Antenatal Ultrasonography Research Articles

Current Management of Urinary Tract Infection and Vesicoureteral Reflux.

Urinary tract infection (UTI) is defined as the growth of a significant number of microorganisms of a single species in the urine, in the presence of symptoms. Symptoms in young children are non-specific such as fever without focus; young infants may manifest with irritability, failure to thrive, jaundice, vomiting and diarrhea. Older children usually have symptoms of cystitis or pyelonephritis. Symptoms of cystitis are dysuria, frequency, new onset incontinence and malodorous urine while symptoms of pyelonephritis are high grade fever, flank pain and vomiting. Rapid urine testing by microscopy for pus cells, dipstick testing for leukocyte esterase and nitrite, and enhanced urinalysis are supportive tests. Urine culture samples should be collected with proper technique and results interpreted for significant growth accordingly. Antibiotic therapy for 7-14 d for complicated UTI and 3-4d for uncomplicated UTI is adequate. Further evaluation is recommended clinically for bladder-bowel dysfunction and obvious anatomical defects and by imaging for vesicoureteral reflux (VUR), usually by micturating cystourethrography (MCU). Since MCU involves exposure to radiation and urethral catheterization, it is now reserved for children with parenchymal involvement or recurrent UTI. VUR is the backward flow of urine into one or both ureters. Clinical manifestations other than UTI include incidental diagnosis on antenatal ultrasonography. Reflux nephropathy, the renal scarring associated with VUR may manifest clinically as hypertension, proteinuria and renal failure. The management of VUR is primarily with antibiotic prophylaxis. Anatomical correction is indicated in case of breakthrough febrile UTI. No intervention has been shown to reduce renal scarring.

A survey of current use, dilemma and outlook of antenatal ultrasonography in Taiwan

ObjectiveAccording to World Health Organization's Jungner and Wilson criteria for competent screening programs, routine antenatal ultrasound screening is legit and effective to improve both maternal and perinatal outcomes. Health Promotion Administration, Ministry of Health and Welfare in Taiwan followed expert recommendations and started reimbursing one antenatal ultrasonography around mid-second trimester since 1995. However, medical disputes pertaining to examination results grew, while confusions challenged doctors and patients alike. The aim of this study is to assess current use of antenatal ultrasonography for low-risk pregnancies in Taiwan. Specifically, the indications, test frequencies, test items, methods of payment, obstetricians' opinions on important scan timing and areas to be improved are surveyed and analyzed. An overview of international antenatal ultrasound practice guidelines are examined and compared to enhance the quality of antenatal ultrasound screening in Taiwan. Materials and methodsFrom December 2015 to December 2016, 925 questionnaires were distributed to all licensed obstetricians registered to Taiwan Association of Obstetrics and Gynecology as well as Taiwan Society of Perinatology. A 10-min self-reporting questionnaire was sent by mail, with stamped return envelopes included. Respondents remained entirely anonymous and disclosed no personal information. Data was collected and analyzed for statistical analysis. ResultsMost hospitals are well equipped with ultrasound machines of 3 or more functions. Eighty-eight percent of the obstetricians in Taiwan perform prenatal ultrasonography in every office visit for their patients, mostly free of charge. Scans at gestational age 15–22 weeks, <10 weeks, 11–14 weeks and 28–32 weeks are polled as the most importance in the order of significance. In general, they perceive the one-time antenatal scan offered by the Health Promotion Administration as for general obstetrics scan but not higher-leveled studies. Patient education and doctor-patient communications are opined as the 2 most important aspects to enhance antenatal ultrasound quality. ConclusionThis report is the first of its kind in Taiwan. It could potentially serve as guidance for national health policy innovations in maternal and fetal care, such as increasing frequency of scans, specifications of scan timing, indications and consequences as well as patient education about this screening modality.

Antenatal ultrasonography in Cameroon (Central Africa): a review of the past 30 years

Antenatal ultrasonography in Cameroon (Central Africa): a review of the past 30 years

Multicystic dysplastic kidney: Ten-year evaluation

Introduction: Multicystic dysplastic kidney (MCDK) is the most common form of developmental abnormality seen in infants and children. It is almost always unilateral and slightly more frequent in boys and on the left side. The other associated extra-renal abnormalities include esophageal atresia, tracheoesophageal atresia, ventricular septal defect and patent ductus arteriosus. The routine widespread use of antenatal ultrasonography has led to early detection of this abnormality. Materials and Methods: We retrospectively assessed fourteen cases of Multicystic dysplastic kidney between January 2004 and December 2014. All the cases underwent total nephrectomy and the specimens were sent to the department of Pathology with their respective clinical details and pathological findings were analyzed. Results: A total of fourteen (14) patients were diagnosed with unilateral MCDK over a period of 10 years with no sex predilection. Majority were on left side and antenatally diagnosed. Some patients had associated hypertension, vesicoureteral reflux and ureteropelvic junction obstruction. Microscopy revealed renal parenchyma replaced by cysts of variable sizes lined by flattened cuboidal epithelium. Intervening fibrotic stroma with mesenchymal components, primitive glomeruli, nerve bundles and dysplastic ducts. Conclusion: MCDK is mostly a unilateral sporadic anomaly usually found on the left side, however can be familial. It may be associated with hypertension, vesicoureteral reflux and ureteropelvic junction obstruction. Most of the patients can be diagnosed antenatally and confirmed on histopathology. Keywords: Multicystic dysplastic kidney, Dysplastic kidney, Cystic kidney.

Ultrasound Assessment of Placental Thickness in The Last Two Trimesters of Normal Pregnancy and Its Relation with Fetal Outcome

Abstract:Background: The placenta is a vital organ which plays an important role in the normal fetal growth and development process. The aim of work: Is to assess the relation between thickness of the placenta during the 2nd and 3rd trimesters and fetal birth weight and placental weight .Patients & Methods: 50 cases of uncomplicated pregnant women who were attended the outpatient clinic at Zagazig University Maternity Hospital were involved in this cohort study from the period between June 2018 to March 2019;, The thickness of the placenta was measured by trans abdominal ultrasound during second and third trimester .The relation between thickness of the placenta and fetal outcome was examined by Pearson’s correlation. Results: according to our study there was positive relation between thickness of the placenta at the 2ndtrimester and 3rdtrimester with fetal birth weight, placental weight and APGAR score. The fetal outcome was better with normal placental thickness (10th- 90th) in comparison to that with thin (90th) &the incidence of NICU admission increased in thick placenta and thin placenta.Conclusions: The thickness of the placenta by ultrasound can be used beside other biometric parameters in predicting neonatal outcome and measurement of placental parameters should be involved in all routine antenatal ultrasounds.

Congenital lung malformations: a novel application for lung ultrasound?

Congenital lung malformations (CLMs) include a group of different disorders. With widespread use of antenatal ultrasonography (aUS) and increased use of pre-natal magnetic resonance imaging (MRI), CLMs are increasingly detected, nevertheless the best postnatal imaging approach is not yet well defined: newborns usually undergo several chest X-rays and eventually computed tomography to confirm the diagnosis. In this case series, we show lung ultrasound features of three different cases of congenital lung malformations, describing prenatal and postnatal images comparing different imaging techniques.

The fate of antenatal renal pelvis dilatation: a prospective postnatal cohort study

Background: To assess the outcome of fetal hydronephrosis, based on antenatal sonography and to find the best cutoff APD of renal pelvis which lead to surgical outcome.Methods: All patients diagnosed with isolated fetal renal pelvic dilatation (RPD) were prospectively followed between January 2016 and December 2018. RPD was classified according to SFU grading into four grades and by APD classification to 3 groups. Group I (5-9.9 mm), group II (10-14.9 mm) and group III (≥15 mm).Results: Among a total of 57 patients, group I had 32 renal units, none required surgery; group II had 19 renal units, 5 (7.04%) required surgery; group III had 20 units, 11 (15.49%) required surgery. The difference in outcome between the groups was statistically significant (p=0.001). The causes of fetal hydronephrosis was transitional in 33.33%, pelvi ureteric junction obstruction in 33.33%, vesico ureteral reflux in 29.82%, and 3.5 % had posterior urethral valves. Of the 38 infants with RPD, urinary tract infection was seen in 36.84%. Thirty-four patients had MCUG of whom 29.82% had VUR. In 38 patients DTPA was performed with following results: 10.53% had partial obstruction and 14.04% showed complete obstruction.Conclusions: Fetal hydronephrosis less than 5mm runs a benign course. In APD greater than 15 mm and bilateral disease thorough postnatal evaluation and regular follow-up is necessitated for timely intervention. The best cutoff point of anteroposterior renal pelvis diameter that led to surgery was 15 mm, with sensitivity 91% and specificity 73.5%.

P.058 Tuberous sclerosis complex associated intracranial abnormalities identified in utero via antenatal ultrasound

Background: Tuberous sclerosis complex (TSC) is characterized by growth of benign tumors in the skin, brain, kidneys, lung and heart. Prognosis is mostly determined by the extent of brain involvement as tumors in the brain lead to seizures and cognitive problems. Epilepsy is highly associated with the cognitive abnormalities in TSC and recent evidence suggests anti-epileptic treatment before onset of seizures reduces epilepsy severity and risk of mental retardation. Screening and potential identification of TSC in utero via ultrasound would allow for prophylactic seizure management in these children. The sensitivity of antenatal ultrasound in the identification of brain abnormalities associated with TSC has not yet been published. In this case, we review the antenatal ultrasounds of a child with TSC for evidence of brain abnormalities in utero. Methods: Retrospective review Results: Retrospective review of antenatal ultrasounds showed some evidence of intracranial abnormalities. Ultrasound at 34 weeks and 4 days gestation revealed an echogenic density in the right ventricle that correlates with SEGA on post-natal MRI brain at 12 days of life. Post-natal brain ultrasound at 37 weeks revealed multiple cranial abnormalities not seen in utero. Conclusions: There are limitations to antenatal neurosonography in the detection of intracranial abnormalities associated with TSC.

Diagnostic Performance of Antenatal Ultrasound in the Localization of Intestinal Structures Involved in Malrotation With a Higher-risk of Volvulus

Diagnostic Performance of Antenatal Ultrasound in the Localization of Intestinal Structures Involved in Malrotation With a Higher-risk of Volvulus

The rate of brain abnormalities on in utero MRI studies in fetuses with normal ultrasound examinations of the brain and calculation of indicators of diagnostic performance

To estimate the rate of unexpected brain abnormalities detected by in utero magnetic resonance imaging (iuMRI) in fetuses without abnormalities at ultrasonography (USS). A prospective cohort study of pregnant women whose fetus had no structural brain (or body) abnormalities recognised on antenatal ultrasonography. Women were recruited from 12 centres across the UK and underwent iuMRI at 18 gestational weeks or more in the [blinded for review]. The imaging studies were reviewed by an experienced neuroradiologist. The positive and negative predictive values of both USS and iuMRI have been calculated by combining the results of this study with the results from the main [blinded for review] study. One hundred and ninety-eight pregnant women were recruited and underwent iuMRI of 205 fetuses. Brain abnormalities were shown on iuMRI in two fetuses that were not recognised on USS (one case of a focal cortical abnormality and one case of mild ventriculomegaly). The negative predictive value for USS was 99.5% and 100% for iuMRI. To the authors' knowledge, this is the first study comparing USS and iuMRI in low-risk pregnancies. USS has a comparatively high rule-out for fetal brain abnormalities and should remain the screening tool of choice.

Ureteropelvic junction obstruction: three clinical cases with first symptoms during adolescence

Ureteropelvic junction obstruction (UPJO) is defined as urine flow blockage occurring where the ureter enters the kidney and is presented as urinary tract dilatation (UTD), formerly named hydronephrosis. The condition may be congenital or acquired. Most UTD are diagnosed by antenatal ultrasonography, but some cases present later. In adolescence, clinical manifestations include intermittent flank or abdominal pain, hematuria, nephrolithiasis, urinary tract infection, deterioration of renal function, or arterial hypertension. The imaging modality of choice to diagnose UTD is ultrasonography (US). A diuretic renography will allow to identify UPJO. Treatment goals are to prevent renal function deterioration and relieve symptoms. Although conservative treatment measures are favored, some patients require surgical correction (pyeloplasty). Three clinical cases with first symptom onset during adolescence are presented. The first case is a 14-year-old boy with abdominal pain suspected to correspond to acute appendicitis; the second case is a healthy 15-year-old female which presented with dysuria and lumbar pain; the third case is a 15-year-old female with prenatal diagnosis of left ureteropelvic dilation but no further medical problems, with left lumbar pain, dysuria, and fever.Conclusion: A high degree of suspicion is required to include UPJO in the differential diagnosis of flank or back pain in adolescents.

Immature congenital teratoma of the neck: a very rare entity

Congenital teratoma is a very rare tumor, affecting the neck in 3% of all cases.The diagnosis should be performed in antenatal by ultrasonography or magnetic resonance imaging (MRI). The risk of neonatal respiratory distress is very important. We present a rare case of immature cervical teratoma revealed by antenatal ultrasonography with total excision and cure. A 22-year-old woman, G1P1, who came from a rural area, was admitted to our obstetrics department for delivery. She had no document of pregnancy follow-up. The ultrasound exam showing a live fetus at term with voluminous cervical mass. After consultation with the neonatal resuscitation team, a caesarean section was performed. The infant underwent surgical excision at 25 days of life with complete healing. The histological report was confirmed the diagnosis of immature cervical teratoma free of malignant elements. A multidisciplinary management is necessary to avoid complications related to compression, but also to reduce the risk of cancer.

The ethics of lethal congenital malformations. Is palliative therapy possible?

Aim: This study aims to show that palliative care can be offered to babies born with lethal malformations according to the Islamic Code of Ethics, which takes into account the well-being of the mother and her fetus. Methods: For our study, a lethal congenital malformation is defined as a condition that invariably leads to death in utero or the newborn period regardless of attempted supportive care. The cases were identified during weekly prenatal meetings, which discuss abnormal fetal ultrasound findings and genetic testing to provide plans for their management. In addition, cases that were not diagnosed antenatally but diagnosed at birth were also included. The management plans for those cases with lethal malformations were discussed before birth, and the families were counseled, and their consent was taken for nonmonitoring of the fetus during pregnancy and noninterference with the newborn baby except for palliative care. Families who requested full support during pregnancy and delivery were given that option. Results: Over a period of 16 years from 2001 to 2016, a total number of 92705 babies were born in our hospital. Antenatal ultrasounds were performed by the feto-maternal physician team. There were 1563 abnormal fetal ultrasounds (1.7%) with significant various organs malformations. Of these abnormal ultrasounds, 384 were diagnosed as possible lethal congenital malformations (24.6%). The remaining abnormal fetal ultrasounds were compatible with life and were managed according to the standard clinical practices. Fetuses diagnosed with lethal malformations were discussed at length and parents were informed about the lethal outcome and the plan of nonmonitoring of the mother at delivery and avoidance of cesarean section except for maternal indication and eventual palliative care for the live newborn. Parents' consent was obtained, and the decision and the plan of the management are documented clearly in the mother's medical record file. With this management plan, we were able to offer palliative care to the cases of lethal congenital malformations who eventually expired within a short time. Conclusion: Within the guidance of the Islamic Jurisprudence (Figh), it is possible to manage cases of congenital malformations, which are considered incompatible with life palliatively and avoid unnecessary cesarean sections in the mother. This practice has resulted in better utilization of the beds in our busy neonatal intensive care unit.

An Automated Framework for Large Scale Retrospective Analysis of Ultrasound Images.

Objective: Large scale retrospective analysis of fetal ultrasound (US) data is important in the understanding of the cumulative impact of antenatal factors on offspring’s health outcomes. Although the benefits are evident, there is a paucity of research into such large scale studies as it requires tedious and expensive effort in manual processing of large scale data repositories. This study presents an automated framework to facilitate retrospective analysis of large scale US data repositories. Method: Our framework consists of four modules: (1) an image classifier to distinguish the Brightness (B) -mode images; (2) a fetal image structure identifier to select US images containing user-defined fetal structures of interest (fSOI); (3) a biometry measurement algorithm to measure the fSOIs in the images and, (4) a visual evaluation module to allow clinicians to validate the outcomes. Results: We demonstrated our framework using thalamus as the fSOI from a hospital repository of more than 80,000 patients, consisting of 3,816,967 antenatal US files (DICOM objects). Our framework classified 1,869,105 B-mode images and from which 38,786 thalamus images were identified. We selected a random subset of 1290 US files with 558 B-mode (containing 19 thalamus images and the rest being other US data) and evaluated our framework performance. With the evaluation set, B-mode image classification resulted in accuracy, precision, and recall (APR) of 98.67%, 99.75% and 98.57% respectively. For fSOI identification, APR was 93.12%, 97.76% and 80.78% respectively. Conclusion: We introduced a completely automated approach designed to analyze a large scale data repository to enable retrospective clinical research.

Failure of respiratory withdrawal in an infant revealing an agenesis of the corpus callosum: A case report

Introduction: Corpus callosum is a cerebral commissure connecting the two hemispheres. It is the center of many pathological entities, among them, its agenesis, which is a common neurological anomaly usually, detected in antenatal sonography examinations. One in two patients has an associated intracerebral malformation. Imaging plays a major role in the antenatal detection as well as neonatal diagnosis of this entity. Sedation presents a difficult challenge especially in the case of severe neurological complications.

A Rare Association of Small Bowel Atresia and In-Utero Midgut Volvulus Presenting as Fetal Meconium Pseudocyst

Fetal meconium peritonitis (MP) is a rare occurrence. Neonate that survives this rare condition is likely to form a meconium pseudocyst. Hereby, we present a case of a 33-year-old pregnant woman that presented with premature rupture of membranes at 34 weeks of gestation. Antenatal ultrasonography at 33 weeks revealed abnormal dilated bowel within the viable fetus. An emergency Cesarean section was performed and a baby boy was delivered at 34 weeks. Physical examination of the baby at birth revealed a palpable central abdominal mass. Lower gastrointestinal contrast imaging revealed a non-opacified dilated proximal small bowel and opacified collapsed distal small bowels and colon. A laparotomy was carried out and revealed MP with pseudocyst formation due to a midgut volvulus. Interestingly, meconium contamination was confined due to associated atretic small bowel which occurred secondary to the volvulus.

Posterior urethral valve: a retrospective review of cases and challenges of management in a low-resource centre

Objective: Posterior urethral valves (PUV) diagnosis and management remain a major challenge in developing countries. We sought to review cases of PUV managed in our health centre and to highlight the challenges in its management. Methods: A retrospective analysis of patients with PUV managed over a 12month period. Data obtained from patients' medical records include: demography, clinical presentation, serum electrolytes, urea and creatinine, radiological diagnosis, initial management, surgical management and the outcome of management. Results: Eight patients were managed during the period under review. The median age was 26 months. The commonest clinical feature was recurrent fever. Three patients (37.5%) had renal insufficiency requiring peritoneal dialysis at initial presentation. Six patients (75%) had Mohan's valvotomy while two (25%) died before valve ablation. One patient (12.5%) died a month after valve ablation from renal failure, while one (12.5%) had residual valve requiring a repeat valve ablation. Post-operative complication of urosepsis occurred in two patients (25%). Conclusions: Physicians should have a high index of suspicion for PUV in boys who present with recurrent fever or urinary tract infections. Screening for foetal anomalies during routine ante-natal maternal ultrasonography will improve prenatal diagnosis of this condition. Keywords: Low-resource centre, Management, Nigeria, Posterior urethral valve

Optimal Timing of Spinal Ultrasound Evaluations for Sacral Dimples in Neonates: Earlier May Not Be Better.

A spinal ultrasound (US) evaluation during the immediate postnatal period may have limited ability in evaluating filum thickness because of the spinal cord pulsation caused by a crowded subarachnoid space and the cerebrospinal fluid deficiency during this period. This study aimed to determine the optimal timing of spinal US to evaluate sacral dimples in neonates. This study included 585 neonates who had a clinically suspicious sacral dimple and underwent spinal US examinations between January 2015 and August 2017. Patients were classified into 1 of 2 groups based on whether measurements of all parameters were possible (group A) or not (group B). Neonatal and maternal clinical factors, including the antenatal history and US parameters, were compared between groups. Group A included 443 patients, and group B included 82. Patients in group B were significantly younger (6.2 versus 31.0 days), had a younger corrective age (38.9 versus 42.5 weeks), and had a smaller body weight (3.1 versus 4.6 kg) than those in group A (all P < .005). However, no statistically significant differences were found in other patient or maternal factors (P > .05 for all). The pulsation of the conus medullaris and nerve roots of the cauda equina (14.6% versus 100%), thickening and echogenicity of the filum terminale (2.4% versus 100%), and the presence of a normal subarachnoid space (18.3% versus 100%) were significantly more difficult to detect in group B than in group A (all P < .001). For an accurate evaluation, which can reduce unnecessary confusion and costs, spinal US can be delayed until neonates grow beyond 31 days, with a corrected age of older than 42.5 weeks and body weight of greater than 4.6 kg.

Antenatal umbilical coiling index in gestational diabetes mellitus and non-gestational diabetes pregnancy

ObjectiveUmbilical cord abnormalities increase fetal morbidity and mortality. This study was designed to compare antenatal umbilical coiling index (aUCI) in gestational diabetes mellitus (GDM) and non-gestational diabetes mellitus (non-GDM) pregnancy, considering uncertainties about the best time to perform antenatal ultrasonography scan. Materials and MethodsIn this prospective study, 246 parturients were included, 123 with GDM and 123 with non-GDM pregnancy. Gestational diabetes was confirmed at 24–28 weeks of gestation (WG) using one-step strategy. An anatomical ultrasound survey of placenta and umbilical cord was performed at 18–23 as well as 37–41 weeks of gestational age. ResultsAt 18–23 WG, the frequency distribution (10th, 90th percentiles, mean ± SD) of the aUCI in the GDM and non-GDM groups were (0.13,0.66,0.32 ± 0.19) and (0.18,0.74, 0.4 ± 0.31) respectively. These values were (0.12,0.4, 0.25 ± 0.11) in the GDM group at 37–41 WG and (0.17,0.43, 0.29 ± 0.11) in the non-GDM group. A significant relationship was detected between UCI value and GDM/non-GDM groups at both antenatal evaluations (18–23 WG; P = 0.002, 37–41WG; P < 0.001). A significant association at 18–23 WG was found between GDM/non-GDM groups and aUCI categorization (hypocoiling <10th, normocoiling 10th–90th and hypercoiling >90th) (P = 0.001). However, hypocoiling were significantly more frequent in GDM than non-GDM in both antenatal evaluations (P < 0.001, P = 0.006). ConclusionAntenatal UCI in pregnancy complicated by GDM were lower in comparison with non-GDM pregnancy. The most abnormal pattern of coiling in gestational diabetes was hypocoiling in both trimesters. In addition, 18–23 WG is the best time to perform ultrasound scan to detect aUCI and umbilical cord pattern.

Congenital anomalies in antenatal ultrasound scan at a tertiary care teaching hospital

Introductions: Early detection of congenital fetal anomalies by ultrasonography (USG) helps to identify the severity and termination of pregnancy in severe cases. Anomalies cause significant perinatal morbidity and mortality. Aim of this study was to analyse real-time USG detection of prenatal anomalies. &#x0D; Methods: This was a cross-sectional descriptive study of fetal anomalies detected during 2nd and 3rd trimester antenatal USG scan done from 2011 to 2015, in Patan Hospital. Age of mother, parity, gestational age when anomalies detected and, anomalies of previous child, use of folic acid were analysed. Descriptive analysis was done. &#x0D; Results: There were 35,571 deliveries in four years period with 134 (0.37%) congenital anomalies, 99 (79.2%) detected during antenatal USG during 2nd and 3rd trimester. Among 99 anomalies, 29 (29.29%) were detected before 22 weeks. Central nervous system (CNS) anomalies were 47, gastrointestinal 23, renal 12, skin and fetal compartment 8 and rest were less common. Young mothers of less than 30 years were 109 (81.34%) and primi were 85 (63.4%). &#x0D; Conclusions: Antenatal ultrasound can detect fetal anomalies in 2nd and 3rd trimester with higher frequencies belonging to the central nervous system followed by gastrointestinal tract anomalies and renal.