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ANSWERS
CASE 66
Small Bowel Obstruction
1. B and C
2. C
3. B
4. C
References
Colombani M, Ferry M, Garel C, et al: Fetal gastrointestinal MRI: all that glit-
ters in T1 is not necessarily colon. Pediatr Radiol 2010; 40(7):1215-1221.
http://www.ncbi.nlm.nih.gov/pubmed/20052463 (Accessed on June 13, 2012.)
Lee JH, Im SA, Lee G: Evolution of sonographic ndings in a fetus with
ileal atresia. J Clin Ultrasound 2011; 39(6):359-362.
http://www.ncbi.nlm.nih.gov/pubmed/21544826 (Accessed on June 13, 2012.)
Wax JR, Hamilton T, Cartin A, et al: Congenital jejunal and ileal atresia: natu-
ral prenatal sonographic history and association with neonatal outcome.
J Ultrasound Med 2006; 25(3):337-342.
http://www.ncbi.nlm.nih.gov/pubmed/16495494 (Accessed on June 13, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 436-439.
Comment
Differential Diagnosis
Early in pregnancy, there may be no small bowel dilation with
small bowel obstruction. Later in pregnancy, multiple dilated
uid-lled tubular structures within the fetal abdomen should
prompt a broad differential diagnosis. Duodenal atresia would
not be considered in these cases because with duodenal atresia
there is a proximal obstruction. Jejunal and ileal or combined
jejunal-ileal atresia would be considered within the differential diagnosis. Differentiating small bowel from large bowel
obstruction is usually possible. In small bowel obstruction,
the loops are located more centrally within the abdomen and
haustra markings are absent. The presence of polyhydramnios in the third trimester is more indicative of small bowel
obstruction than large bowel obstruction. Common abnormalities or etiologies of small bowel obstruction that should
be considered in these cases include malrotation, volvulus,
and meconium ileus. Meconium ileus is obstruction of the
ileum with meconium but without an anatomic cause of the
obstruction. Bilateral hydroureter should be considered in
the differential diagnosis. However, in these cases, there may
be decreased amniotic uid or oligohydramnios. Hydroureter
is associated with hydronephrosis, and there may be dilation
of the bladder.
Ultrasound Findings
Multiple dilated loops of small bowel, usually located in the
midabdomen, are typical features on ultrasound (Figure).
Often these loops of small bowel have increased peristalsis.
There may be polyhydramnios, especially in the third trimester.
Dilated bowel loops and polyhydramnios together are highly
predictive of small bowel obstruction.
Prognosis and Management
Fetuses with proximal obstruction are more likely to be born
prematurely and to be smaller than fetuses with more distal
obstruction. With more proximal obstruction, there is less
absorption of the nutrients within the amniotic uid, leading
to intrauterine growth restriction. An increased amount of
amniotic uid leading to polyhydramnios may cause premature
delivery. Polyhydramnios may be a trigger for early or premature delivery in these cases. Prognosis depends on the site and
extent of bowel involvement and the precise etiology of jejunal or ileal obstruction. If there are concurrent malformations
or complications such as bowel perforation, meconium peritonitis, or volvulus, the prognosis is much worse.
136
CASE 67
A
1
2
2
1
B
History: A patient presents with a large-for-dates pregnancy.
1. What should be included in the differential diagnosis of the
imaging provided? (Choose all that apply.)
A. Ovarian cyst
B. Meconium pseudocyst
C. Renal cyst
D. Duodenal atresia
E. Cystic sacrococcygeal teratoma
2. Ultrasound ndings of meconium peritonitis include all of
the following except:
A. Ascites
B. Meconium pseudocyst
C. Polyhydramnios
D. Liver calcication
C
Used with permission from Anderson Publishing Ltd. from Victoria T,
et al: Fetal MRI of common non-CNS abnormalities: a review. Appl
Radiol 2011; 40[6]:8-17. © Anderson Publishing Ltd.
3. Which set of prenatal ndings would most commonly
require surgical intervention in the postnatal period?
A. Bowel dilation and meconium pseudocyst
B. Calcication plus bowel dilation
C. Calcication plus ascites
D. Calcication plus polyhydramnios
4. Which of the following conditions is usually not associated
with meconium peritonitis?
A. Cystic brosis
B. Bowel atresia
C. Intrauterine infection
D. Enteric duplication cyst
137
ANSWERS
CASE 67
Meconium Pseudocyst
1. A and B
2. D
3. A
4. D
References
Gupta P, Sharma R, Kumar S, et al: Role of MRI in fetal abdominal cystic
masses detected on prenatal sonography. Arch Gynecol Obstet 2010;
281(3):519-526.
http://www.ncbi.nlm.nih.gov/pubmed/19672611 (Accessed on June 13, 2012.)
McGahan JP, Hanson F: Meconium peritonitis with accompanying pseudo-
cyst: prenatal sonographic diagnosis. Radiology 1983; 148(1):125-126.
http://www.ncbi.nlm.nih.gov/pubmed/6344135 (Accessed on June 13, 2012.)
Zangheri G, Andreani M, Ciriello E, et al: Fetal intra-abdominal calcications
from meconium peritonitis: sonographic predictors of postnatal surgery.
Prenat Diagn 2007; 27(10):960-963.
http://www.ncbi.nlm.nih.gov/pubmed/17654754 (Accessed on June 13, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 440, 447.
Comment
Differential Diagnosis
A fairly broad differential diagnosis is associated with the
presence of a large cystic mass within the abdomen of a
fetus. In this case, meconium pseudocyst resulting from
bowel perforation is the most likely etiology. However, in a
female fetus, a large ovarian cyst with hemorrhage may have
a very similar appearance. Sacrococcygeal teratoma usually
arises from the deep pelvis and extends external to the fetus,
but this also could be considered within the differential diagnosis. The pelvic portion usually is not as large as in the case
identied here. Numerous other cysts occur within the abdomen, including mesenteric or enteric duplication cysts and
choledochal cysts.
Ultrasound Findings
Ultrasound ndings of meconium pseudocyst include a
hypoechoic mass with internal echoes representing the
extraluminal meconium and a very echogenic wall around the
meconium (Figures A and B). This wall may eventually calcify. Bowel dilation is often present, which suggests associated
bowel obstruction from jejunal or ileal atresia, volvulus, or
meconium ileus. Fetal MRI shows similar ndings (Figure C).
Prognosis and Management
A fetus with peritoneal calcications only can be expected to
have a very favorable outcome, usually without intervention.
In most cases, fetuses with bowel dilation and a meconium
pseudocyst require surgery more frequently than fetuses with
other combinations of ndings associated with meconium
peritonitis. However, fetuses with multiple ndings of intraabdominal calcication, pseudocyst, ascites, and bowel dilation
nearly always require surgery.
138
CASE 68
A
History: In two patients, screening ultrasound through the
fetal abdomen shows an isolated abnormality.
1. What should be included in the differential diagnosis of
intraabdominal echogenicities in these cases? (Choose all
that apply.)
A. Meconium peritonitis
B. In utero infection
C. Hepatic infarction
D. Vascular calcications
E. Cystic brosis
2. Which of the following intraabdominal tumors in the fetus
or newborn is not associated with calcications?
A. Neuroblastoma
B. Teratoma
C. Wilms tumor
D. Hemangioma
B
3. Which is the least likely organ to have intraabdominal calcications in the fetus or neonate?
A. Liver
B. Spleen
C. Kidney
D. Adrenal gland
4. Which of the following statements concerning intraabdominal calcications is false?
A. Outcome in these fetuses is usually unfavorable.
B. When an intraabdominal calcication is identied,
a comprehensive fetal ultrasound scan should be
performed.
C. Intraabdominal calcications may be due to fetal
gallstones.
D. Calcications secondary to meconium peritonitis with-
out associated bowel obstruction have a good prognosis.
139
ANSWERS
CASE 68
Fetal Liver Calcifications
1. A, B, C, and E
2. C
3. C
4. A
References
Nyberg DA, Neilsen IR: Abdomen and gastrointestinal tract. In Nyberg DA,
McGahan JP, Pretorius DH, et al (eds): Diagnostic Imaging of Fetal Anomalies.
Philadelphia: Lippincott Williams & Wilkins, 2003, pp 547-602.
Scotet V, Duguépéroux I, Audrézet MP, et al: Focus on cystic brosis
and other disorders evidenced in fetuses with sonographic nding of
echogenic bowel: 16-year report from Brittany, France. Am J Obstet Gynecol
2010; 203(6):592.e1-592.e6.
http://www.ncbi.nlm.nih.gov/pubmed?term=20932506 (Accessed on June
13, 2012.)
Zangheri G, Andreani M, Ciriello E, et al: Fetal intra-abdominal calcications
from meconium peritonitis: sonographic predictors of postnatal surgery.
Prenat Diagn 2007; 27(10):960-963.
http://www.ncbi.nlm.nih.gov/pubmed?term=17654754 (Accessed on June
13, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 439-443.
Comment
Differential Diagnosis
The differential diagnosis of fetal abdominal calcications
depends on the precise location of the calcications. Intrahepatic calcications are usually benign and may be due to hepatic
infarcts (Figures A and B). However, abdominal calcications
may be associated with TORCH (toxoplasmosis, other infection, rubella, cytomegalovirus, herpes simplex) infections, in
which case the calcications may be more widespread throughout the abdomen. Calcications in the right upper quadrant may
also be secondary to fetal gallstones. Gallstones are uncommon
and usually resolve postnatally. Calcications in the left upper
quadrant of the abdomen may be secondary to either liver or
splenic calcications. TORCH infections should be included
in the differential diagnosis. Hyperechoic bowel is a subjective
nding, but when seen it is usually dened to be as echogenic as
surrounding bone. Hyperechoic bowel may be associated with
numerous etiologies, including cystic brosis, but it is also a
marker for chromosomal abnormalities. Meconium peritonitis
could be considered within the differential diagnosis because
extraluminal calcication may be seen on the surface of the
liver. If calcications are isolated without bowel obstruction
or ascites, they are usually benign. When a fetus with intraabdominal calcications is examined, careful ultrasound scanning
should be performed because certain tumors, such as neuroblastomas, teratomas, or hemangiomas, may calcify.
Ultrasound Findings
Ultrasound ndings of intraabdominal calcications depend
on the location. In this case, an echogenic focus with some
acoustic shadowing within the liver would be a classic nding
for liver calcication, which is usually benign (Figures A and B).
Calcications on the surface of the liver may be secondary to
meconium peritonitis.
Prognosis and Management
Intraabdominal calcications are usually benign. If they are
isolated to the liver, the outcome is almost uniformly favorable. A complete ultrasound examination should be performed
to exclude other etiologies, such as TORCH infection, in
which the prognosis may be different because intracranial calcications or intrauterine growth restriction may be present.
Careful ultrasound scanning to exclude an associated calcied
intraabdominal mass should be performed. Prognosis depends
on the etiology of the mass.
140
CASE 69
A
History: A patient in her third trimester presents with
abdominal and pelvic pain and vaginal bleeding.
1. Which abnormality is shown in the ultrasound images provided of a third-trimester pregnancy?
A. Subchorionic hemorrhage
B. Placental abruption
C. Placental contraction
D. Chorioangioma of the placenta
2. What is the presentation in most women with this pelvic
abnormality?
A. Pain or bleeding
B. Unusually large weight gain
C. Pedal edema
D. Fever
B
3. What is the incidence of fetal death in this condition?
A. 1%
B. 5% to 10%
C. 20% to 35%
D. 95%
4. Which characteristic of the retroplacental blood makes it
difcult to diagnose with ultrasound?
A. A very small collection
B. A very large collection
C. Elevation of the placenta from the uterine wall
D. Blood appearing isoechoic to the placenta
141
ANSWERS
CASE 69
Placental Abruption
1. B
2. A
3. C
4. D
References
Glantz C, Purnell L: Clinical utility of sonography in the diagnosis and treat-
ment of placental abruption. J Ultrasound Med 2002; 21(8):837-840.
http://www.ncbi.nlm.nih.gov/pubmed/12164566 (Accessed on June 13, 2012.)
Nyberg DA, Cyr DR, Mack LA, et al: Sonographic spectrum of placental
abruption. AJR Am J Roentgenol 1987; 148(1):161-164.
http://www.ncbi.nlm.nih.gov/pubmed/3538831 (Accessed on June 13, 2012.)
Townsend RR, Laing FC, Jeffrey RB Jr: Placental abruption associated with
cocaine abuse. AJR Am J Roentgenol 1988; 150(6):1339-1340.
http://www.ncbi.nlm.nih.gov/pubmed/3285653 (Accessed on June 13, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 494-495.
Comment
Hemorrhage around the Placenta
Hemorrhage around the placenta is classied according to its
location. Many hemorrhages occur in a subchorionic location.
Hemorrhage between the placenta and the uterine wall is called
retroplacental. If the hemorrhage extends from the retroplacental region lateral to the placenta, it is called marginal. Intraplacental hemorrhage may accompany a retroplacental bleed. A
retroplacental hemorrhage that separates the placenta from the
uterine wall prematurely is called an abruption, which can be
partial or complete.
Presentation
A patient with placental abruption often presents with pelvic
or uterine pain and bleeding. Vaginal hemorrhage occurs with
large retroplacental hematomas when the peripheral margins
of the placenta are disrupted and the fetal membranes are
stripped from the decidua basalis. Risk factors for developing
an abruption include maternal hypertension, cigarette smoking, alcohol consumption, cocaine abuse, trauma, and premature rupture of the membranes.
Ultrasound Findings
Ultrasound can show many of these hemorrhages; a hypoechoic
(Figure A) or hyperechoic (depending on the stage) retroplacental collection can be seen elevating the placenta from the
uterine wall. However, if the bleed is entirely isoechoic to the
placenta, it may not be apparent (Figure B). Ultrasound is generally not sensitive enough to detect placental abruption. When
an abruption is diagnosed, assessment of fetal well-being and
follow-up ultrasound imaging are important.
Prognosis
The prognosis for the fetus is related to the volume of hemorrhage and the degree of placental separation. The bleed, even
if extensive, can be decompressed if vaginal bleeding is present. If the hemorrhage remains conned to the retroplacental
region (“concealed”), the outcome can be worse for the fetus
and the mother. A concealed hemorrhage may result in complete placental separation and fetal death and a consumptive
coagulopathy in the mother.
142
CASE 70
A
P = hard palate.
C
D
History: An asymptomatic patient with a second-trimester
pregnancy undergoes imaging.
1. What should be included in the differential diagnosis for
Figures B to D? (Choose all that apply.)
A. Bilateral cleft lip
B. Bilateral cleft lip and palate
C. Midline cleft lip
D. Midline cleft lip and palate
2. What is the predilection, if any, for the predominant side
for a cleft lip?
A. Left
B. Right
C. The midline is equal comparing right with left.
3. Which type of cleft lip and palate has the highest mortality?
A. Bilateral cleft lip and palate
B. Cleft lip alone
C. Midline cleft lip and palate
D. Unilateral cleft lip and palate
4. At what gestational age is ultrasound most reliable for
detecting hard palate anomalies?
A. After 34 weeks
B. Between 28 weeks and 34 weeks
B
C. Before week 8
D. Before 24 weeks
143
ANSWERS
CASE 70
Cleft Lip and Palate
1. A, B, C, and D
2. A
3. C
4. D
References
Babcook CJ, McGahan JP, Chong BW, et al: Evaluation of fetal midface
anatomy related to facial clefts: use of US. Radiology 1996; 201(1):113-118.
http://www.ncbi.nlm.nih.gov/pubmed/8816530 (Accessed on June 13, 2012.)
Kazan-Tannus JF, Levine D, McKenzie C, et al: Real-time magnetic reso-
nance imaging aids prenatal diagnosis of isolated cleft palate. J Ultrasound
Med 2005; 24(11):1533-1540.
http://www.ncbi.nlm.nih.gov/pubmed/16239657 (Accessed on June 13, 2012.)
Mernagh JR, Mohide PT, Lappalainen RE, et al: US assessment of the
fetal head and neck: a state-of-the-art pictorial review. Radiographics 1999;
19(Spec No):S229-S241.
http://www.ncbi.nlm.nih.gov/pubmed/10517457 (Accessed on June 13, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 387, 388, 480.
Comment
Description
Cleft lip, with or without cleft palate, is the most common
facial anomaly (Figures B to D). Cleft lip is associated with
cleft palate in 80% of cases. Isolated cleft lip has a better
prognosis. The incidence of cleft lip is 1 in 1000 births. When
it occurs unilaterally, with or without cleft palate, it is more
commonly seen on the left side. In the setting of bilateral
cleft lip and palate, a premaxillary protrusion may be present;
this was detected in 85% in one series. This soft tissue mass
arising from the upper lip occurs when the maxilla is anteriorly
displaced.
Ultrasound Classification
Nyberg described the following ultrasound classication for
cleft lip and palate:
Type 1: Cleft lip alone
Type 2: Unilateral cleft lip and palate
Type 3: Bilateral cleft lip and palate
Type 4: Midline cleft lip and palate (Figure C)
Type 5: Facial defects associated with amniotic bands or a
limb–body wall complex
Types 4 and 5 are associated with higher mortality. The
poor prognosis of type 4 cleft lip and palate relates to concurrent anomalies or trisomies, particularly trisomy 13. Type 5
clefts have associated defects of the torso, limb, or cranium as
part of the limb–body wall complex.
Ultrasound Imaging
Although an evaluation of the palate is not part of standard
prenatal ultrasound scans, it is important because ultrasound
can reliably show the normal facial structures of the lip and
hard palate in axial and coronal planes and exclude most cases
of cleft lip and palate. The defect of cleft lip and palate is recognized because of the gap in the upper lip seen on coronal
views of the nose and lips (Figures B to D). Detection of hard
palate anomalies is more reliable before 24 weeks of gestation.
Small type 1 and 2 defects may be missed, particularly with a
sagittal view. Soft palate abnormalities, when isolated, may also
escape detection. Fetal MRI is increasingly being used for ne
assessment of complicated ultrasound images.
144
CASE 71
A
B
History: Two ultrasound scans were obtained in a patient in
the early second trimester of pregnancy.
1. What should be included in the differential diagnosis for the
nonvisualized fetal stomach in Figures A and B? (Choose all
that apply.)
A. Esophageal atresia with or without a tracheoesophageal
stula
B. Oligohydramnios from any etiology
C. Cleft lip/palate
D. Normal fetus
E. Diaphragmatic hernia
2. Etiologies of polyhydramnios include all of the following
except:
A. Fetal macrosomia
B. Duodenal atresia
C. Anorectal atresia
D. Anencephaly
C
Used with permission from Anderson Publishing Ltd. from Victoria T,
et al: Fetal MRI of common non-CNS abnormalities: a review. Appl
Radiol 2011;40(6):8-17. © Anderson Publishing Ltd.
3. Which of the following ndings is not associated with
esophageal atresia?
A. There is an association with tracheoesophageal stula in
most cases.
B. Concurrent fetal macrosomia is often associated with
esophageal atresia.
C. There is an association with VACTERL syndrome.
D. A dilated proximal esophagus may be observed in
fetuses with esophageal atresia.
4. Which of the following statements concerning the progno-
sis and management of esophageal atresia is false?
A. The most common anomalies associated with esopha-
geal atresia are other gastrointestinal malformations.
B. The most common chromosomal abnormality associ-
ated with esophageal atresia is Turner syndrome (XO
karyotype).
C. The prognosis may be much worse for esophageal atre-
sia diagnosed prenatally than for cases that are not diag-
nosed before birth.
D. In fetuses that have successful repair of esophageal
atresia, a common complication is repeated pneumonia.
145