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BACKGROUND AND PURPOSE: Third and fourth branchial apparatus anomalies are rare congenital anomalies. The purpose of this study was to investigate imaging features of these lesions on fetal MR imaging in comparison with lymphatic malformations, the major competing differential diagnosis in these cases. MATERIALS AND METHODS: A retrospective review of our institutional fetal MR imaging database between 1997 and 2019 resulted in 4 patients with confirmed third and fourth branchial apparatus anomalies and 14 patients with confirmed lymphatic malformations. The imaging features were reviewed by consensus, and the Fisher exact test was used to evaluate statistically significant differences between these 2 populations. RESULTS: Four cases of third and fourth branchial apparatus anomalies were imaged at 29 weeks 1 day (range, 23 weeks 1 day to 33 weeks 4 days). All 4 cases demonstrated unilateral, unilocular cysts without reduced diffusion or hemorrhage and a medially directed beaked contour that tapered between the spine and airway at the level of the piriform sinus. Compared with 14 cases of fetal lymphatic malformations imaged at 27 weeks 6 days (range, 21 weeks 3 days to 34 weeks 6 days), third and fourth branchial apparatus cysts were significantly more likely to be unilocular (P

The Appropriateness Criteria for the imaging screening of second and third trimester fetuses for anomalies are presented for fetuses that are low risk, high risk, have had soft markers detected on ultrasound, and have had major anomalies detected on ultrasound. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTIVES Congenital diaphragmatic hernia (CDH) can cause a significant mass effect in the fetal thorax, displacing the heart into the opposite hemithorax. In left-sided CDH (L-CDH), this is associated with smaller left-sided cardiac structures and reduced left-ventricular cardiac output (LVCO). The effect of these physiologic changes on cerebral blood flow is not well understood. We sought to describe the middle cerebral artery (MCA) pulsatility index (PI), a measure of cerebrovascular impedance, in fetuses with L-CDH and those with right-sided CDH (R-CDH) compared with unaffected fetuses, and the relationship between MCA-PI and LVCO. We hypothesized that MCA-PI would be lower in fetuses with L-CDH and similar in those with R-CDH compared to controls, and that MCA-PI would be correlated with LVCO. METHODS We identified all fetuses with CDH evaluated at The University of California San Francisco, San Francisco, CA, USA from 2011 to 2018. Fetal echocardiograms and ultrasound scans were reviewed. Umbilical artery and MCA Doppler examinations were assessed to calculate pulsatility indices. Ventricular outputs were calculated using Doppler-derived stroke volume and fetal heart rate. Lung-to-head ratio (LHR), estimated fetal weight, biparietal diameter (BPD) and head circumference (HC) were obtained from fetal sonograms. Measurements in fetuses with CDH, according to the side of the defect, were compared with those in unaffected, gestational age-matched controls. A subset of CDH survivors had available data on neurodevelopmental outcome, as assessed using the Bayley Scales of Infant Development, 3rd edition. RESULTS A total of 64 fetuses with CDH (L-CDH, n = 53; R-CDH, n = 11) comprised the study groups, with 27 unaffected fetuses serving as controls. Mean gestational age at evaluation was similar between the three groups. Compared to controls, fetuses with L-CDH had significantly lower LVCO expressed as a percentage of combined cardiac output (CCO) (32%; 95% CI, 29-35% vs 38%; 95% CI, 33-42%; P = 0.04) and lower MCA-PI Z-score (-1.3; 95% CI, -1.7 to -1.0 vs 0.08; 95% CI, -0.5 to 0.6; P

INTRODUCTION: The incidence of fetal gallstones is estimated at 0.45% and its clinical relevance after birth remains unknown. This study aimed to describe the natural history of fetal gallstones and their clinical sequelae after birth. METHODS: We queried a database of fetuses referred for second and third trimester sonograms performed for high-risk pregnancies, and identified cases with fetal gallstones (1996–2019). Demographics, prenatal/postnatal imaging findings, and clinical sequelae were collected. A literature review was performed according to PRISMA guidelines. RESULTS: We screened approximately 200,000 obstetric sonograms; 34 fetuses were found to have cholelithiasis. The median gestational age at the time of US was 35 weeks (range 22 – 38). Fifty-six percent were female and 11.8% were twin pregnancies with one affected fetus. Median maternal age was 28 years (range 17–42). Eight fetuses underwent postnatal imaging and 4 had persistent cholelithiasis. There was one case of in utero demise. Two patients had structural anomalies (renal and cardiac) by US. A subset of 17 patients was followed long-term (range 3–20 years), and none developed clinical sequelae from cholelithiasis. DISCUSSION/CONCLUSIONS: No child developed postnatal clinical sequelae related to cholelithiasis identified in utero. Fetal cholelithiasis can be managed expectantly without follow-up imaging in asymptomatic patients.

Vaginal bleeding can occur throughout pregnancy with varied etiologies. Although history and physical examination can identify many etiologies, imaging, in particular ultrasound (US), is the backbone of current medical practice. US pregnant uterus transabdominal, US pregnant uterus transvaginal, and US duplex Doppler velocimetry are usually appropriate for the evaluation of women with painless vaginal bleeding, those with painful vaginal bleeding, and also for those with second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. US cervix transperineal may be appropriate for those with painless or painful vaginal bleeding but is usually not appropriate for second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. Because the outcome of pregnancies is unequivocally related to the specific etiology of the vaginal bleeding, knowledge of imaging results directly informs patient management to optimize the outcome for mother and fetus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A fetus with an increased nuchal translucency at 11 to 14 weeks gestation is at risk for aneuploidy, genetic syndromes, structural anomalies, and intrauterine fetal demise in both single and twin gestations. In addition to referral to genetics for counseling and consideration of diagnostic genetic testing, a detailed anatomic survey and fetal echocardiogram are indicated in the second trimester to screen for congenital malformations and major heart defects. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Placenta accreta spectrum disorder (PASD) is the current terminology recommended by the International Federation of Obstetrics and Gynecology (FIGO) and should replace terms such as abnormally adherent/invasive placenta or morbidly adherent placenta. PASD refers to a variety of potential clinical complications, which may result from abnormal placental implantation. More specifically, placenta accreta refers to a defect in the decidua basalis where the chorionic villi adhere directly to the myometrium with trophoblastic invasion. Accurate antenatal diagnosis is needed to plan for an appropriate delivery strategy at an experienced center in order to reduce maternal and potential fetal morbidity and mortality. Obtaining radiologic and clinical data when PASD is first suspected can play a significant role in formulating an appropriate delivery strategy. Depending on the clinical risk factors and initial imaging findings, transabdominal ultrasound of the pregnant uterus with duplex Doppler and transvaginal ultrasound as needed are the most appropriate imaging procedures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

US has an established role in the prenatal detection of congenital and developmental disorders. Many pregnant women undergo US at 18-20 weeks of gestation for assessment of fetal anatomy and detection of structural anomalies. With advances in fetoscopy and minimally invasive procedures, in utero fetal interventions can be offered to address some of the detected structural and physiologic fetal abnormalities. Most interventions are reserved for conditions that, if left untreated, often cause in utero death or a substantially compromised neonatal outcome. US is crucial for preprocedural evaluation and planning, real-time procedural guidance, and monitoring and assessment of postprocedural complications. Percutaneous needle-based interventions include in utero transfusion, thoracentesis and placement of a thoracoamniotic shunt, vesicocentesis and placement of a vesicoamniotic shunt, and aortic valvuloplasty. Fetoscopic interventions include myelomeningocele repair and tracheal balloon occlusion for congenital diaphragmatic hernia. In rare cases, open hysterotomy may be required for repair of a myelomeningocele or resection of a sacrococcygeal teratoma. Monochorionic twin pregnancies involve specific complications such as twin-twin transfusion syndrome, which is treated with fetoscopic laser ablation of vascular connections, and twin reversed arterial perfusion sequence, which is treated with radiofrequency ablation. Finally, when extended placental support is necessary at delivery for repair of congenital high airway obstruction or resection of lung masses, ex utero intrapartum treatment can be planned. Radiologists should be aware of the congenital anomalies that are amenable to in utero interventions and, when necessary, consider referral to centers where such treatments are offered.

ObjectiveMonochorionic, diamniotic (MCDA) twin pairs are predisposed to various pregnancy complications due to the unique placental angioarchitecture of monochorionicity. Few studies have evaluated the outcomes of weight-discordant MCDA pairs without selective fetal growth restriction (SFGR) or the risk factors for development of SFGR. This study aims to describe the natural history of expectant, noninvasive management of weight-discordant MCDA twins and to evaluate risk factors associated with progression to SFGR.Study designThis was a retrospective cohort study at a single, tertiary care center in the United States. All MCDA twins with isolated intertwin weight discordance (ITWD) ≥ 20% diagnosed before 26 weeks' gestational age (GA) were included. The primary outcome of descriptive analyses was overall pregnancy outcome, incorporating both survival to delivery and GA at delivery, as defined by the North American Fetal Therapy Network. The secondary outcome was SFGR in one twin (defined as estimated fetal weight

We present a rare prenatal diagnosis of bilateral choroid plexus papillomas by obstetrical ultrasound and fetal MRI at 20 weeks 6 days gestation. The fetus demonstrated bilateral enlarged, echogenic choroid plexus with increased Doppler flow suggestive of vascularized choroid tissue. Same-day fetal MRI demonstrated that the choroid plexus appeared enlarged bilaterally without definite hemorrhage. The combined features on ultrasound and MRI suggested bilateral choroid plexus papillomas with increased cerebrospinal fluidproduction, leading to ventriculomegaly and enlarged extra-axial spaces. The diagnosis was confirmed by postnatal pathology, which demonstrated WHO grade II atypical choroid plexus papillomas.

US-guided procedures have an essential role in the diagnosis and treatment of multiple obstetric and gynecologic conditions, can be performed with either transvaginal or transabdominal approaches, and include biopsy of masses, aspiration of fluid collections, injection of therapeutic materials, and saline-infused sonohysterography and hysterosalpingo contrast-enhanced sonography.

Objective This article describes the natural history of stage I twin–twin transfusion syndrome (TTTS) including risk of progression to higher stage TTTS and pregnancy outcomes, and to identify risk factors for progression. Study Design Retrospective cohort study of monochorionic diamniotic (MCDA) twin pregnancies from 2006 to 2016 with expectantly managed Quintero stage I TTTS. Results A total of 30 MCDA twin pregnancies with expectantly managed stage I TTTS were identified. Of these, eight (26.7%) progressed to higher stage TTTS. Median gestational age (GA) at diagnosis for those that progressed was 18.9 ± 2.9 weeks versus 21.4 ± 3.4 weeks in those that remained stable (p = 0.06). Presence of an arterioarterial (A-A) anastomosis was assessed for 20/30 patients, and eight A-A were identified. Of those, 7/8 (87.5%) remained stable. In the complete cohort, a tiny or transiently visible bladder was noted in seven donor twins. Of these, 4/7 (57.1%) progressed. Excluding one termination, 47/58 (81.0%) fetuses survived. Conclusion With expectant management of stage I TTTS, nearly three-fourths of pregnancies remain stable and most have survival of ≥ 1 twin. A-A anastomoses were not associated with progression to higher stage TTTS, whereas earlier GA at diagnosis or a small or intermittently visible donor bladder may herald greater risk of progression.

Objective The significance of polyhydramnios of one twin in the absence of oligohydramnios of the cotwin in monochorionic diamniotic (MCDA) twin pregnancies (polyhydramnios affecting a recipient-like twin [PART]) is unknown. Our aim is to assess the risk of progression to twin–twin transfusion syndrome (TTTS) with PART, progression to ≥ stage II TTTS, and neonatal survival. Study Design This study was a retrospective cohort study of MCDA twin pregnancies with PART evaluated at a referral center from 2008 to 2015. Results Sixty-four MCDA twin pregnancies with PART were identified. Fifteen (23.4%) progressed to TTTS, including 10 (15.6%) who progressed to ≥ stage II TTTS. Three pregnancies were terminated and one underwent selective reduction by radiofrequency ablation. Overall survival was 113 out of 128 (88.3%). Of those who remained stable, 91.8% (N = 45) had survival of both neonates. In multivariate analysis, the presence of arterioarterial (A-A) anastomosis by in utero Doppler ultrasound was associated with decreased risk of progression to TTTS (odds ratio: 0.12, p = 0.03, 95% confidence interval: 0.02–0.78). Conclusion Most MCDA twin pregnancies with PART do not progress to TTTS and have a favorable prognosis. Progression rates are higher than observed in uncomplicated MCDA twins; however, so close surveillance is warranted. The presence of an A-A anastomosis appears to confer decreased risk of progression to TTTS.

Objectives Liver inflammation and fibrosis may impair the ability of sonography to identify steatosis. We determined the accuracy of sonography in grading steatosis in patients with chronic hepatitis B compared to liver biopsy. Methods We conducted was a single-center retrospective study of all nontransplanted patients with chronic hepatitis B undergoing sonography and liver biopsy between 2004 and 2014 (n = 109). Steatosis was graded by sonography as none, mild, moderate, or severe. Liver histologic analysis graded steatosis (0

Purpose To determine if ultrasonographic (US) findings, including Doppler US findings, are associated with subsequent pancreas transplant failure. Materials and Methods A cohort of adult patients who underwent pancreas transplantation at a tertiary institution over the course of 10 years (from 2003 to 2012) was retrospectively evaluated for failure, which was defined as return to insulin therapy or surgical graft removal. The institutional review board provided a waiver of informed consent. All US images obtained within the 1st postoperative year were reviewed for three findings: arterial flow (presence or absence of intraparenchymal forward diastole flow), splenic vein thrombus, and edema. These findings were correlated with pancreas graft failure within 1-year after surgery by using Cox proportional hazards models and hazard ratios. Results A total of 228 transplants were included (mean patient age, 41.6 years; range, 19-57 years; 122 men, 106 women). Absent or reversed arterial diastolic flow was identified in nine of 20 failed transplants (sensitivity, 45%; 95% confidence interval [CI]: 23, 68) and in 15 of 208 transplants that survived (specificity, 93% [193 of 208]; 95% CI: 89, 96). The Cox proportional hazard ratio was 6.2 (95% CI: 3.1, 12.4). Splenic vein thrombus was identified in 10 of 20 failed transplants (sensitivity, 50%; 95% CI: 27, 73) and in 25 of 208 transplants that survived (specificity, 88% [183 of 208]; 95% CI: 83, 92). The Cox proportional hazard ratio was 4.2 (95% CI: 2.4, 7.4). Edema had the lowest specificity (Cox proportional hazard ratio, 2.0; 95% CI: 1.3, 2.9). In the multivariate analysis, only absent or reversed arterial diastolic flow remained significantly associated with transplant failure (adjusted hazard ratio, 3.6; 95% CI: 1.0, 12.8; P = .045). Conclusion Absent or reversed diastolic arterial Doppler flow has a stronger association with transplant failure than does splenic vein thrombus or edema. (©) RSNA, 2016.

Unilateral bronchial atresia is a rare prenatal diagnosis that can be confused with other congenital lung abnormalities, particularly congenital pulmonary airway malformation. Accurate distinction between these entities is important for appropriate clinical care and prognosis. Familiarity of the key imaging and clinical features of unilateral bronchial atresia in comparison to other fetal lung abnormalities should increase the likelihood of achieving a timely and accurate diagnosis.

Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Objectives: Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and is caused by abnormal vascular connections between a pump twin and an acardiac mass. The effects of abnormal vascular connections on cerebral vasculature in the pump twin are unknown. We hypothesize that abnormal cerebral vascular impedance, as assessed by the pulsatility index (PI), is present in pump twins and that fetal intervention alters cerebral impedance. Methods: Fetal echocardiograms performed between 2010 and 2013 in pregnancies diagnosed with TRAP (n = 19), recorded at presentation, and uncomplicated monochorionic twin pregnancies (controls, n = 18; 36 fetuses) were analyzed. In all subjects, the middle cerebral artery (MCA)-PI, combined cardiac output (CCO) and cardiothoracic ratio were calculated, and the values for cases and controls were compared. Results: The mean gestational age at the time of echocardiography was 20 weeks in both groups. MCA-PI was lower in TRAP cases than in controls (1.55 (95%CI, 1.47-1.64) vs 1.74 (95% CI, 1.65-1.82), respectively; P = 0.004). CCO in TRAP cases was mildly elevated for gestational age (199.7 (95%CI, 138.4-261.1) mL/min) compared with that of controls (131.4 (95%CI, 102.2-160.7) mL/min). In six TRAP cases with a second echocardiogram available, the mean MCA-PI increased after intervention, from 1.5 (95%CI, 1.3-1.7) to 1.8 (95% CI, 1.4-2.2). Conclusions: TRAP pump twins have lower cerebral vascular impedance than do controls, suggestive of a brain-sparing effect. MCA-PI appeared to increase in a small group of pump twins after intervention. These findings suggest a fetal cerebral autoregulatory response to a high cardiac output state that begins to change after fetal intervention. The long-term implications for neurodevelopmental outcome warrant further study.

Hepatic steatosis develops after liver transplantation (LT) in 30% of adults, and nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in nontransplanted children. However, posttransplant steatosis has been minimally studied in pediatric LT recipients. We explored the prevalence, persistence, and association with chronic liver damage of hepatic steatosis in these children. In this single-center study of pediatric patients transplanted 1988-2015 (n = 318), 31% of those with any posttransplant biopsy (n = 271) had ≥ 1 biopsy with steatosis. Median time from transplant to first biopsy with steatosis was 0.8 months (interquartile range [IQR], 0.3-6.5 months) and to last biopsy with steatosis was 5.5 months (IQR, 1.0-24.5 months); 85% of patients with steatosis also had for-cause biopsies without steatosis. All available for-cause biopsies were re-evaluated (n = 104). Of 9 biopsies that could be interpreted as nonalcoholic steatohepatitis (NASH)/borderline NASH, with steatosis plus inflammation or ballooning, 8 also had features of cholestasis or rejection. Among 70 patients with surveillance biopsies 3.6-20.0 years after transplant, only 1 overweight adolescent had a biopsy with NAFLD (grade 1 steatosis, mild inflammation, no ballooning or fibrosis)-despite a 30% prevalence of overweight/obesity in the cohort and 27% with steatosis on previous for-cause biopsy. Steatosis on preceding for-cause biopsy was not associated with portal (P = 0.49) or perivenular fibrosis (P = 0.85) on surveillance biopsy. Hepatic steatosis commonly develops early after transplant in children and adolescents, but it rarely persists. Biopsies that did have steatosis with NASH characteristics were all for-cause, mostly in patients with NAFLD risk factors and/or confounding causes of liver damage. Prospective studies that follow children into adulthood will be needed to evaluate if and when hepatic steatosis presents a longterm risk for pediatric LT recipients. Liver Transplantation 23 957-967 2017 AASLD.

OBJECTIVES The purpose of this study was to assess the feasibility and utility of targeted hepatic sonography to evaluate for hepatic steatosis during a subspecialty clinic visit. METHODS In this pilot study, we performed targeted hepatic sonography on 25 overweight children aged 7 to 17 years consecutively seen in a pediatric obesity clinic. Long-axis images of the right lobe of the liver and a split-screen image of liver and spleen were taken. Images were interpreted in real time by the radiologist and shown to the family. Demographics, clinical measurements, and laboratory parameters were also collected from the specialty clinic visit on the same day. RESULTS Sonography required a median of 4 minutes during the visit (interquartile range, 3-5 minutes). All consented patients completed the study. The median alanine aminotransferase (ALT) level was 23 U/L in those with no steatosis (n = 14), 26 U/L with mild steatosis (n = 6), and 41 U/L with moderate/marked steatosis (n = 5). Children with ALT levels of 25 to 50 U/L had very variable sonographic measures of hepatic steatosis. When the participants were categorized by the overall degree of fatty liver, hepatic steatosis was significantly associated with the aspartate aminotransferase level (P = .028), ALT level (P = .003), and diastolic blood pressure (P = .05) but did not correlate with age, sex, Latino race, or insulin resistance. CONCLUSIONS Targeted hepatic sonography added information not apparent from routine ALT screening and provided immediate feedback to clinicians and families about the effect of obesity on end organs. This examination could be a feasible, informative addition to screening for children at high risk for nonalcoholic fatty liver disease who are seen in clinics that specialize in obesity.

Background: Pfeiffer syndrome (PS) is one of several related craniosynostosis and occurs in 1 out of every 100,000 births. The diagnosis has historically been based on the clinical neonatal findings of bilateral coronal craniosynostosis, midface hypoplasia, with broad thumbs and great toes. Case: A craniosynostosis suggestive of PS was identified on prenatal ultrasound at 34+3 weeks gestation by findings of polyhydramnios, a cloverleaf skull, ventriculomegaly, hypertelorism, marked orbital proptosis, short limbs, broad digits, and an abnormality of the spine. Prenatal molecular testing of the FGFR genes revealed an exon 10, p.Y340C mutation in the FGFR2 gene. Conclusion: PS can now be diagnosed prenatally. In our case, the specific mutation was associated with an especially severe phenotype. The ultrasonographic findings in conjunction with the molecular diagnosis allowed us to better inform the patient and medical staff about the diagnosis and prognosis.

Fetal endoscopic tracheal occlusion (FETO) is a novel technique to treat cases of isolated severe congenital diaphragmatic hernia (CDH). Although there are benefits of MRI over ultrasound in assessing lung volumes, it is unknown whether there are benefits of MRI for localizing the tracheal balloon. This is a retrospective study reviewing the imaging characteristics of FETO in patients who underwent both MRI and ultrasound exams done to localize tracheal balloons.

Liver inflammation and fibrosis may impair the ability of sonography to identify steatosis. We determined the accuracy of sonography in grading steatosis in patients with chronic hepatitis B compared to liver biopsy.We conducted was a single-center retrospective study of all nontransplanted patients with chronic hepatitis B undergoing sonography and liver biopsy between 2004 and 2014 (n = 109). Steatosis was graded by sonography as none, mild, moderate, or severe. Liver histologic analysis graded steatosis (0,5%; 1,33%; 2,66%; or 3, ≥66%) and staged fibrosis (F0-F4). Severe steatosis was defined as grade 2 or 3. Clinical variables within 6 months of liver biopsy were collected, and the association with steatosis was analyzed by univariate logistic regression.Patients were predominantly Asian (83%), male (62%), and hepatitis B e antigen negative (62%). Twenty-nine percent of patients were obese; 9% had diabetes mellitus; 23% had hypertension; and 31% had dyslipidemia. Forty-four percent of patients had steatosis on liver biopsy; 8% had severe steatosis. The presence of any steatosis on sonography correctly identified any steatosis on liver biopsy in 29 of 48 patients (60%). The absence of steatosis on sonography ruled out severe steatosis on biopsy (specificity, 100%). Severe steatosis on sonography correctly predicted the presence of severe steatosis on liver biopsy (89%; P .001); however, it was not accurate at distinguishing between steatosis grades. Predictors of biopsy-proven steatosis on univariate analysis included diabetes (P .001), hypertension (P = .03), hypercholesterolemia (P = .02), and body mass index (P .001).Sonography had excellent accuracy in identifying patients with steatosis on biopsy. Abdominal sonography can be used to predict clinically important steatosis in patients with chronic hepatitis B.

Background/Purpose Congenital pulmonary airway malformations (CPAM) are rare lesions often diagnosed during routine prenatal ultrasound. The presence of hydrops fetalis is an indicator of poor prognosis. Here we present a retrospective review of fetuses undergoing either open fetal surgery or steroids for predominantly microcystic CPAM with hydrops fetalis. Method A retrospective review of patients undergoing open fetal surgery or steroids for CPAM at our institution was performed. The primary outcome was survival. Results A retrospective review of all patients referred to our institution with the diagnosis of CPAM was performed. Fetuses with predominantly microcystic CPAM and the presence of hydrops fetalis treated with steroid or surgery were included. Thirteen patients were treated with steroids, and 11 patients underwent open fetal surgery. In the steroid group 12 (92%) of 13 fetuses survived to delivery versus 9 (82%) of 11 in the open fetal surgery group. Only 5 (56%) of 9 of the patients in the open fetal surgery group survived to neonatal discharge compared to 10 (83%) of 12 in the steroid group. Conclusions In the present retrospective study, improved survival was seen in fetuses with hydrops fetalis and predominantly microcystic CPAM treated with steroids when compared with open fetal surgery. Steroids should be considered for first-line therapy in these cases.

The placenta and umbilical cord play important roles in the development of the growing fetus. The placenta can be clearly identified by the 14th gestational week and should be evaluated during each obstetric ultrasound examination.This article reviews the formation of the placenta and its expected sonographic appearance throughout gestation along with its normal variants. Expected findings in a singleton pregnancy are primarily addressed. The next portion of the article covers placental abnormalities of clinical consequence, including anomalies of appearance, location, and function.The umbilical cord is also discussed, focusing on the relevance of the location of the umbilical cord's insertion into the placenta.

Objective To describe the spectrum of cardiac defects in monochorionic (MC) twins discordant for congenital heart disease (CHD) in a referral center population. Method Retrospective study of all twin gestations undergoing echocardiography between 2000 and 2009 at our institution. Results A total of 356 twin pairs were evaluated during the study period, 202 for suspected twin-twin transfusion syndrome (TTTS) and the remainder for other indications. Twenty-nine MC pairs were discordant for CHD: laterality defects, 24% [right (2) or left (3) isomerism (3), primitive heart (2)]; ventricular hypoplasia secondary to semilunar valve obstruction, 14% [hypoplastic left heart syndrome (2), severe pulmonary stenosis (PS) or atresia (2)]; valvar dysplasias in TTTS recipients, 27% [PS (4), mitral/tricuspid dysplasia (4)]; conjoining, 14% (4); and other developmental errors, 21% [conotruncal (1), tricuspid atresia (2), ventricular septal defect (2)]. Conclusions The spectrum of lesions in individuals assumed to be genetically identical and the disproportionate incidence of laterality and ventricular hypoplasia in this population leads us to propose potential mechanisms for the development of CHD in this population including local environmental or epigenetic factors influencing gene expression differentially, abnormal reciprocal laterality signaling between twinned embryos, or placental vascular factors affecting hemodynamics, either early in gestation or later in the setting of TTTS, leading to valvar lesions and ventricular hypoplasia. Copyright © 2011 John Wiley & Sons, Ltd.

Objective To examine the diagnostic precision of ultrasound examination for placenta accreta in women with placenta previa and to compare the morbidity associated with accreta to that of previa alone. Methods This was a retrospective cohort study of all women with previa with/without accreta examined at the University of California, San Francisco (UCSF) between 2002 and 2008. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of ultrasound examination for the diagnosis of accreta were calculated and compared with results from similar studies in the literature. Univariable analysis was used to compare clinical outcomes. Results The PPV of an ultrasound diagnosis of accreta was 68% and NPV was 98%. Ultrasound had a sensitivity of 89.5%. Compared with previa alone, accreta had an odds ratio (OR) of 89.6 (95% CI, 19.44–412.95) for estimated blood loss > 2 L, an OR of 29.6 (95% CI, 8.20–107.00) for transfusion and an OR of 8.52 (95% CI, 2.58–28.11) for length of hospital stay > 4 days. Conclusion Placenta accreta is associated with greater morbidity than is placenta previa alone. Ultrasound examination is a good diagnostic test for accreta in women with placenta previa. This is consistent with most other studies in the literature. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Objective To investigate prevalence and predictors of cardiovascular risk in pediatric liver transplant recipients using noninvasive markers of subclinical atherosclerosis: carotid intima-media thickness (cIMT) and aorta intima-media thickness (aIMT). Study design Cross-sectional study of 88 pediatric liver transplant recipients. The cIMT and aIMT were measured by ultrasound imaging using standardized protocol. Results Participants were 15.4 ± 4.8 years of age, and 11.2 ± 5.6 years post-transplantation. The cIMT and aIMT were both higher in males than females. In analyses adjusted for sex, age, and height, the cIMT was higher in subjects transplanted for chronic/cirrhotic liver disease and lower in subjects on cyclosporine (n = 9) than tacrolimus (n = 71). The cIMT was not associated with rejection history or current corticosteroid use. The cIMT increased with increasing diastolic blood pressure and triglycerides. The aIMT (n = 83) also increased with age, and its rate of increase post-transplant varied by age at transplantation. In adjusted analyses, aIMT was higher in subjects with glucose intolerance. In analysis of patients ≤20 years of age for whom blood pressure percentiles could be calculated (n = 66), aIMT increased with increasing diastolic blood pressure percentile (0.010 mm per 5-percentile; 95% CI, 0.000-0.021; P = 0.05). Neither the cIMT nor the aIMT was associated with obesity, systolic hypertension, or other dyslipidemia at study visit. Conclusion Measures of long-term cardiovascular risk were associated with conditions that are more common in pediatric liver transplant recipients than nontransplanted peers, namely, diastolic hypertension and glucose intolerance. Larger, longitudinal studies are warranted to investigate whether cIMT could be useful for stratifying these patients' cardiovascular risk—and potential need for proactive intervention—during long-term follow-up.

Objective: To examine the outcomes of patients with twin reversed arterial perfusion (TRAP) sequence in which the acardiac twin was ≤50% the weight of the pump twin. Methods: This was a retrospective study conducted with institutional review board approval. The records of all patients referred to UCSF for suspected diagnosis of TRAP between 1994 and 2009 were reviewed (n = 76). Patients with pregnancies complicated by TRAP with an acardiac twin ≤50% the weight of the pump twin were included (21 patients). Exclusion criteria were loss to follow-up (1 patient) and syndromic abnormalities in the pump twin (2 patients). Results: Of the 18 patients with viable pregnancies that met the criteria for analysis, 7 (39%) underwent radiofrequency ablation (RFA) of the acardiac twin and 11 (61%) underwent conservative management. None of the pump twins in either group had hydrops fetalis. Three of the 11 acardiac twins in the conservative management group did not undergo RFA because they did not have blood flow at presentation to UCSF. Survival to delivery was 100% (7/7) in the RFA group and 91% (10/11) in the conservative management group. When we eliminated from our analysis the 3 pregnancies in the conservative management group without blood flow to the acardiac twin, survival to delivery was 88% (7/8). The single death occurred in 1 of the 3 monochorionic-monoamniotic pregnancies in the conservative management group, all of whom had blood flow to the acardiac twin. There were no statistically significant differences in gestational age at delivery, birth weight or survival between the RFA and conservative management groups, even after stratification by blood flow. Conclusions: Conservative management with close monitoring appears to be a safe option for TRAP pregnancies in which the acardiac twin is ≤50% the weight of the pump twin.

Obstetric ultrasound (US) is an integral part of fetal surgery for open and minimally invasive techniques. With advances in US imaging, the ability to refine diagnosis, predict prognosis, and contribute to fetal treatment continues to grow. Current research in fetal diagnosis and treatment includes identifying the most reliable sonographic features for determining prognosis before and after surgery.

To determine the frequency and histopathologic basis of hepatic surface nodularity at imaging in patients with fulminant hepatic failure.The committee on human research approved this HIPAA-compliant study and waived written informed consent. Thirty-five consecutive patients [24 female [mean age, 38 years +/- 19 (standard deviation); range, 1-67 years] and 11 male [mean age, 29 years +/- 22; range, 2-61 years]] with a mean age of 35 years +/- 20 (range, 1-67 years) who underwent liver transplantation for fulminant hepatic failure at our institution during a 5-year period were retrospectively identified. Pretransplant ultrasonographic (n = 38; three patients each had two studies) and computed tomographic (n = 2) studies were retrospectively and independently reviewed for hepatic surface nodularity. Liver explant histopathologic findings (n = 33; slides unavailable in two patients) were reviewed for cirrhosis and for the combination of alternating foci of confluent regenerative nodules and necrosis. Differences among patients with nodular versus smooth liver surfaces in the proportion with the two histopathologic findings were compared with Fisher exact test. Differences in illness duration and maximum liver biochemical indices were compared with Mann-Whitney Rank Sum test.Fifteen of 35 patients (43%) demonstrated hepatic surface nodularity at pretransplant imaging, none of whom had cirrhosis at histopathologic examination. One patient with a smooth liver surface had cirrhosis. Compared with those who had a smooth liver surface, patients with hepatic surface nodularity had a significantly greater proportion with the histopathologic finding of a combination of alternating foci of confluent regenerative nodules and necrosis (12 of 14 vs one of 19, P.001), longer illness duration (31 days +/- 32 vs 13 days +/- 13, P = .029), and lower maximum liver biochemical indices.Hepatic surface nodularity is commonly seen at imaging in fulminant hepatic failure and usually reflects a combination of alternating foci of confluent regenerative nodules and necrosis; this is important because an erroneous radiologic diagnosis of cirrhosis in this setting could adversely affect transplantation status.

Context: As a result of more sensitive techniques to detect recurrent thyroid cancer, the number of patients presenting with small, nonpalpable recurrent thyroid cancer in cervical lymph nodes is increasing. Surgical excision of nonpalpable recurrent thyroid cancer can be difficult, particularly in a previously operated area. Objective: The objective of this study was to investigate whether preoperative insertion of a hook needle under ultrasound guidance is useful in neck reoperations for recurrent thyroid cancer. Patients: Ten consecutive patients presenting over a 4-month period with nonpalpable, ultrasound-visible, fine needle biopsy-proven recurrent thyroid cancer in previously operated neck compartment(s) were studied. Main Outcome Measures: We measured whether it was technically possible to insert a hook needle preoperatively, rate of negative neck exploration, and complication rate. Results: The hook needle was inserted in seven patients. In three patients, the hook needle was not inserted; one patient had palpable disease 4 months after the preoperative clinic visit, one patient had a tumor too close to the carotid artery, and one patient had multiple bilateral foci of recurrent disease in the central neck. One patient had bleeding after insertion of the needle due to a penetration of an anterior jugular vein that was easily managed at neck reexploration. No other complication occurred during the hook needle insertion, and the only surgical complication was a transient recurrent nerve palsy. All pathology reports showed malignant disease. Conclusion: Hook needle-guided excision of recurrent thyroid cancer is feasible and appears to be a promising tool for safe and successful reoperation of patients with small recurrent thyroid cancer in cervical lymph nodes.

Objective Transvaginal sonography (TVS) is routinely performed as part of a pelvic sonogram in postmenopausal women, and images of the endometrium are frequently obtained. In women without vaginal bleeding, the threshold separating normal from abnormally thickened endometrium is not known. The aim of this study was to determine an endometrial thickness threshold that should prompt biopsy in a postmenopausal woman without vaginal bleeding. Methods This was a theoretical cohort of postmenopausal women aged 50 years and older who were not receiving hormone therapy. We determined the risk of cancer for a postmenopausal woman with vaginal bleeding when the endometrial thickness measures > 5 mm, and then determined the endometrial thickness in a woman without vaginal bleeding that would be associated with the same risk of cancer. We used published and unpublished data to determine the sensitivity and specificity of TVS, the incidence of endometrial cancer, the percentage of women symptomatic with vaginal bleeding, and the percentage of cancer that occurs in women without vaginal bleeding. Ranges for each estimate were included in a sensitivity analysis to determine the impact of each estimate on the overall results. Results In a postmenopausal woman with vaginal bleeding, the risk of cancer is approximately 7.3% if her endometrium is thick (> 5 mm) and 11 mm) and 0.002% if the endometrium is thin (≤ 11 mm). The estimated risk of cancer was sensitive to the percentage of cancer cases that were estimated to occur in women without vaginal bleeding. For the base case we estimated that 15% of cancers occur in women without vaginal bleeding. When we changed the estimate to project that only 5% of cancers occur in women without vaginal bleeding, the projected risk of cancer with a thick measurement was only 2.2%, whereas when we estimated that 20% of endometrial cancers occur in women without bleeding, the projected risk of cancer with a thick measurement was 8.9%. As a woman's age increases, her risk of cancer increases at each endometrial thickness measurement. For example, using the 11 mm threshold, the risk of cancer associated with a thick endometrium increases from 4.1% at age 50 years to 9.3% at age 79 years. Varying the other estimates used in the decision analysis within plausible ranges had no substantial effect on the results. Conclusions In a postmenopausal woman without vaginal bleeding, if the endometrium measures > 11 mm a biopsy should be considered as the risk of cancer is 6.7%, whereas if the endometrium measures ≤ 11 mm a biopsy is not needed as the risk of cancer is extremely low. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Objectives To evaluate the reliability of sonographic lung-to-head ratio (LHR) measurement as a predictor of survival in fetuses with congenital diaphragmatic hernia (CDH) and to compare the probability of survival in those with temporary tracheal occlusion (TO) or standard care with respect to the LHR. Methods Fifty-six fetuses with left CDH with liver herniated into the thorax at complete prenatal evaluation were included in logistic regression analyses of antenatal predictors of survival to hospital discharge. Sixteen subjects underwent TO and 40 received standard care. Results LHR was a significant predictor of survival, with probability of survival increasing with increasing LHR (odds ratio (OR) 8.5, P = 0.04). When subjects with anomalies were excluded, the LHR effect was similar after adjustment for TO (OR 7.1, P = 0.11). Linear spline models suggested a plateau in survival at an LHR of 1.0 and all models suggested increased odds of survival with TO. Minimum LHR measurements had a high degree of inter- and intraobserver agreement (intraclass correlation coefficients of 0.70 and 0.80, respectively). Conclusions Calculation of the LHR in fetuses with CDH is a reliable and powerful predictor of survival to hospital discharge, although improving odds of survival may plateau at an LHR of 1.0. TO may have an independent benefit on survival to hospital discharge. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

Background/Purpose: In rare instances in monochorionic twin pregnancies, one twin can have a discordant anomaly (eg, cystic hygroma). If this twin dies in utero, neurologic injury and death can occur in the surviving cotwin. To protect the normal twin, the authors developed an approach to separate the circulations and ablate the umbilical cord of the abnormal twin. Methods: From September 1998 to February 2001, 6 cases of discordant anomalous twins were diagnosed by prenatal ultrasound scan in which the anomaly was lethal or parents desired prenatal termination for this abnormal twin. All underwent surgical intervention with gestational ages varying from 19 to 24 weeks. Results: Depending on cord insertion site and placental anatomy, blood flow was interrupted to the anomalous fetus by either radiofrequency ablation (RFA; 2 cases), cord transection (1 case), or cord transection after laser ablation of communicating vessels (3 cases). Fetal death occurred in one normal twin 4 days postoperatively. Average age at delivery for the 5 surviving fetuses was 34.5 weeks' gestation. On follow-up, all surviving infants are neurologically intact. Conclusion: An otherwise normal monochorionic twin threatened by an anomalous cotwin can be salvaged successfully with a strategy tailored to interrupt the vascular connections between the 2 twins. J Pediatr Surg 37:1736-1739. Copyright 2002, Elsevier Science (USA). All rights reserved.

Summary: The high risks of monochorionic (MC) twin gestations are largely related to the vascular anatomy of the shared placentae and the presence of intertwin vascular connections. These anastomoses are implicated in twin-twin transfusion syndrome and co-twin sequelae after intrauterine death of one twin. Twin-twin transfusion syndrome is the most common complication of MC twinning. Obstetrical sonography, with the use of Doppler techniques, can be used to assess these high-risk pregnancies and to interrogate the vascular connections in the shared placentae. The information obtained can improve our understanding of the pathophysiology of syndromes that complicate these pregnancies and may help inform obstetrical management.

To determine whether fetal growth measured at serial ultrasonographic (US) examinations can predict neonatal morbidity, independent of whether gestational age is known.Women (n = 321) who had singleton pregnancies and underwent two or more second- or third-trimester obstetric US examinations were included in a retrospective cohort analysis. Inadequate fetal growth was defined as growth at or below the 10th percentile. The relative risk of each poor outcome was calculated for fetuses with inadequate growth, compared with the risk for fetuses with normal growth.Inadequate fetal growth was associated with 3.9 times the risk of a birth weight less than 2,500 g, 17.7 times the risk of a birth weight less than the 3rd percentile for gestational age, 2.3 times the risk of preterm birth, 2.6 times the risk of a long newborn hospital stay, and 3.6 times the risk of neonatal intensive care unit admission. After adjusting for confounding variables, including fetal weight, fetal growth remained a significant predictor of small birth size and poor outcomes. Inadequate growth predicted the risk of poor outcomes, even when gestational age was unknown. When inadequate growth was used to identify fetuses at risk, 21%-67% of neonates who were small at birth or had poor outcomes were identified at false-positive rates of only 5%-9%. For all outcomes, inadequate growth enabled identification of more fetuses with poor birth outcomes than low estimated fetal weight.Morbidity is significantly increased among fetuses who demonstrate less than expected growth. Growth between two US examinations can be used to estimate the risk of neonatal morbidity, even when gestational age is unknown.

To assess the value of central quality assurance (QA) reading of transvaginal ultrasonographic (US) images obtained to measure endometrial thickness and to assess image quality.Results of 2,000 US examinations performed in 1,000 subjects during one of two multicenter drug trials were evaluated. Endometrial thickness was measured at the study site; images were then sent to the QA center, where an experienced sonologist evaluated endometrial thickness and image quality.In 360 (18%) of the 2,000 examinations, image quality was insufficient for central QA reading. Repeat examinations were requested, and suggestions for improvement in technique were provided. In 349 (97%) of the 360 examinations, repeat US images were of acceptable quality. In 99 (5%) of the 1,989 examinations in which endometrial thickness was measured, central measurement of thickness differed by more than 2 mm from that of the site. In a group (n = 300) that was followed up for 1 year, requests for repeat US examinations decreased from 24% at baseline to 11% at 1 year.Central QA reading provides a consistent evaluation of endometrial thickness on US images obtained in multicenter drug trials and helps to ensure the acquisition of high-quality transvaginal US images. It further leads to demonstrable improvement in site performance.

Arterio-venous connections, which are known to occur in monochorionic twin placentae and are a mechanism for the development of twin-to-twin transfusion syndrome, can be demonstrated in utero by means of targeted sonography with the use of spectral and color flow Doppler techniques.

Extralobar pulmonary sequestrations are part of the spectrum of thoracic bronchopulinonary malformations. Less frequently, they are located in the abdomen. Postnatal resection is indicated because of the risk of infection (thoracic lesions) and the difficulty in distinguishing infradiaphragmatic lesions from a variety of tumors. We herein present the clinical and technical details of two cases of extralobar sequestration, one located in the thorax and the other in the abdomen, both treated successfully with minimally invasive techniques.

Routine prenatal ultrasound revealed a unilocular cystic mass associated with upper thoracic hemivertebrae that grew to 6 cm at 28 weeks and was associated with hydrops. A thoraco-amniotic shunt decompressed the cyst and resolved the hydrops, but the shunt occluded 17 days later. Preterm labour led to vaginal delivery at 31 2/7 weeks. Postnatally, the cyst was decompressed by thoracentesis due to respiratory distress. It was resected on day four of life. Severe tracheobronchomalacia was present post-operatively, presumably due to prenatal mass effect of the cyst. At one year of age, the child has recovered completely without adverse respiratory or neurological sequelae.

Despite advances in postnatal care, patients born with a congenital diaphragmatic hernia (CDH) suffer substantial morbidity and mortality. The present study was undertaken to determine the prognostic influence of prenatally-diagnosed liver herniation in the hemithorax in fetuses with CDH. The medical records of 48 patients evaluated for a prenatally-diagnosed left CDH were retrospectively reviewed. Patients were analysed according to the position of the liver by prenatal ultrasound; 32 fetuses had a major portion of the liver herniated into the left hemithorax ('liver up') and 16 had an intra-abdominal liver ('liver down'). Liver position was determined using colour-flow Doppler ultrasonography. There were two fetal deaths in the liver-up group and one in the liver-down group. The liver-up group more frequently required extracorporeal membrane oxygenation (ECMO) support (53 per cent) compared with the liver-down group (19 per cent). Postnatal survival was significantly less in the liver-up group (43 per cent) vs. the liver-down group (93 per cent). Fetuses with congenital diaphragmatic hernia and liver herniated into the hemithorax have a much worse prognosis than similarly afflicted fetuses without liver herniation. Prenatal ultrasonographic diagnosis of congenital diaphragmatic hernia allows for preparation for a critically ill newborn and aids in prenatal family counselling.

Before transjugular intrahepatic portosystemic shunts (TIPS), sonography is used to identify patients with unsuitable hepatic and portal venous anatomy and to plan the procedure for those with suitable anatomy. Specifically, sonography is used to assess the size and morphology of the liver parenchyma, to detect hepatic masses, cysts, or biliary ductal dilatation, and to evaluate the hepatic vasculature for patency and direction of flow. A survey of the abdomen also will show the amount of ascites and the location of the liver relative to external landmarks. During TIPS, sonography may be used to facilitate atraumatic entry into the internal jugular vein or to guide puncture of the portal vein. After TIPS, routine sonography is used to detect shunt dysfunction. We routinely image patients at 24 hours, 3 months, 6 months, and every 6 months thereafter. Three findings most suggestive of shunt malfunction that prompt further investigation by shunt venography are (1) absent Doppler flow within the shunt, (2) peak flow velocity in the midshunt of 50 cm/sec or less, (3) reversal of flow direction in the intrahepatic portal vein branches from hepatofugal to hepatopetal.

Objective Primary hydrothorax is a rare congenital anomaly with outcomes ranging from spontaneous resolution to fetal demise. We reviewed our experience with fetuses diagnosed with primary hydrothorax to evaluate prenatal management strategies. Methods We reviewed the records of patients evaluated for fetal pleural effusions at our Fetal Treatment Center between 1996 and 2013. To define fetuses with primary hydrothorax, we excluded those with structural or genetic anomalies, diffuse lymphangiectasia, immune hydrops, and monochorionic diamniotic twin gestations. Results We identified 31 fetuses with primary hydrothorax, of whom 24 had hydrops. Hydropic fetuses were more likely to present with bilateral effusions. Of all fetuses with primary hydrothorax, 21 had fetal interventions. Survival without hydrops was 7/7 (100%), whereas survival with hydrops depended on whether or not the patient had fetal intervention: 12/19 (63%) with intervention and 1/5 (20%) without intervention. Premature delivery was common (44%) among those who had fetal intervention. Conclusions Fetal intervention for primary hydrothorax may lead to resolution of hydrops, but preterm birth and neonatal demise still occur. Understanding the pathophysiology of hydrops may provide insights into further prenatal management strategies, including targeted therapies to prevent preterm labor.

Some fetuses with sacrococcygeal teratoma (SCT) develop hydrops, but there is no consensus on an appropriate prognostic marker for poor prognosis. The purpose of this study is to establish predictors of poor prognosis in fetuses with SCT.A retrospective review of patients with prenatally diagnosed SCT from 1986 to 2011 was performed. Patients with outcome data and ultrasound exams before 32 weeks gestational age (GA) were included (n=37). Tumor volume-to-fetal weight ratio (TFR) and tumor morphology were assessed as sonographic predictors of poor prognosis.Twelve patients (32%) had good prognosis, and twenty-five patients (68%) had poor prognosis. All patients with poor prognosis had a morphology score ≥ 3, which is a significant predictor of poor prognosis (p0.0001). TFR was assessed, and a receiver operating characteristic (ROC) analysis identified a cutoff value of 0.12 before 24 weeks GA and 0.11 before 32 weeks GA as predictors for poor prognosis. TFR is a significant predictor of poor prognosis (p0.0001).Patients with cystic SCT all had good prognosis. TFR0.12 was validated as a sonographic predictor of poor prognosis. TFR and tumor morphology can be used to counsel expectant families with prenatally diagnosed SCT regarding prognosis.

Umbilical venous anatomy variation is considered extremely rare. The intrahepatic persistent right umbilical vein represents one version in the spectrum of umbilical vein variations. Prior reports of a prenatally diagnosed persistent right umbilical vein suggest it is strongly associated with severe fetal anomalies including congenital heart disease and gastrointestinal malformations. Our experience contrasts with these findings. Nine cases of intrahepatic persistent right umbilical vein were identified via prenatal sonography between July 1992 and January 1994. The gestational ages of the fetuses ranged from 20 to 36 weeks. Targeted fetal surveys were performed in all nine fetuses and formal fetal echocardiograms were obtained in six. All nine infants have been delivered. In nine cases, the intrahepatic persistent right umbilical vein was an isolated observation with no abnormalities identified pre- or postnatally except one case of hypospadias. Formal fetal echocardiography was normal in all six of the fetuses studied. Given previous reports describing a high risk of congenital malformations in association with the presence of a persistent right umbilical vein, the sonographic finding of this anomaly should still prompt targeted fetal sonography and fetal echocardiography. However, our series indicates that this vascular variant may occur as an isolated abnormality and may not necessarily represent the ominous finding suggested previously.

To determine whether sonograms of the liver and spleen, obtained with 5-MHz linear-array transducers, aid in detection of hepatosplenic microabscesses in patients with acquired immunodeficiency syndrome (AIDS).Abdominal sonographic examinations (n = 111) were performed in 102 consecutive patients with AIDS. A 3.5-MHz sector transducer was used in each study, with additional images of the hepatic and splenic parenchyma obtained with a 5-MHz linear-array transducer. Each study was reviewed without benefit of the 5-MHz images, and categories of the hepatic and splenic parenchyma were as follows: 1, lesions definitely present; 2, lesions possibly present; and 3, lesions absent. The 5-MHz images were subsequently reviewed, and studies were recategorized. Findings were correlated with results of pathologic examination.The 5-MHz scans enabled identification of focal hepatic or splenic lesions in 14 of 96 studies placed in category 2 or 3 on the basis of the 3.5-MHz sector scans.In patients with AIDS, 5-MHz sonograms of the liver and spleen enable detection of microabscesses not confidently identified on 3.5-MHz scans.