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1242 PART IV Obstetric and Fetal Sonography112. Twickler D, Budorick N, Pretorius D, et al. Caudal regression versussirenomelia: sonographic clues. J Ultrasound Med. 1993;12(6):323-330.113. Sepulveda W, Corral E, Sanchez J, et al. Sirenomelia sequence versus renalagenesis: prenatal diferentiation with power Doppler ultrasound. UltrasoundObstet Gynecol. 1998;11(6):445-449.114. Baxi L, Warren W, Collins MH, Timor-Tritsch IE. Early detection of caudalregression syndrome with transvaginal scanning. Obstet Gynecol. 1990;75(3 Pt 2):486-489.115. Stocker JT, Heifetz SA. Sirenomelia. A morphological study of 33 cases andreview of the literature. Perspect Pediatr Pathol. 1987;10:7-50.116. Stevenson RE, Jones KL, Phelan MC, et al. Vascular steal: the pathogeneticmechanism producing sirenomelia and associated defects of the visceraand sot tissues. Pediatrics. 1986;78(3):451-457.117. Bloechle M, Bollmann R, Zienert A, et al. [Fetal teratoma—diagnosis andmanagement]. Zentralbl Gynakol. 1992;114(4):175-180.118. Altman RP, Randolph JG, Lilly JR. Sacrococcygeal teratoma: AmericanAcademy of Pediatrics Surgical Section Survey-1973. J Pediatr Surg.1974;9(3):389-398.119. Sheth S, Nussbaum AR, Sanders RC, et al. Prenatal diagnosis of sacrococcygealteratoma: sonographic-pathologic correlation. Radiology. 1988;169(1):131-136.120. Bond SJ, Harrison MR, Schmidt KG, et al. Death due to high-output cardiacfailure in fetal sacrococcygeal teratoma. J Pediatr Surg. 1990;25(12):1287-1291.121. Langer JC, Harrison MR, Schmidt KG, et al. Fetal hydrops and death fromsacrococcygeal teratoma: rationale for fetal surgery. Am J Obstet Gynecol.1989;160(5 Pt 1):1145-1150.122. Gross SJ, Benzie RJ, Sermer M, et al. Sacrococcygeal teratoma: prenataldiagnosis and management. Am J Obstet Gynecol. 1987;156(2):393-396.123. Teal LN, Angtuaco TL, Jimenez JF, Quirk Jr JG. Fetal teratomas: antenataldiagnosis and clinical management. J Clin Ultrasound. 1988;16(5):329-336.124. Robertson FM, Crombleholme TM, Frantz 3rd ID, et al. Devascularizationand staged resection of giant sacrococcygeal teratoma in the prematureinfant. J Pediatr Surg. 1995;30(2):309-311.
CHAPTER36The Fetal ChestDorothy BulasSUMMARY OF KEY POINTS• Normal fetal lungs appear homogeneously echogenic onultrasound surrounding the heart with a cardiothoracic ratiothat remains constant through the second and thirdtrimesters.• Pulmonary hypoplasia can be primary or secondary andunilateral or bilateral.• Congenital pulmonary airway malformations (CPAMs) are aspectrum of disorders that include bronchopulmonarymalformation, hybrid lesions (CPAM and sequestration),and congenital lobar overinlation/bronchial atresia.• A large fetal lung mass can compress and shift the heartand vena cava, resulting in fetal hydrops.• Congenital pulmonary airway malformation volume ratio(CVR) is the CPAM volume divided by the headcircumference. A CVR of 1.6 or less without a dominantcyst is considered low risk for the development ofhydrops.• Congenital lobar overinlation (CLO) appears echogenic onultrasound and can involve a segment or subsegment oflung. CLO accounts for up to 20% of prenatally diagnosedfetal lung malformations.• Congenital diaphragmatic hernias have a variable outcomedependent on severity of lung hypoplasia, liver herniation,and the presence of additional anomalies.CHAPTER OUTLINEDEVELOPMENT OF STRUCTURES INTHE CHESTPulmonary DevelopmentNormal Sonographic Features of theFetal ChestNormal DiaphragmNormal ThymusPULMONARY HYPOPLASIA,APLASIA, AND AGENESISCONGENITAL PULMONARY AIRWAYMALFORMATION SPECTRUMCongenital Pulmonary AirwayMalformationBronchopulmonary SequestrationCongenital Lobar OverinlationPLEUROPULMONARYBLASTOMACONGENITAL HIGH AIRWAYOBSTRUCTIONBRONCHOGENIC CYSTNEURENTERIC CYSTPLEURAL EFFUSIONPERICARDIAL EFFUSIONPULMONARY LYMPHANGIECTASIACONGENITAL DIAPHRAGMATICHERNIAOther Hernias and EventrationAssociated AnomaliesMorbidity and MortalityIn Utero TherapyCONCLUSIONFamiliarity with the normal development of the fetal chestis critical both for recognizing chest anomalies and forunderstanding the consequences of these anomalies. Accurateprenatal diagnosis of thoracic lesions is important in providingappropriate recommendations for counseling, planning potentialin utero interventions, and determining the optimal mode ofdelivery and postnatal care. Prenatal imaging can identify thoraciclesions and assess their impact on mediastinal structures andpotential development of hydrops. Although chest abnormalitiesmay be associated with lethal pulmonary hypoplasia, fatalchromosomal abnormalities, and lethal structural anomalies,many chest lesions resolve in utero with minimal sequelae. Fetalmagnetic resonance imaging (MRI) can be a useful adjunct incases with unclear sonographic diagnosis or potential need forin utero interventions.DEVELOPMENT OF STRUCTURES INTHE CHESTPulmonary DevelopmentIn the human lung, there are ive distinct stages of development,during which the lung matures and the number of alveoliincreases. 1,2 At birth, the lungs are functional but structurallyimmature; the greatest increase in number of alveoli occurspostnatally. During the irst 3 years of life, the alveoli are formedthrough a septation process that increases the gas exchange surfacearea. It is important to understand that this lung developmentprocess is ongoing, and that space-occupying lesions, or extrinsicabnormalities that do not allow for normal lung growth, canlead to improper lung development.1243
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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 31 Chromosomal Abnormalitie
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ABCDFIG. 31.12 Sonographic Findings
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CHAPTER32Multifetal PregnancyMary C
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CHAPTER 32 Multifetal Pregnancy 111
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ABFIG. 32.5 Sonographic Findings Se
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CHAPTER33The Fetal Face and NeckAna
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CHAPTER 33 The Fetal Face and Neck
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ABCDFIG. 33.13 Hypertelorism With E
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ABCDFIG. 33.16 Dacryocystocele. (A)
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ABCDEFFIG. 33.24 Unilateral Complet
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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
Page 1345 and 1346:
CHAPTER 34 The Fetal Brain 1173FIG.
Page 1347 and 1348:
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
Page 1363 and 1364: CHAPTER 34 The Fetal Brain 1191ABCF
Page 1365 and 1366: CHAPTER 34 The Fetal Brain 1193ABCF
Page 1367 and 1368: CHAPTER 34 The Fetal Brain 1195spor
Page 1369 and 1370: ABCCCDEFFIG. 34.24 Type 2 Lissencep
Page 1371 and 1372: CHAPTER 34 The Fetal Brain 1199ABFI
Page 1373 and 1374: CHAPTER 34 The Fetal Brain 120120 w
Page 1375 and 1376: CHAPTER 34 The Fetal Brain 1203Ultr
Page 1377 and 1378: CHAPTER 34 The Fetal Brain 1205ABCD
Page 1379 and 1380: VSSABHHPHCDEFFIG. 34.35 Intracrania
Page 1381 and 1382: CHAPTER 34 The Fetal Brain 1209VABC
Page 1383 and 1384: CHAPTER 34 The Fetal Brain 1211Huma
Page 1385 and 1386: CHAPTER 34 The Fetal Brain 1213121.
Page 1387 and 1388: CHAPTER 34 The Fetal Brain 1215221.
Page 1389 and 1390: CHAPTER 35 The Fetal Spine 1217ABCF
Page 1391 and 1392: CHAPTER 35 The Fetal Spine 1219L1S3
Page 1393 and 1394: CHAPTER 35 The Fetal Spine 1221FTFT
Page 1395 and 1396: CHAPTER 35 The Fetal Spine 1223FIG.
Page 1397 and 1398: CHAPTER 35 The Fetal Spine 1225TABL
Page 1399 and 1400: CHAPTER 35 The Fetal Spine 1227Feta
Page 1401 and 1402: CHAPTER 35 The Fetal Spine 1229MMAB
Page 1403 and 1404: ABCDEFFIG. 35.15 Skin-Covered Myelo
Page 1405 and 1406: CHAPTER 35 The Fetal Spine 1233diic
Page 1407 and 1408: CHAPTER 35 The Fetal Spine 1235CCSC
Page 1409 and 1410: CHAPTER 35 The Fetal Spine 1237chon
Page 1411 and 1412: CHAPTER 35 The Fetal Spine 1239BSCT
Page 1413: CHAPTER 35 The Fetal Spine 124162.
Page 1417 and 1418: CHAPTER 36 The Fetal Chest 1245seco
Page 1419 and 1420: CHAPTER 36 The Fetal Chest 1247TABL
Page 1421 and 1422: CHAPTER 36 The Fetal Chest 1249Left
Page 1423 and 1424: CHAPTER 36 The Fetal Chest 12511ABC
Page 1425 and 1426: CHAPTER 36 The Fetal Chest 1253ABCF
Page 1427 and 1428: CHAPTER 36 The Fetal Chest 1255cent
Page 1429 and 1430: CHAPTER 36 The Fetal Chest 1257Left
Page 1431 and 1432: CHAPTER 36 The Fetal Chest 1259ABCD
Page 1433 and 1434: CHAPTER 36 The Fetal Chest 1261RTLT
Page 1435 and 1436: CHAPTER 36 The Fetal Chest 1263ARig
Page 1437 and 1438: CHAPTER 36 The Fetal Chest 12659. B
Page 1439 and 1440: CHAPTER 36 The Fetal Chest 1267107.
Page 1441 and 1442: CHAPTER 36 The Fetal Chest 1269204.
Page 1443 and 1444: CHAPTER 37 The Fetal Heart 1271TABL
Page 1445 and 1446: CHAPTER 37 The Fetal Heart 1273TABL
Page 1447 and 1448: CHAPTER 37 The Fetal Heart 1275Plac
Page 1449 and 1450: CHAPTER 37 The Fetal Heart 1277ADop
Page 1451 and 1452: CHAPTER 37 The Fetal Heart 1279LVRV
Page 1453 and 1454: CHAPTER 37 The Fetal Heart 1281RARV
Page 1455 and 1456: CHAPTER 37 The Fetal Heart 1283RARV
Page 1457 and 1458: CHAPTER 37 The Fetal Heart 1285Norm
Page 1459 and 1460: CHAPTER 37 The Fetal Heart 1287RVLV
Page 1461 and 1462: CHAPTER 37 The Fetal Heart 1289RVTA
Page 1463 and 1464: 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
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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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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
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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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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 1943 and 1944:
ABCFIG. 51.39 Hepatosplenomegaly. W
Page 1945 and 1946:
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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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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:
Page 2109 and 2110:
ABCDFIG. 55.13 Normal and Dislocate
Page 2111 and 2112:
Page 2113 and 2114:
Page 2115 and 2116:
CHAPTER 56 Pediatric Interventional
Page 2117 and 2118:
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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 2177 and 2178:
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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