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Extensive congenital pulmonary airway malformation (CPAM) of the left fetal lung and associated marked dextroposition of the fetal heart were noted at 21 weeks’ gestation. The right fetal lung appeared compressed with the cardiomediastinal shift angle measuring approximately 20 degrees. Potential subsequent right pulmonary hypoplasia was considered. At 26 weeks’ gestation, despite the continued presence of extensive CPAM of the left fetal lung, spontaneous resolution of the dextroposition of the fetal heart was noted. Subsequent repeat ultrasound assessments confirmed gradual continued in-utero regression of the left lung lesion. The patient spontaneously delivered a vigorous infant neonate at 39 and 4/7 weeks’ gestation. Birth weight was 3175 grams, and following brief CPAP management for mild transient tachypnea of the newborn, and negative chest X-ray, the infant was discharged in good health on Day 2 of life. Neonatal CT angiography demonstrated CPAM of the left lower lobe. In addition, a feeding vessel was seen emanating directly from the thoracic aorta, indicating an intralobar brochopulmonary sequestration (BPS) component of the left lung lesion, consistent with a hybrid lung lesion (CPAM and intralobar BPS). At 2 months of life the infant underwent uneventful resection of the left lower lobe with pathology confirmation of the hybrid lung lesion. This case demonstrates that relatively rapid regression of severe cardiomediastinal shift associated with extensive hybrid lung lesions may occur. Our case indicates that spontaneous regression of marked cardiomediastinal shift appears to be a reassuring prognostic sign despite the continued presence of this lesion.

Etiologies underlying the relatively infrequent third-trimester sonographic depiction of dilated fetal bowel include (functional or mechanical) bowel obstruction, intestinal atresia, volvulus, annular pancreas, intestinal malrotation, intussusception, gastrointestinal duplications, cystic fibrosis-associated meconium ileus, congenital chloride diarrhea, microvillus inclusion disease, intestinal neuronal dysplasia, and meconium plug syndrome. Fetal bowel obstruction may be associated with aneuploidy (mostly Trisomy 21 in association with esophageal or duodenal atresia), and rarely select microduplications or deletions. We present unusual sonographic findings associated with transient marked proximal fetal bowel dilatation in association with concurrent development of oligohydramnios, in a growth-restricted fetus at 35 weeks’ gestation. This case supports that upon observation of dilated loops of fetal bowel, while not negating the potential need for delivery secondary to potential bowel compromise, consideration should be given for observation in anticipation of potential spontaneous resolution of this condition, especially among growth-restricted fetuses with decreased amniotic fluid volume in prematurity.

The tricuspid valve positioned between the right atrium and right ventricle is composed of 3 leaflets (anterior, posterior, and septal) anchored by a collagenous fibrous annulus, a saddle-shaped, oval structure, providing a firm yet dynamic structural support for the tricuspid valve. The annulus is considered to separate between the right atrium and right ventricle. Structural anomalies of the fetal tricuspid valve are rare and include Ebstein's anomaly, tricuspid atresia, partial absence, unguarded tricuspid orifice (absent leaflets) cleft, double orifice, bicuspid valve and Uhl anomaly (absence of the right ventricular myocardium with an apposing endocardium and epicardium). We present an unusual case in which a prominent peripheral circular structure was noted above the periphery of the fetal tricuspid valve at 31 weeks’ gestation. Inflow across the tricuspid valve was unimpaired, with no tricuspid regurgitation. The right atrium appeared normal with a normal functioning foramen ovale, and the entire fetal cardiac anatomy and function were normal with no signs of congestive cardiac failure or fetal hydrops. The prominent non-obstructing circular structure in immediate proximity to the tricuspid valve leaflets was considered to represent a prominent tricuspid annulus. An appropriate for gestational age fetus was delivered at term and neonatal echocardiography was normal. This case emphasizes that normal variations in fetal anatomical structures should always be considered and specifically that unimpaired inflow across the tricuspid valve in diastole is key upon encountering an unusually prominent fetal tricuspid annulus, which may be noted at a considerable distance above the tricuspid leaflets within the right atrium.

Placenta accreta spectrum (PAS) defined by various degrees of abnormally invasive placentation is strongly associated with severe maternal morbidity and maternal mortality, mainly reflecting maternal hemorrhage. Predisposing factors for this condition include: multiparity, placenta previa, previous uterine surgeries (previous curettage, cesarean delivery, and myomectomy), smoking and previous PAS. Prenatal sonographic findings associated with PAS include the presence of placenta previa, loss of the hypoechoic retroplacental sonolucency, myometrial thinning, interruption of the irregularity of the bladder wall, excessive vascularity of the uterovesical plane, placental lacunae, increased placental vascularity, bridging vessels with vascularity extending from the placental bed across the uterine wall into the bladder or other pelvic organs. PAS is very rare among nulliparous patients, especially those without previous uterine surgery. We describe an unusual case of PAS in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus in whom a fundal placenta with PAS and thinned and areas of absent myometrium suspected at midtrimester sonography, sustained uterine atony and severe hemorrhage at delivery, necessitated massive blood transfusion and subtotal hysterectomy. Both mother and infant did well. Pathology confirmed PAS and marked uterine thinning. Although PAS most commonly is associated with placenta previa and the presence of previous cesarean delivery, this case emphasizes the need for alertness of at times subtle prenatal sonographic findings of PAS irrespective of placental location even among nulliparous patients, especially those with systemic lupus erythematosus.

Ectopic pregnancies, implantation of a fertilized ovum in any location other than within the endometrial cavity, occur in 1-2% of all pregnancies. Despite current enhanced early diagnosis enabled by serum beta-human choriogonadotropin (hCG) levels and high-resolution ultrasound, this clinical entity continues to account for between 2.7 and 6% of all maternal deaths. The most common site of ectopic implantation is the Fallopian tube (>90% of cases), and less commonly in previous Cesarean scar, ovary, cervix, or the abdomen. Complete tubal abortion refers to a tubal pregnancy having been expelled from the distal portion of the Fallopian tube into the peritoneal cavity and may be associated with either considerable hemorrhage, spontaneous resolution, or rarely serve as an initial nidus for an abdominal pregnancy. We present unusual sonographic findings of a complete tubal abortion in a patient with minimal symptomology.

Reverse diastolic flow of the fetal middle cerebral artery is a rare, yet ominous finding which has been associated with adverse perinatal outcomes including: intracranial hemorrhage, growth restriction, fetal-maternal hemorrhage, severe anemia, hydrops, hepatic anomaly, subsequent stillbirth, and early neonatal death. We report a case in which following notation of a nonreassuring fetal heart rate at 32 weeks’ gestation, sonographic documentation of persistent reverse diastolic flow of the fetal middle cerebral artery was noted in association with sonographic findings of vascular placental dysmorphology and an asymptomatic concealed placental abruption. Subsequent fetal heart rate tracing consistent with uteroplacental insufficiency led to immediate Cesarean birth of an anemic yet nonacidotic, nonhypoxic neonate, who did well following management of respiratory distress syndrome and partial exchange transfusion. Placental abruption was confirmed at delivery. Histopathology of the placenta confirmed the presence of localized chorangiomatosis (“wandering” chorangioma). The association of reverse diastolic flow of the fetal middle cerebral artery, placental chorangiomatosis and placental abruption has not been reported previously. We conclude that in the presence of prenatal sonographic findings of placental dysmorphology and or placental abruption, insonation of the fetal middle cerebral artery should be performed to assess the possibility of increased peak systolic velocity and possible reverse diastolic flow, both associated with fetal anemia and increased likelihood of an adverse perinatal outcome.

An interstitial pregnancy is an ectopic pregnancy located within the proximal intramural segment of the Fallopian tube traversing the myometrium. This type of ectopic pregnancy is relatively rare, occurring in approximately 1%-3% of all ectopic pregnancies. Given the myometrial mantle surrounding the gestational sac, which is considerably thicker than in other tubal pregnancies, patients with interstitial pregnancies classically manifest symptoms later in gestation. Thus, there is an increased risk of life-threatening intraperitoneal hemorrhage upon rupture of the myometrium encompassing the pregnancy. We present an unusual case of early sonographic diagnosis of an interstitial pregnancy in an asymptomatic patient at 7 and 3/7 weeks’ gestation, discuss predisposing factors, hallmarks of sonographic diagnosis, and review the literature regarding available clinical management modalities. With the increasing application of point of care ultrasound (POCUS) by emergency room physicians and other providers in outpatient facilities, our case emphasizes both the importance of correct sonographic identification of interstitial pregnancy and the clinical importance of uniform early first-trimester sonography, preferably no later than 7-8 weeks’ gestation.

Small bowel atresia constitutes congenital obstruction of the lumen of the duodenum, jejunum or ileum, and is one of the most common causes of neonatal bowel obstruction with a reported incidence of between 1.3 and 2.8 per 10,1000 live births. Complete absence of the small bowel, or near total jejuno-ileal atresia (in the absence of malrotation or gastroschisis), are extremely rare. Mid-trimester prenatal sonographic finding of dilated fetal bowel led to the finding of interstitial 8q21.13q21.2 duplication. Following delivery at 32 weeks’ gestation, at laparotomy almost complete small bowel atresia was noted. Anastomosis between the existing small bowel and colon was performed. At 7 months of age, the infant continued to receive total parenteral nutrition supplemented by gastrostomy and oral-spoon formula feeding, and weighed 7 kg (50th centile). This is the first report of the association interstitial 8q21.13q21.2 duplication, which includes OMIM genes (RALYL, LRRCC1, and E2F5) and extensive small bowel atresia.