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- PublicationCaesarean Scar Ectopic: sonographic findings and management dilemmasThe last decade has seen an increase in caesarean section (CS) rates in Ireland and internationally with a concommitant rise in the incidence of caesarean scar ectopic. Greater awareness of the common sonographic presentations of caesarean scar ectopic at different gestational ages may improve detection rates and reduce morbidity (Timor-Tritsch et al, 2012). The prevalence of caesarean scar ectopics is thought to be 1 in 2000 pregnancies causing significant morbidity and mortality (Sieczko et al, 2014). Defined as implantation of the pregnancy within the scar, it is thought to occur due to a fistula devoloped between the scar and the endometrium.The potential for uterine rupture causing massive haemorrhage is caused by trophoblastic invasion from the implantation site without the supportive myometrium (Jungkman and Anderson, 2015). Four cases identifed in an Irish tertiary referal centre over 4 years demonstrate the differing presentations of caesarean scar ectopic and the management dilemmas discussed in the setting of Irish legislation in relation to termination of pregnancy.
- PublicationSonographic soft markers in the second trimester: Subtle indicators or significant findings?Advances in ultrasound technology over recent times, mean that the once controversial area of aneuploidy detection is becoming a popular topic for sonographers worldwide. Improved resolutions from high end machines mean that very subtle anatomic variants may have a part to play in the detection of chromosomal abnormalities. When combined with laboratory testing and risk assessment tools, early detection of these soft markers can provide a rationale for the diagnosis and management of fetal chromosomal defects.
- PublicationIs there a role for Placental Volume, Vasculature and Calcification in monitoring Post-term Pregnancies?Objectives: This study aims to assess if three dimensional power Doppler (3DPD) ultrasound of the placenta, evaluating placental volume, vascularisation, and blood flow in post-term pregnancies differs from normal. It also examines whether computer analysis identifies the increased calcification normally present in the placenta after 40 weeks. Methods: This was a prospective cohort study involving 50 women with post-term pregnancies. Gestational age (GA) ranged from 40-41+6 weeks gestation. 3DPD ultrasound was used to evaluate placental volume, vascularisation index (VI), flow index (FI) and vascularisation-flow index (VFI). Following each scan the percentage of calcification was also calculated, by computer analysis. Results were compared with previously determined normal values (36-40 weeks gestation) and correlated with Doppler values and placental histology. Results: Results showed that placental volume, VI, FI and VFI are not influenced by GA when the pregnancy has advanced beyond 40 weeks and that values are similar between post-term pregnancies and normal pregnancies between 36 and 40 weeks. Placental volume was seen to decrease in post-term pregnancies as the mean UtA PI increased (P=0.047). FI was reduced in cases where chorangiosis was found at histology (P=0.033), identifying the increased vessel number associated with these cases. Computer analysis of placental calcification identified the increased calcification expected after 40 weeks, and also showed that calcification continues to increase between 40 and 42 weeks (P=0.029). Conclusion: This study suggests that 3DPD placental assessment may provide additional information, assisting clinicians in decision making in post-term pregnancies.
- PublicationNovel placental ultrasound assessment: Potential role in pre-gestational diabetic pregnancyObjectives: Management of women with pre-gestational diabetes continues to be challenging for clinicians. This study aims to determine if 3D power Doppler (3DPD) analysis of placental volume and flow, and calculation of placental calcification using a novel software method, differ between pregnancies with type 1 or type 2 diabetes and normal controls, and if there is a relationship between these ultrasound placental parameters and clinical measures in diabetics. Methods: This was a prospective cohort study of 50 women with diabetes and 250 controls (12–40 weeks gestation). 3DPD ultrasound was used to evaluate placental volume, vascularisation index (VI), flow index (FI) and vascularisation-flow index (VFI). Placental calcification was calculated by computer analysis. Results in diabetics were compared with control values, and correlated with early pregnancy HbA1c, Doppler results and placental histology. Results: Placental calcification and volume increased with advancing gestation in pre-gestational diabetic placentae. Volume was also found to be significantly higher than in normal placentae. VI and VFI were significantly lower in diabetic pregnancies between 35 and 40 weeks gestation. A strong relationship was seen between a larger placental volume and both increasing umbilical artery pulsatility index and decreasing middle cerebral artery pulsatility index. FI was significantly lower in cases which had a booking HbA1c level ≥6.5%. Ultrasound assessed placental calcification was reduced with a histology finding of delayed villous maturation. No other correlation with placental histology was found. Conclusions: This study shows a potential role for 3D placental evaluation, and computer analysis of calcification, in monitoring pre-gestational diabetic pregnancies.
Scopus© Citations 20 839
- PublicationPoor agreement between operators on grading of the placentaAbnormal placental grading is associated with poor pregnancy outcome. The aim of this study was to measure intra- and interobserver variability in placental grading. Five expert sonographers independently graded 90 images on two occasions, each viewing separated by 1 week. A number of measures were employed to standardise assessment and minimise potential for variation: prior agreement was established between observers on the classifications for placental grading; a controlled viewing laboratory was used for all viewings; ambient lighting was optimal and monitors were calibrated to the GSDF standard. Kappa (κ) analysis was used to measure observer agreement. Substantial variations between individuals' scores were observed. A mean κ-value of 0.34 (range from 0.19 to 0.50) indicated fair interobserver agreement over the two occasions and only nine of the 90 images were graded the same by all five observers. Intraobserver agreement had a moderate mean κ-value of 0.52, with individual comparisons ranging from 0.45 to 0.66. This study demonstrates that, despite standardised viewing conditions, Grannum grading of the placenta is not a reliable technique even among expert observers. The need for new methods to assess placental health is required and work is ongoing to develop 2D and 3D software-based methods.
Scopus© Citations 18 660
- PublicationLooking though the keyhole at MegacystisMegacystis is a sonographic feature of an abnormally large fetal bladder for gestational age. The incidence is estimated globally as 0.38% with predominantly male fetuses affected. Even with treatment options and early diagnosis this condition has a relatively poor prognosis.
- PublicationImaging and assessment of placental functionThe placenta is the vital support organ for the developing fetus. This article reviews current ultrasound (US) methods of assessing placental function. The ability of ultrasound to detect placental pathology is discussed. Doppler technology to investigate the fetal, placental, and maternal circulations in both high-risk and uncomplicated pregnancies is discussed and the current literature on the value of three-dimensional power Doppler studies to assess placental volume and vascularization is also evaluated. The article highlights the need for further research into three-dimensional ultrasound and alternative methods of placental evaluation if progress is to be made in optimizing placental function assessment.
765Scopus© Citations 22
- Publication3D Power Doppler ultrasound and computerised placental assessment in normal pregnancyBackground: In recent years there have been significant developments in the use of 3D Power Doppler (3DPD) imaging and quantitative 3DPD histogram analysis to estimate both placental volume and intra-placental vasculature. This study aims to determine if placental volume, vascularisation and blood flow are correlated with gestational age in normal pregnancy. It also examines whether or not a new software method for analysis of percentage calcification (the ‘placentometer’) correlates well with gestation. Material and method: This was a prospective cohort study of 250 women with normal pregnancies (12 + 6 to 39 + 5 weeks gestation). 3DPD ultrasound was used to evaluate placental volume, vascularisation index (VI), flow index (FI) and vascularisation-flow index (VFI). Placental volume (calculated at 35–40 weeks gestation), was correlated with birth weight. Following each scan the percentage of calcification was also calculated using the placentometer. Results: Placental volume correlated significantly with gestational age: 66.676 + 0.623 × GA (P < 0.001). No significant change with gestation was noted in VI, FI and VFI (VI: P = 0.199, FI: P = 0.299, VFI: P = 0.557). Software analysis of the percentage of calcification, demonstrated the expected increase in calcification as gestation increased: −4.605 + 0.032 × GA (P < 0.001). From 35 to 40 weeks gestation volume was related to birth weight (P < 0.01). Conclusion: This study shows that in normal low-risk pregnancy placental volume increases with gestational age, whereas vascularisation and blood flow are independent of gestation. Placental volume in late pregnancy is related to birth weight. Software analysis of the percentage of calcification demonstrates an increase with advancing gestation.
Scopus© Citations 5 395
- PublicationIs Grannum Grading of the Placenta Reproducible?Current ultrasound assessment of placental calcification relies on Grannum grading. The aim of this study was to assess if this method is reproducible by measuring inter- and intra-observer variation in grading placental images, under strictly controlled viewing conditions. Thirty placental images were acquired and digitally saved. Five experienced sonographers independently graded the images on two separate occasions. In order to eliminate any technological factors which could affect data reliability and consistency all observers reviewed images at the same time. To optimise viewing conditions ambient lighting was maintained between 25-40 lux, with monitors calibrated to the GSDF standard to ensure consistent brightness and contrast. Kappa (κ) analysis of the grades assigned was used to measure inter- and intra-observer reliability. Intra-observer agreement had a moderate mean κ-value of 0.55, with individual comparisons ranging from 0.30 to 0.86. Two images saved from the same patient, during the same scan, were each graded as I, II and III by the same observer. A mean κ-value of 0.30 (range from 0.13 to 0.55) indicated fair inter-observer agreement over the two occasions and only one image was graded consistently the same by all five observers. The study findings confirmed the lack of reproducibility associated with Grannum grading of the placenta despite optimal viewing conditions and highlight the need for new methods of assessing placental health in order to improve neonatal outcomes. Alternative methods for quantifying placental calcification such as a software based technique and 3D ultrasound assessment need to be explored.
Scopus© Citations 2 398
- PublicationReference ranges for fetal volumes in the late first trimester, obtained using 9-degree rotational stepsObjectives: In the course of another study, we calculated fetal volume centile values for each week of gestation from 11 to 14 weeks using nine-degree rotation steps.