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1104 PART IV Obstetric and Fetal Sonographyhe sonographic indings observed in fetuses with trisomy18 vary with gestational age. As expected, anomalies such ascystic hygromas are seen more frequently in the late irst andearly second trimester, whereas cardiac defects and growthrestriction tend to be later indings. In a review of 47 fetuseswith trisomy 18, Nyberg et al. 183 identiied cardiac defectsin 14% before 24 weeks’ gestation and in 78% scanned ater24 weeks. Intrauterine growth restriction (IUGR) was seenin 28% of afected fetuses scanned at less than 24 weeks andin 89% of those evaluated in the third trimester. IUGR, incombination with polyhydramnios, is an ominous observationhighly predictive of trisomy 18. 183,185 In addition tothose mentioned earlier, other indings, such as radial raydefects, rocker-bottom feet, clubfeet, strawberry-shaped skull(lattening of occiput with pointing of frontal bones), andabnormal-appearing cerebellum and cisterna magna, have beenreported. 179-190Choroid Plexus CystsChoroid plexus cysts (CPCs) are discrete echolucencies withinthe choroid plexus that result from the folding of the neuroepithelium,trapping secretory products and desquamated cells 191(Fig. 31.11A). CPCs are seen in 1% to 2% of the normal fetusesand are most common in the second trimester, usually resolvingby 28 weeks’ gestation. 180-182 About 30% of fetuses with trisomy18 have CPCs. 182,183 he majority of fetuses with trisomy 18 alsohave other structural anomalies to suggest aneuploidy. 180-183Cyst number, size, and laterality are not useful in distinguishingafected fetuses from normal fetuses. 192-194 Additionally,resolution of CPCs does not necessarily relect a normalkaryotype. 195he predictive value of isolated CPCs for aneuploidy is lowwhen no other abnormalities are seen. 155,182 herefore ater aCPC is seen, a detailed ultrasound assessment of the fetus shouldbe performed. In the setting of an isolated CPC, correlation witha priori risk of trisomy 18 based on an accepted screening protocolis recommended. 155,196 Cheng et al. 197 reported on the signiicanceof isolated CPCs in a population previously screened with NTand found that the likelihood ratio for trisomy 18 was notincreased in those with normal NT measurements. Noninvasiveprenatal screening with cell-free DNA can be considered. Invasivetesting is not warranted in the setting of an isolatedCPC. 185,193,194,198-202TRISOMY 13 (PATAU SYNDROME)Trisomy 13 is the third most common autosomal trisomy witha prevalence of 1.9 in 10,000 total births. 176 With improvingprenatal diagnosis and associated high termination rates, thelive birth prevalence has decreased to 0.03 in 1000. 177 Individualswith trisomy 13 have numerous structural abnormalities and areseverely intellectually disabled. Anomalies oten seen includeforebrain defects, ocular malformations, facial clets, heart defects,and abnormal extremities. In fetuses that are not terminated,there is a 46% intrauterine fetal death rate and 93% earlyneonatal mortality rate. 203 Rarely, survival is more long term. 204Sonographic detection of fetuses with trisomy 13 is 90% to 100%(Fig. 31.12). 157,158,205-209Trisomy 13: Common Sonographic FindingsHoloprosencephalyMicrocephalyNeural tube defectsFacial clefts, ocular anomaliesCardiac defectsEchogenic intracardiac focusCongenital diaphragmatic herniaOmphaloceleEchogenic kidneysPostaxial polydactylyIntrauterine growth restrictionCardiac and central nervous system defects are the mostfrequently identiied anomalies. he most common centralnervous system malformations identiied in trisomy 13 areholoprosencephaly, ventriculomegaly, microcephaly, andposterior fossa malformations. Alobar holoprosencephaly isoten associated with severe midline facial defects, includinghypotelorism, microphthalmia, anophthalmia, cyclopia, andproboscis. In addition, fetuses with trisomy 13 oten have postaxialpolydactyly, abnormal hand coniguration, echogenic kidneys,atypical calciications, and IUGR. 205-209TRIPLOIDYTriploidy is the result of a complete extra set of chromosomes (69chromosomes) and is not related to maternal age. 210 he extra setof chromosomes may be paternally derived (diandric), usuallyfrom a double fertilization, or maternally derived (digynic) fromfertilization of a diploid egg. 211 he frequency of the parental originhas been widely disparate with diandric cases in 20% to 85%. 212Triploidy occurs in 1% to 3% of conceptions, and most are spontaneouslyaborted. 213,214 he prevalence of triploidy at 11 to 14 weeksis 1 in 6614 and survival of a fetus with triploidy beyond 20 weeks’gestation is unusual. 48,210 Paternal triploid origin is oten associatedwith a large placenta illed with cystic spaces and moderate growthrestriction. Triploidy on the basis of an extra maternal chromosomalcomplement is usually associated with a small placenta and asymmetricIUGR. 211,213 Fetuses with triploidy have a multitude ofstructural malformations, most oten involving the central nervoussystem, heart, and hands 214,215 (Fig. 31.13).Triploidy: Common Sonographic FindingsNeural tube defectsVentriculomegalyPosterior fossa anomaliesMicrognathiaCardiac anomaliesOmphaloceleRenal anomaliesTalipes equinovarus3-4 SyndactylyAsymmetric growth restrictionAbnormal placenta (hydropic changes or small)Oligohydramnios
ABCDFIG. 31.12 Sonographic Findings in Trisomy 13. (A) Alobar holoprosencephaly at 11 weeks. (B) Proboscis (arrow). (C) Postaxial polydactylyon three-dimensional image at 14 weeks. (D) Three-dimensional scan of a third-trimester fetus shows a large, midline facial cleft.ABCD E FFIG. 31.13 Second-Trimester Sonographic Findings in Triploidy. (A) Dandy-Walker malformation (arrow). (B) and (C) Asymmetrical IUGR.Note the discrepancy in size of the head and body. (D) Syndactyly of the ingers (arrow). (E) Scan through the placenta showing multiple lucenciesas well as an omphalocele (arrow). (F) Maternal ovaries with multiple cysts characteristic of theca lutein cysts.
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viiiContributorsOlga R. Brook, MDAs
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xContributorsChristy K. Holland, Ph
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xiiContributorsRupa Radhakrishnan,
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xxiiContentsVOLUME IIPART IV Obstet
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xxivVideo ContentsVideo 12.8 Angiog
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xxviVideo ContentsVideo 26.20 High-
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xxviiiVideo Contents42 Fetal Measur
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2 PART I Physicsphysics. he amplitu
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4 PART I Physics× ms×FIG. 1.4 Ult
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6 PART I Physicsθ 1 = 20°Tissue A
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8 PART I Physicssignature. Broad-ba
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10 PART I PhysicsFIG. 1.13 B-Mode I
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12 PART I PhysicsIn these transduce
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14 PART I PhysicsFIG. 1.17 Tissue H
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16 PART I PhysicsKey Points of Ultr
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18 PART I PhysicsA - Normal liverv
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20 PART I PhysicsFIG. 1.27 Reverber
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22 PART I Physics-0 dBUncorrected-0
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24 PART I Physicsθ = 0°cos θ = 1
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26 PART I PhysicsABFIG. 1.38 Color
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28 PART I PhysicsChanges in Doppler
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30 PART I PhysicsABFIG. 1.44 Wall F
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32 PART I PhysicsABCDFIG. 1.46 Alia
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CHAPTER2Biologic Effects and Safety
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36 PART I PhysicsPressurePulse repe
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38 PART I PhysicsUltrasound imaging
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40 PART I Physicsacoustic power and
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42 PART I PhysicsFIG. 2.6 Acoustic
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44 PART I PhysicsThe AIUM Statement
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46 PART I Physics1. Current ultraso
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48 PART I PhysicsEPIDEMIOLOGYWith a
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50 PART I Physicscontrols whether t
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52 PART I Physics70. Hwang JH, Tu J
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54 PART I PhysicsA B 5 μmFIG. 3.1
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56 PART I Physicsstudies with Levov
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58 PART I Physicsabdominal organs.
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60 PART I PhysicsHarmonic B-Mode Im
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62 PART I PhysicsFIG. 3.9 Contrast-
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64 PART I Physicsdramatic manifesta
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66 PART I Physics5 µmFIG. 3.15 Fra
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68 PART I Physicsplatelet lysis), n
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70 PART I PhysicsEnhancement1 2 3 4
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72 PART I Physics46. Hamilton MF, B
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PART TWO: Abdominal and Pelvic Sono
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76 PART II Abdominal and Pelvic Son
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100 PART II Abdominal and Pelvic So
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ABFIG. 5.20 Microabscesses in Two P
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ABFIG. 6.32 Distal Cholangiocarcino
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CHAPTER7The PancreasThomas Winter a
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CHAPTER8The Gastrointestinal TractS
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ABFIG. 8.16 Lymphadenopathy in Two
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A B CD E FG H IFIG. 8.23 Inlammator
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FIG. 8.56 Gastrointestinal Stromal
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CHAPTER9The Kidney and Urinary Trac
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Remnant ofpronephrosMesonephrosBMes
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CHAPTER11The Adrenal GlandsChristin
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CHAPTER12The RetroperitoneumRaymond
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CHAPTER13Dynamic Ultrasound of Hern
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CHAPTER14The PeritoneumAnthony E. H
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CHAPTER15The UterusDouglas Brown an
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CHAPTER16The AdnexaRochelle Filker
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692 PART III Small Parts, Carotid A
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CHAPTER20The Parathyroid GlandsBonn
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*** *FIG. 21.8 Terminal Ductolobula
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CHAPTER22The ScrotumDaniel Sommers
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CHAPTER23Overview of Musculoskeleta
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CHAPTER25Musculoskeletal Interventi
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ABCDFIG. 25.15 Biceps Tendon Sheath
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CHAPTER27Peripheral VesselsMark E.
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ABFIG. 27.29 Chronic Deep Venous Th
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1000 PART III Small Parts, Carotid
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e2APPENDIXUltrasound Artifacts: A V
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FIG. A.18 Comet-Tail Artifact. On c
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e12APPENDIXUltrasound Artifacts: A
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I-2 IndexAcetabulumdescription of,
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I-4 IndexAnemiafetal, hydrops from,
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I-6 IndexAttenuationcoeicient, 36of
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I-8 IndexBlood low. See also Cerebr
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I-10 IndexBreast(s) (Continued)thic
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I-12 IndexCat-scratch disease, pedi
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I-14 IndexChorion laeve, 1465-1466C
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I-16 IndexContrast agents (Continue
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I-18 IndexCyst(s) (Continued) Cyst(
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I-20 IndexDoppler ultrasound (Conti
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I-22 IndexEndocardial cushion(s), 1
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I-24 IndexFibroma(s) (Continued)par
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I-26 IndexGerminal epithelium, 565G
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I-28 IndexHematoma(s) (Continued)pe
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I-30 IndexHoloprosencephaly (HPE) (
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I-32 IndexImplants, breast (Continu
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I-34 IndexJaundice (Continued)bile
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I-36 IndexLipomyelocele, closed spi
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I-38 IndexMammary ductsnormal sonog
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I-40 IndexMolar pregnancy. See Hyda
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I-42 IndexNonrhizomelic chondrodysp
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I-44 IndexPancreas (Continued)percu
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I-46 IndexPeritoneum (Continued)tum
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I-48 IndexPosterior fossa (Continue
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I-50 IndexPyloric musclehypertrophy
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I-52 IndexSample volume size, Doppl
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I-54 IndexSpectral broadening, in D
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I-56 IndexSuperoanteromedial ridge,
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I-58 Indexhrombosis (Continued)of s
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I-60 IndexTrisomy 18 (Edwards syndr
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I-62 IndexUrinary tract, pediatric
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I-64 IndexWalker-Warburg syndromeco
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DIAGNOSTICULTRASOUND
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DIAGNOSTICULTRASOUND5TH EDITIONCARO
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ABOUT THE EDITORSCarol M. Rumack, M
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ContributorsviiCONTRIBUTORSJacques
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ContributorsixPeter M. Doubilet, MD
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ContributorsxiAna P. Lourenco, MDAs
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ContributorsxiiiWendy hurston, MDAs
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In memory of my parents, Drs. Ruth
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PrefacexviiPREFACEhe ith edition of
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AcknowledgmentsxixACKNOWLEDGMENTSWe
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ContentsxxiCONTENTSVOLUME IPART I P
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Video ContentsxxiiiVIDEO CONTENTS4
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Video Contentsxxv19 The Thyroid Gla
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Video Contentsxxvii33 The Fetal Fac
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Video Contentsxxix52 The Pediatric
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DIAGNOSTICULTRASOUND
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PART FOUR: Obstetric and Fetal Sono
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CHAPTER 28 Overview of Obstetric Im
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ABCDFIG. 28.9 Second-Trimester Biom
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CHAPTER 29 Bioeffects and Safety of
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CHAPTER 30 The First Trimester 1049
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CHAPTER 30 The First Trimester 1051
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Page 1261 and 1262: CHAPTER 31 Chromosomal Abnormalitie
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Page 1287 and 1288: CHAPTER32Multifetal PregnancyMary C
Page 1289 and 1290: CHAPTER 32 Multifetal Pregnancy 111
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Page 1305 and 1306: CHAPTER33The Fetal Face and NeckAna
Page 1307 and 1308: CHAPTER 33 The Fetal Face and Neck
Page 1317 and 1318: ABCDFIG. 33.13 Hypertelorism With E
Page 1319 and 1320: ABCDFIG. 33.16 Dacryocystocele. (A)
Page 1327 and 1328:
ABCDEFFIG. 33.24 Unilateral Complet
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CHAPTER 33 The Fetal Face and Neck
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CHAPTER 34 The Fetal Brain 1167impo
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CHAPTER 34 The Fetal Brain 1169cmAB
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CingulatePOCalcarineAB21 wkCD25 wkI
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CHAPTER 34 The Fetal Brain 1173FIG.
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CHAPTER 34 The Fetal Brain 1175LTAR
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CHAPTER 34 The Fetal Brain 1177CC12
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CHAPTER 34 The Fetal Brain 1179SPEC
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CHAPTER 34 The Fetal Brain 1181ABCD
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CHAPTER 34 The Fetal Brain 1183asym
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CHAPTER 34 The Fetal Brain 1185FIG.
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CHAPTER 34 The Fetal Brain 1187Cere
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CHAPTER 34 The Fetal Brain 1189loba
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CHAPTER 34 The Fetal Brain 1191ABCF
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CHAPTER 34 The Fetal Brain 1193ABCF
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CHAPTER 34 The Fetal Brain 1195spor
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ABCCCDEFFIG. 34.24 Type 2 Lissencep
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CHAPTER 34 The Fetal Brain 1199ABFI
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CHAPTER 34 The Fetal Brain 120120 w
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CHAPTER 34 The Fetal Brain 1203Ultr
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CHAPTER 34 The Fetal Brain 1205ABCD
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VSSABHHPHCDEFFIG. 34.35 Intracrania
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CHAPTER 34 The Fetal Brain 1209VABC
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CHAPTER 34 The Fetal Brain 1211Huma
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CHAPTER 34 The Fetal Brain 1213121.
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CHAPTER 34 The Fetal Brain 1215221.
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CHAPTER 35 The Fetal Spine 1217ABCF
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CHAPTER 35 The Fetal Spine 1219L1S3
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CHAPTER 35 The Fetal Spine 1221FTFT
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CHAPTER 35 The Fetal Spine 1223FIG.
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CHAPTER 35 The Fetal Spine 1225TABL
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CHAPTER 35 The Fetal Spine 1227Feta
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CHAPTER 35 The Fetal Spine 1229MMAB
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ABCDEFFIG. 35.15 Skin-Covered Myelo
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CHAPTER 35 The Fetal Spine 1233diic
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CHAPTER 35 The Fetal Spine 1235CCSC
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CHAPTER 35 The Fetal Spine 1237chon
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CHAPTER 35 The Fetal Spine 1239BSCT
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CHAPTER 35 The Fetal Spine 124162.
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CHAPTER36The Fetal ChestDorothy Bul
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CHAPTER 36 The Fetal Chest 1245seco
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CHAPTER 36 The Fetal Chest 1247TABL
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CHAPTER 36 The Fetal Chest 1249Left
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CHAPTER 36 The Fetal Chest 12511ABC
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CHAPTER 36 The Fetal Chest 1253ABCF
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CHAPTER 36 The Fetal Chest 1255cent
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CHAPTER 36 The Fetal Chest 1257Left
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CHAPTER 36 The Fetal Chest 1259ABCD
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CHAPTER 36 The Fetal Chest 1261RTLT
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CHAPTER 36 The Fetal Chest 1263ARig
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CHAPTER 36 The Fetal Chest 12659. B
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CHAPTER 36 The Fetal Chest 1267107.
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CHAPTER 36 The Fetal Chest 1269204.
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CHAPTER 37 The Fetal Heart 1271TABL
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CHAPTER 37 The Fetal Heart 1273TABL
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CHAPTER 37 The Fetal Heart 1275Plac
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CHAPTER 37 The Fetal Heart 1277ADop
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CHAPTER 37 The Fetal Heart 1279LVRV
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CHAPTER 37 The Fetal Heart 1281RARV
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CHAPTER 37 The Fetal Heart 1283RARV
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CHAPTER 37 The Fetal Heart 1285Norm
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CHAPTER 37 The Fetal Heart 1287RVLV
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CHAPTER 37 The Fetal Heart 1289RVTA
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CHAPTER 37 The Fetal Heart 1291LVRA
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CHAPTER 37 The Fetal Heart 1293Aspl
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CHAPTER 37 The Fetal Heart 1295PLVL
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CHAPTER 37 The Fetal Heart 1297HR-L
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CHAPTER 37 The Fetal Heart 129951.
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CHAPTER 38 The Fetal Gastrointestin
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UrogenitalsinusMesonephrosMesonephr
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CHAPTER 39 The Fetal Urogenital Tra
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CHAPTER 40 The Fetal Musculoskeleta
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CHAPTER 41 Fetal Hydrops 1413ABFIG.
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ABCDFIG. 41.2 Ascites. (A) Fluid ou
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CHAPTER 41 Fetal Hydrops 1417A B CD
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CHAPTER 41 Fetal Hydrops 1423later
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CHAPTER 41 Fetal Hydrops 1427CHABCH
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CHAPTER 41 Fetal Hydrops 1429Monoch
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CHAPTER 41 Fetal Hydrops 1431feedin
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CHAPTER 41 Fetal Hydrops 1433TABLE
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CHAPTER 41 Fetal Hydrops 1435sampli
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CHAPTER 41 Fetal Hydrops 1437Predel
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CHAPTER 41 Fetal Hydrops 143973. Ma
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CHAPTER 41 Fetal Hydrops 1441169. I
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CHAPTER42Fetal Measurements: Normal
Page 1617 and 1618:
CHAPTER 42 Fetal Measurements 1445F
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CHAPTER 42 Fetal Measurements 1447T
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CHAPTER 42 Fetal Measurements 1451p
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CHAPTER 42 Fetal Measurements 1453d
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CHAPTER 42 Fetal Measurements 1455A
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CHAPTER 42 Fetal Measurements 1459A
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CHAPTER 42 Fetal Measurements 14618
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CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
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CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
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CHAPTER 44 Cervical Ultrasound and
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Page 1683 and 1684:
PART FIVE: Pediatric SonographyCHAP
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CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
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CHAPTER 46 Duplex Sonography of the
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CHAPTER47Doppler Sonography of the
Page 1765 and 1766:
CHAPTER 47 Doppler Sonography of th
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CHAPTER 48 The Pediatric Head and N
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CHAPTER 49 The Pediatric Spinal Can
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Page 1865 and 1866:
RA B CDEFGFIG. 49.27 Neuroblastoma
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CHAPTER50The Pediatric ChestChetan
Page 1875 and 1876:
CHAPTER 50 The Pediatric Chest 1703
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CHAPTER 51 The Pediatric Liver and
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Page 1939 and 1940:
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Page 1943 and 1944:
ABCFIG. 51.39 Hepatosplenomegaly. W
Page 1945 and 1946:
Page 1947 and 1948:
CHAPTER52The Pediatric Urinary Trac
Page 1949 and 1950:
CHAPTER 52 The Pediatric Urinary Tr
Page 1951 and 1952:
TABLE 52.4 Mean Total Renal Volumes
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Page 2003 and 2004:
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CHAPTER53The Pediatric Gastrointest
Page 2007 and 2008:
CHAPTER 53 The Pediatric Gastrointe
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CHAPTER 54 Pediatric Pelvic Sonogra
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CHAPTER 55 The Pediatric Hip and Ot
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Page 2107 and 2108:
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ABCDFIG. 55.13 Normal and Dislocate
Page 2111 and 2112:
Page 2113 and 2114:
Page 2115 and 2116:
CHAPTER 56 Pediatric Interventional
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Page 2129 and 2130:
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ABCFIG. 56.15 Access for Drainage o
Page 2133 and 2134:
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APPENDIXUltrasound Artifacts: A Vir
Page 2143 and 2144:
APPENDIX Ultrasound Artifacts: A Vi
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Page 2179 and 2180:
IndexAAA anastomoses. See Arterial/
Page 2181 and 2182:
Index I-3Adnexa (Continued)transvag
Page 2183 and 2184:
Index I-5Arrays, transducer, 11-12A
Page 2185 and 2186:
Index I-7Bioefects (Continued) Biop
Page 2187 and 2188:
Index I-9Brain, neonatal/infant (Co
Page 2189 and 2190:
Index I-11Carcinoma(s) (Continued)
Page 2191 and 2192:
Index I-13Cervix (Continued)for sym
Page 2193 and 2194:
Index I-15Color Doppler ultrasound
Page 2195 and 2196:
Index I-17Cystic artery, 194promine
Page 2197 and 2198:
Index I-19Diabetes mellituschronic
Page 2199 and 2200:
Index I-21Echinococcal disease (Con
Page 2201 and 2202:
Index I-23Exudate ascites, 506-507E
Page 2203 and 2204:
Index I-25Gallbladder (Continued)ad
Page 2205 and 2206:
Index I-27Gyriabnormalities of, in
Page 2207 and 2208:
Index I-29Hernia(s). See also Diaph
Page 2209 and 2210:
Index I-31Hyperechoic tissue, in br
Page 2211 and 2212:
Index I-33Internal jugular vein (IJ
Page 2213 and 2214:
Index I-35Kidneys, pediatric (Conti
Page 2215 and 2216:
Index I-37Liver transplantation (Co
Page 2217 and 2218:
Index I-39Mesentery, small bowel, 5
Page 2219 and 2220:
Index I-41Nasal bone, fetal (Contin
Page 2221 and 2222:
Index I-43Orbits, fetal (Continued)
Page 2223 and 2224:
Index I-45Patau syndrome. See Triso
Page 2225 and 2226:
Index I-47Pleural efusionsfetal, 12
Page 2227 and 2228:
Index I-49Prostate (Continued)thera
Page 2229 and 2230:
Index I-51Renal transplantation (Co
Page 2231 and 2232:
Index I-53Shunt(s) (Continued) Skel
Page 2233 and 2234:
Index I-55Splenic vein (Continued)t
Page 2235 and 2236:
Index I-57Testis(es) (Continued)cys
Page 2237 and 2238:
Index I-59Transcranial Doppler (TCD
Page 2239 and 2240:
Index I-61Umbilical cord, 1481-1487
Page 2241 and 2242:
Index I-63Vein of Galen (Continued)
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