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ANSWERS
CASE 47
Subchorionic Hemorrhage
1. A, B, C, and D
2. D
3. D
4. D
References
Bennet GL, Bromley B, Lieberman E, et al: Subchorionic hemorrhage in the
rst-trimester pregnancies: prediction of pregnancy outcome with sonography. Radiology 1996; 200(3):803-806.
http://www.ncbi.nlm.nih.gov/pubmed/8756935 (Accessed on June 11,
2012.)
Dogra V, Paspulati RM, Bhatt S: First trimester bleeding evaluation. Ultra-
sound Q 2005; 21(2):69-85.
http://www.ncbi.nlm.nih.gov/pubmed/15905817 (Accessed on June 11,
2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 349-351, 493-494.
Comment
Differential Diagnosis of Vaginal Bleeding
The differential diagnosis of a pregnant woman who presents
with vaginal bleeding in the rst trimester includes spontaneous abortion (miscarriage), ectopic pregnancy, anembryonic
pregnancy, molar pregnancy, and subchorionic hemorrhage.
Incidence of Subchorionic Hemorrhage
Early in gestation, a hemorrhage is often within the endometrial canal but may be subchorionic. Approximately 20%
of women with rst-trimester bleeding have a subchorionic
hematoma. Later in the pregnancy, if the hemorrhage has not
been decompressed by vaginal bleeding, it is often identied
below the amniochorionic membrane (subchorionic if over
the placenta or submembranous if anywhere else).
Ultrasound Appearance
On ultrasound, a rst-trimester hemorrhage appears as a crescentic or oval uid collection adjacent to the gestational sac in
the endometrial canal (Figures A to C). It is important not to
confuse an unfused amniotic membrane (chorionic- amniotic
separation), a normal nding that may be seen up to 16 weeks’
gestation, with this diagnosis. In the second and third trimesters, a hemorrhage appears as a crescentic or ovoid mass projecting into the amniotic space (Figure D).The echogenicity
varies with the age of the hemorrhage. The bleed is anechoic
acutely, becomes heterogeneous in the subacute stage, and
eventually resumes an anechoic appearance when chronic.
Follow-up studies are imperative to conrm a decrease in size
and progressive liquefaction (becoming anechoic).
Sequela
Studies have shown that the spontaneous abortion rate is
increased in patients when a subchorionic hemorrhage is
identied early in the gestation from a baseline of 2% to 9%.
The outcome depends on the size (volume) of the hemorrhage (Figure A of one patient with rst-trimester pregnancy
compared with Figures B and C of the other rst-trimester
patient), the gestational age of the fetus, the degree of separation of the chorionic sac by the hemotoma (a higher degree
confers a threefold increase in risk of spontaneous abortion),
and the maternal age. The prognosis is worse for larger hemorrhages, fetuses with a gestational age of 8 weeks or less, and
women 35 years old or older.
96
CASE 48
A
C
History: A patient presents for a routine 20-week ultrasound scan.
1. Figures A and B are from the same fetus. What should
be included in the differential diagnosis? (Choose all that
apply.)
A. Varix of the umbilical vein
B. Persistent intrahepatic right portal vein rather than left
portal vein
C. Omphalocele
D. Two-vessel umbilical cord
E. Gastroschisis
2. Which of the following is not associated with a single umbil-
ical artery?
A. Sirenomelia
B. Intrauterine growth restriction
C. Dandy-Walker malformation
D. Renal abnormalities
3. Which of the following statements concerning the umbili-
cal artery is false?
A. There are usually two arteries and one vein.
B. The arteries originate from the fetal internal iliac arter-
ies, and their direction is toward the placenta.
C. There is an even number of right-sided (dextral) and
left-sided (sinistral) twists of the cord in normal cases.
D. The umbilical vein is larger in diameter than the umbili-
B
cal artery.
4. Which of the following is not a more common chromo-
somal abnormality associated with a single umbilical artery?
A. Trisomy 18
B. Trisomy 13
C. Trisomy 21
D. Triploidy karyotype
97
ANSWERS
CASE 48
Single Umbilical Artery (Two-Vessel
Umbilical Cord)
1. D
2. C
3. C
4. C
References
Dagklis T, Degueiredo D, Staboulidou I, et al: Isolated single umbilical
artery and fetal karyotype. Ultrasound Obstet Gynecol 2010; 36(3):291-295.
http://www.ncbi.nlm.nih.gov/pubmed/20549772 (Accessed on June 11,
2012.)
Hua M, Odibo AO, Macones GA, et al: Single umbilical artery and its associ-
ated ndings. Obstet Gynecol 2010; 115(5):930-934.
http://www.ncbi.nlm.nih.gov/pubmed/20410765(Accessed on June 11,
2012.)
Murphy-Kaulbeck L, Dodds L, Joseph KS, et al: Single umbilical artery risk
factors and pregnancy outcomes. Obstet Gynecol 2010; 116(4):843-850.
http://www.ncbi.nlm.nih.gov/pubmed/20859147 (Accessed on June 11,
2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 490-492.
Comment
Differential Diagnosis
Differential diagnosis in this case is simple. Only two vessels,
representing a single umbilical artery and a single umbilical
vein, are identied within the free portion of the umbilical
cord (Figure A). Usually two arteries and a vein are identied.
Similarly, on the image through the fetal abdomen and bladder,
a single umbilical artery is identied that curves around the
fetal bladder from the internal iliac artery into the insertion of
the umbilical cord (Figure B). On the other side of the bladder,
the umbilical artery is absent. This would be the only logical
differential diagnosis in this case.
Ultrasound Findings
Sometimes it may be difcult to identify the three vessels
within the free-oating portion of the umbilical cord because
of maternal body habitus or the presence of oligohydramnios. In these cases, color Doppler or power Doppler may be
helpful to identify the two arteries and the single vein. Probably most helpful is demonstration of absence of the intraabdominal segment of the missing umbilical artery. Usually the
two arteries are noted running alongside the bladder (Figure
C). This view is greatly enhanced by either color Doppler or
power Doppler imaging and may be used for conrmation of
the diagnosis of a two-vessel umbilical cord.
Prognosis and Management
The prognosis and management may depend on associated
abnormalities. Although congenital anomalies may not be present in most cases, the incidence of intrauterine growth restriction
is higher even in fetuses without associated anomalies. In these
cases, continued ultrasound assessment of fetal growth throughout pregnancy is suggested. There also may be increased incidence of abnormalities of the placenta or abnormal insertion of
the umbilical cord, such as velamentous insertion of the umbilical cord; this could potentially result in vasa previa. Scanning the
placenta insertion of the cord may be important in these cases.
A two-vessel cord may be associated with congenital abnormalities, including central nervous system anomalies, cardiac
malformation, gastrointestinal abnormalities, and genitourinary
abnormalities. A comprehensive examination of the fetus should
be performed. In some series with a two-vessel cord, when no in
utero structural abnormalities were detected by ultrasound, postnatal ultrasound showed an abnormality. Chromosomal defects,
most commonly trisomy 18 and trisomy 13 but many other
abnormalities as well, are associated with a two-vessel umbilical
cord. If there are any associated abnormalities of a fetus with
a two-vessel cord, chromosomal analysis should be considered.
98
CASE 49
A
History: A patient undergoes a rst-trimester ultrasound
examination in which real-time and M-mode images are
obtained.
1. The ultrasound features in Figure A and Figure B may
be secondary to which of the following? (Choose all that
apply.)
A. Triploidy karyotype
B. Trisomy 13
C. Turner syndrome (45XO)
D. Trisomy 18
E. Fetal syndromes
2. The M-mode ultrasound scan of a normal second-trimester
pregnancy in Figure C is labeled A to D. Line C best cor-
responds to:
A. The anterior fetal chest
B. The junction between the cardiac atria and the lung
C. The cardiac ventricles
D. Intraventricular septal valves
3. In a rst-trimester fetus, increased nuchal translucency and
abnormal karyotype can be identied in all of the following
except:
A. Down syndrome
B. Complex cardiac disease
C. Trisomy 18
D. Aqueductal stenosis
4. Which of the following is not an ultrasound nding associ-
ated with fetal demise?
A. Spalding sign
B. Normal Doppler signals in the fetus
C. Fetal body wall edema
D. Poor visualization of fetal anatomy
B
A
B
C
C
D
99
ANSWERS
CASE 49
Fetal Demise
1. A, B, C, D, and E
2. D
3. D
4. B
References
Ishii K, Murakoshi T, Hayashi S, et al: Ultrasound predictors of mortality in
monochorionic twins with selective intrauterine growth restriction. Ultra-
sound Obstet Gynecol 2011; 37(1):22-26.
http://www.ncbi.nlm.nih.gov/pubmed/20878679 (Accessed on June 12,
2012.)
Platt LD, Manning FA, Murata Y, et al: Diagnosis of fetal death in utero by
real-time ultrasound. Obstet Gynecol 1980; 55(2):191-193.
http://www.ncbi.nlm.nih.gov/pubmed/7352079 (Accessed on June 12,
2012.)
Skornick-Rapaport A, Maslovitz S, Kupferminc M, et al: Proposed manage-
ment for reduced fetal movements: ve years’ experience in one medical
center. J Matern Fetal Neonatal Med 2011; 24(4):610-613.
http://www.ncbi.nlm.nih.gov/pubmed/20828236 (Accessed on June 12,
2012.)
Comment
Differential Diagnosis
There is really no differential diagnosis for embryonic or fetal
demise. The only differential diagnosis is the potential etiology
of the embryonic or fetal demise and if there is a chromosomal or hereditary basis. This information may predict potentially adverse outcome with future pregnancies. The differential
diagnosis for increased nuchal translucency is broad and can
include central nervous system, cardiac, genitourinary, and gastrointestinal anomalies; fetal anemia; various syndromes; and
chromosomal abnormalities.
Ultrasound Findings
Suspicion for embryonic or fetal demise includes lack of Doppler signals obtained by the health care worker on a routine
visit or lack of fetal motion noted by the mother later in pregnancy. Ultrasound is performed and shows lack of embryonic
or fetal motions and demise (Figure A). Demise is documented
further by real-time clips and M-mode ultrasound documenting no fetal or cardiac activity (Figure A). Color Doppler ultrasound is not recommended in the rst trimester of pregnancy.
However, when there is an extremely strong indication of
embryonic demise, color Doppler may be used to conrm lack
of embryonic cardiac or other fetal activity (Figure B). Color
Doppler ultrasound can also be used in the second or third
trimester to document further lack of fetal cardiac motion.
Other ndings of embryonic or fetal demise include increased
body wall edema, overlapping of the cranial sutures (Spalding
sign), lack of visualization of fetal anatomic structure, and disorganized appearance of embryonic or fetal anatomy.
M-mode ultrasound is useful to document embryonic or
fetal cardiac activity. This imaging is performed as if there is a
line dropped through the embryo or fetus, and the screen is electronically moved from right to left. When any motion occurs,
it is recorded on M-mode ultrasound. The cursors are placed
on the heart strip, which electronically converts the cardiac
motion into embryonic or fetal cardiac heart rate (Figure C).
In the image in Figure C, A refers to the anterior fetal chest, B
refers to the anterior heart border, C shows motion within the
atrioventricular valves, and D refers to the border between the
left atrium and lung.
Prognosis and Management
Management of embryonic or fetal demise depends on the etiology of demise and the potential for any increased recurrent
risks with subsequent pregnancy.
100
CASE 50
A
B
History: A 31-year-old woman presents with pelvic pain
and vaginal bleeding and beta-human chorionic gonadotropin
(HCG) of 4400 mIU/mL. She is 7 weeks pregnant based on
menstrual history.
1. What should be included in the differential diagnosis for a
woman with a positive beta-HCG and the image shown in
Figure A? (Choose all that apply.)
A. Very early intrauterine pregnancy
B. Decidual reaction of an ectopic pregnancy
C. Recent miscarriage
D. Normal intrauterine pregnancy of at least 5 weeks’ ges-
tational age
2. What is the diagnosis for this patient with a positive beta-
hCG based on evaluation of the ultrasound images?
A. Ruptured ectopic pregnancy
B. Cornual ectopic pregnancy
C. Normal intrauterine pregnancy
D. Nonruptured ectopic pregnancy
C
D
3. How early does trophoblastic tissue produce beta-hCG?
A. Day 1
B. Day 8
C. Day 60
D. Day 90
4. What are the ultrasound ndings after methotrexate therapy to treat an ectopic pregnancy?
A. Usual resolution of the mass within 1 week of treatment
B. Usual immediate termination of Doppler ow to the
mass
C. Persistence of the mass for more than 3 months even
after beta-hCG has become zero
D. No changes on ultrasound
101
ANSWERS
CASE 50
Ruptured Ectopic Pregnancy
1. A, B, and C
2. A
3. B
4. C
References
Dogra V, Pasoulati RM, Bhatt S: First trimester bleeding evaluation. Ultra-
sound Q 2005; 21(2):69-85.
http://www.ncbi.nlm.nih.gov/pubmed/15905817 (Accessed on June 12,
2012.)
Frates MC, Doubilet PM, Durfee SM, et al: Sonographic and Doppler char-
acteristics of the corpus luteum: can they predict pregnancy outcome?
J Ultrasound Med 2001; 20(8):821-827.
http://www.ncbi.nlm.nih.gov/pubmed/11503918 (Accessed on June 12,
2012.)
Stein MW, Ricci ZJ, Novak L, et al: Sonographic comparison of the tubal
ring of ectopic pregnancy with the corpus luteum. J Ultrasound Med 2004;
23(1):57-62.
http://www.ncbi.nlm.nih.gov/pubmed/14756354 (Accessed on June 12,
2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 363-364, 367.
(Figures A to D). Ultrasound abnormalities can be seen with a
beta-hCG of 30 to 60 mIU/mL. A “tubal ring,” a 1- to 3-cm
mass with a central hypoechoic area surrounded by concentric
hyperechoic tissue, is present in 70% of all unruptured ectopic
pregnancies. A tubal ring may be detected even if the tube is
ruptured. Intraperitoneal uid is seen in 63% of unruptured
ectopic pregnancies; echogenic uid suggests a hemoperitoneum (Figure B). However, 20% of patients with a ruptured
tube have no uid or only a trace of detectable uid. An extrauterine gestational sac can also be seen. If a corpus luteum cyst
is present, it is contralateral to the site of the ectopic gestation
in one third of cases and on the same side as the ectopic pregnancy in many cases (Figure C). Gray-scale and Doppler ultrasound characteristics of the corpus luteum cyst have shown
no apparent relationship to rst-trimester pregnancy outcome.
The presence of an extraovarian adnexal mass is the most
common ultrasound nding in an ectopic pregnancy. Ultrasound signs to distinguish an ectopic pregnancy from a corpus luteum cyst include decreased wall echogenicity compared
with the endometrium and an anechoic texture, which suggest
a corpus luteum cyst. Most important, the corpus luteum is
intraovarian, and intraovarian ectopic pregnancies are exceedingly rare. If the mass is intraovarian, it is almost always the
corpus luteum.
Comment
Location of Ectopic Pregnancy
An ectopic pregnancy can involve any portion of the fallopian tube. The most common location is the isthmic portion;
interstitial ectopic pregnancies (in the thinnest part of the fallopian tube, adjacent to the uterus) are much less common
but extremely important to detect because of the high risk of
severe hemorrhage if a rupture occurs.
Ultrasound Imaging
Transvaginal ultrasound enables detection of several ndings that correlate with the presence of an ectopic pregnancy
Treatment
Methotrexate is increasingly administered for the treatment of
ectopic pregnancy. At our institution, a tubal ring greater than
or equal to 2.5 cm is a contraindication to methotrexate, and
laparoscopy or laparotomy is required for treatment; similarly,
signs of a ruptured ectopic pregnancy or clinical instability
require surgery. After methotrexate administration, an adnexal
mass may transiently enlarge with increased Doppler ow. It is
not unusual for the mass to persist for more than 3 months,
even after the beta-hCG level has declined to zero.
102
CASE 51
A
B
Used with permission from McGahan JP, et al: Fetal abdomen and pelvis. In McGahan JP, Goldberg BB [eds]: Diagnostic Ultrasound, 2nd ed.
New York: Informa Healthcare USA, 2008; 1278.
C
Used with permission from McGahan JP, et al: Fetal abdomen and pelvis. In McGahan JP, Goldberg BB [eds]: Diagnostic Ultrasound, 2nd ed.
New York: Informa Healthcare USA, 2008; 1278.
D
RV = right ventricle; RA = right atrium, LA = left atrium; LV = left ventricle;
HV = hepatic vein; E = esophagus. Used with permission from Anderson
Publishing Ltd. From Hellinger J, et al. Fetal MRI in the Third Dimension.
Applied Radiology. 2010; 39(7)8-19. © Anderson Publishing Ltd.
History: A pregnant woman in the late second trimester
presents for a routine ultrasound study.
1. What is the diagnosis?
A. Ebstein anomaly
B. Hypoplastic left heart
C. Mitral stenosis
D. Atrioventricular canal
2. Which of the following statements about the tricuspid
valve is true?
A. It is calcied.
B. There is regurgitation through this valve.
C. It has two cusps.
D. It is never stenotic.
3. What maternal drug results in this anomaly?
A. Digitalis
B. Insulin
C. Lithium
D. Salicylates
4. What is the signicance of the fossa ovalis in this diagnosis?
A. A small fossa ovalis has a worse prognosis
B. A large fossa ovalis has a worse prognosis.
C. The fossa ovalis is irrelevant in this diagnosis.
D. It is duplicate in this diagnosis.
103
ANSWERS
CASE 51
Ebstein Anomaly
1. A
2. B
3. C
4. A
References
Pavlova M, Fouron JC, Susan P, et al: Factors affecting the prognosis of
Ebstein’s anomaly during fetal life. Am Heart J 1998; 135(6 Pt 1):
1081-1085.
http://www.ncbi.nlm.nih.gov/pubmed/9630115 (Accessed on June 12,
2012.)
Vettraino IM, Huang R, Comstock CH: The normal offset of the tricuspid
septal leaet in the fetus. J Ultrasound Med 2002; 21(10):1099-1104.
http://www.ncbi.nlm.nih.gov/pubmed/12369664 (Accessed on June 12,
2012.)
Weil SR, Huhta JC: Sonographic differential diagnosis of fetal cardiac abnor-
malities. Semin Ultrasound CT MR 1993; 14(4):298-317.
http://www.ncbi.nlm.nih.gov/pubmed/8217265 (Accessed on June 12,
2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 416-417.
Comment
Description and Prognosis
Ebstein anomaly results from displacement of a dysplastic
tricuspid valve into the right ventricle with the medial leaflet and sometimes the posterior leaet of the tricuspid valve
located closer to the apex of the heart than normal. There is
consequent massive enlargement of the right atrium and atrialized right ventricle. Cardiac failure can result. Maternal lithium
ingestion during pregnancy is a risk factor. The mortality rate
of the neonate in the perinatal period may be 85% and is considerably higher if the neonate presents with cyanosis.
Ultrasound Imaging
Fetal ultrasound shows a severely enlarged heart. The right
atrium or atrialized right ventricle or both are greatly dilated
(Figures A and B). The true residual right ventricle is small.
The tricuspid valve is regurgitant (Figure C), and tricuspid
and pulmonic stenoses may be present. The ductus arteriosus should be examined because ductal ow from the aorta to
the pulmonary artery predicts postnatal ductal dependence for
adequate pulmonary ow as a result of right-to-left shunting
of desaturated blood.
Follow-up
Follow-up examinations are performed to measure the size of
the chambers throughout the gestation period and to evaluate for decompensation revealed by hydrops fetalis. The true
size of the right ventricular cavity is one factor that dictates
the heart’s ability to compensate for increased pulmonary blood
ow postnatally. Left ventricular output affects whether a fetus
with this anomaly will reach term without problems. Because
the fetal cardiac chambers run in parallel (rather than in a series
as the postnatal heart functions) and because communications
exist between the great vessels and cardiac atria, the left ventricle may be able to compensate for right ventricular dysfunction.
MRI has been used to show the cardiac anatomy (Figure D).
104
