cases, of which 378 (41,3%) were non-isolated. At 20-weeks non-isolated cases had significantly lower HC z-scores compared to isolated cases (z= -0.70 vs -0.03; p<0.001) and during pregnancy the head growth showed a larger decrease (z= -0.03 vs -0.01 per week; p=0.01). The placental pathology group (n=37) had the smallest HC z-score (z= -1.28) at 20 weeks and largest decrease in head growth (-0.06 per week). HC z-scores were lower, but to a lesser extent, compared to non-isolated CHD in subjects with a genetic syndrome (n=217) (z= -0.71; -0.04 per week) or extra-cardiac malformations (n=124) (z= -0.49; -0.02 per week). CHD types that result in low oxygenation or flow to the brain were more frequently present in isolated cases.
Smaller HC amongst CHD cases appears to be strongly associated with additional pathology. Placental pathology and genetic syndromes seem to be important attributors for restricted head growth. This effect appears irrespective of altered hemodynamics caused by the CHD. Previously reported smaller HC in CHD must, in our opinion, be attributed to additional pathology. Neurodevelopment studies in CHD should, therefore, always differentiate between isolated and non-isolated cases. This article is protected by copyright. All rights reserved.
Amniotic fluid volume at presentation with early preterm premature rupture of the membranes and the association with severe neonatal respiratory morbidity.Ultrasound in Obstetrics and Gynecology
Amniotic fluid volume (AFV) plays an important role in early fetal lung development, and oligohydramnios in early pregnancy has been associated with pulmonary hypoplasia. We aimed to evaluate the association between AFV at the time of presentation with early preterm premature rupture of membranes (PPROM) and severe neonatal respiratory morbidity and other adverse pregnancy outcomes.
We performed a retrospective study of all women with a singleton pregnancy admitted to a single tertiary referral center between 2004-2014 for expectant management of PPROM at 200/7 -286/7 weeks' gestation. The primary exposure was AFV at presentation, classified by the sonographic maximal vertical pocket as: >2cm (normal AFV), ≤2cm and > 1cm (oligohydramnios), ≤1 cm (severe oligohydramnios). The primary outcome was a composite variable of severe respiratory morbidity defined as any of the following: 1) Need for respiratory support in the form of mechanical ventilation using endotracheal tube for ≥ 72 hours and need for surfactant; 2) Bronchopulmonary dysplasia, defined as requirement for oxygen at postmenstrual age of 36 weeks of gestation or at the time of transfer to a level II facility. Odds ratios (OR) and 95%-confidence intervals (95%-CI) for the primary and secondary outcomes were calculated for each AFV category at presentation (using normal AFV as reference) after adjusting for gestational age at PPROM, latency, birthweight, mode of delivery, and chorioamnionitis.
A total of 580 women were eligible for the study, of whom 304 (52.4%) had normal AFV, 161 (27.8%) had oligohydramnios, and 115 (19.8%) had severe oligohydramnios at presentation. The rate of severe respiratory morbidity for the corresponding AFV groups was 16.1%, 26.7%, and 45.2% respectively. Compared with normal AFV at presentation, oligohydramnios (aOR=3.27, 95%-CI 1.84-5.84) and severe oligohydramnios (aOR=4.11, 95%-CI 2.26-7.56) at presentation were independently associated with severe respiratory morbidity. Other variables that were independently associated with the primary outcome were: gestational age at PPROM (aOR=0.54, 95%-CI 0.43-0.69), latency (aOR=0.94, 95%-CI 0.91-0.98), and Cesarean delivery (aOR=2.01, 95%-CI 1.21-3.32).
In women with early PPROM, AFV at presentation, as assessed by the maximal vertical pocket on ultrasound exam, has an independent association with severe neonatal respiratory morbidity. This information may be taken into consideration when counselling women with early PPROM regarding neonatal outcomes and management options. This article is protected by copyright. All rights reserved.