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OBJECTIVE: To review the role of sacro-iliac magnetic resonance imaging (MRI) in the diagnosis of axial spondyloarthritis (AxSpA), with a focus on gender differences. METHODS: The experience of the authors and the results of an informal literature review are reported. RESULTS: Inflammatory changes of the sacro-iliac joint are the hallmark of AxSpA. Early, non-radiographic sacroiliitis may be diagnosed with MRI through the assessment of bone marrow edema (BMO) as well as concomitant structural damage. The MRI protocol should include three necessary sequences, i.e., fat-saturated T2-weighted sequences on two orthogonal planes, T1-weighted semi-coronal sequence, and fat-suppressed T1-weighted semi-coronal sequence. Inflammatory changes comprise required signs (BMO and/or osteitis) and additional signs, including synovitis (better defined as joint space enhancement), enthesitis, and capsulitis. Structural changes consist of erosions, sclerosis, fat metaplasia, and ankylosis. Due to mechanical axial strain, inflammatory changes in the sacro-iliac joint can be found in healthy individuals, runners, and patients with nonspecific low back pain. The prevalence of BMO is higher in women during pregnancy and postpartum, even 12 months after childbirth, but the extent and distribution of MRI findings may help in the differential diagnosis. Other challenges in the MRI diagnosis of sacroiliitis are subchondral T2 hyperintensity during developmental age, periarticular sclerosis in healthy subjects, or osteitis condensans ilii, and several pathological conditions that may mimic AxSpA, some of which are more frequently found in women. CONCLUSIONS: The described diagnostic challenges impose a multidisciplinary approach combining imaging findings with clinical and laboratory data.

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OBJECTIVE: Female urethral diverticulum (UD), an evagination of the urethral mucosa into the surrounding connective tissue, is extremely rare in pregnancy. No clear guidelines on the optimal management of UD have been established, except for a common conservative approach. Here, we discuss how to manage UD with pregnancy. CASE REPORT: A 39-year-old gravida 4, para 0, abortion 3 (G4P0A3) woman at 34+0 gestational weeks (GW) visited our outpatient department with a 6-cm septate vaginal mass. Transvaginal ultrasound sonography (TVUS) revealed a 5.5 x 4.9-cm multicystic mass, which was confirmed as UD with pelvic MRI. She was admitted because of preterm labor. A cesarean section was performed at 36+5 GW due to a previous myomectomy, and a healthy male baby was born. UD was still observed in the patient two months after delivery. Periurethral diverticulectomy was performed, and pathological analysis revealed UD with chronic inflammation and edema. CONCLUSION: Previous reports and our case report show that UD can develop during pregnancy and that pelvic MRI is suitable for its accurate diagnosis. Vaginal delivery is possible in pregnant women with the small size of the UD. UD aspiration can permit vaginal delivery in a few cases; however, pus can occur at the aspirated site after the operation. If UD is still observed after delivery, urethral diverticulectomy is recommended.

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Foot and ankle disorders are common during pregnancy, driven by significant physiological changes including weight distribution, hormonal fluctuations, and fluid balance. These changes often result in conditions such as varicose veins, thrombophlebitis, deep vein thrombosis (DVT), edema, overpronation, ankle sprains, metatarsalgia, stress fractures, ligament tears, synovitis, tendon tears, tenosynovitis, paratenonitis, plantar fasciitis, and Morton's neuroma. This paper emphasizes the diagnostic utility of ultrasound for these conditions, given its safety, non-invasiveness, and real-time imaging capabilities without ionizing radiation. Ultrasound is particularly effective for diagnosing venous disorders like varicose veins and thrombophlebitis, leveraging Doppler ultrasound to assess vein structure and function. It is also instrumental in identifying DVT, detecting vein dilation, reflux, and thrombosis. For conditions such as edema, ultrasound helps differentiate physiological from pathological causes, ensuring accurate diagnosis and management. In cases of musculoskeletal issues like overpronation, ankle sprains, ligament tears, and tendon pathologies, ultrasound provides detailed images of soft tissues, allowing for precise diagnosis and effective treatment planning. It is equally useful for detecting metatarsalgia, plantar fasciitis, and Morton's neuroma, offering insights into soft tissue abnormalities and guiding therapeutic interventions. Ultrasound's role extends to diagnosing foreign bodies in the foot and ankle, where it demonstrates high sensitivity and specificity. The accessibility and cost-effectiveness of ultrasound make it an invaluable tool in various healthcare settings, ensuring timely and accurate diagnosis and management of foot and ankle disorders during pregnancy, ultimately enhancing patient outcomes and quality of life.

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Pregnant women with severe osteogenesis imperfecta (OI) are uncommon, and there are limited data regarding anaesthesia for caesarean section in these high-risk individuals. The presence of anatomical and physiological abnormalities can pose technical challenges for the anaesthetist. This report describes the successful implementation of epidural anaesthesia in a parturient with severe OI. To our knowledge, this is the first documented use of ultrasound-assisted neuraxial anaesthesia and wrist blood pressure monitoring in such patients undergoing caesarean section. Understanding the pathophysiological changes associated with OI is crucial for ensuring safe administration of anaesthesia to these women.

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OBJECTIVES: Investigate effects of integrated training for pelvic floor muscles (PFM) with and without transabdominal ultrasonography (TAUS) imaging-guided biofeedback in postpartum women with pregnancy-related pelvic girdle pain (PPGP). DESIGN: Three-arm, single-blinded randomized controlled trial SETTING: University laboratory PARTICIPANTS: Fifty-three postpartum women with PPGP randomized into stabilization exercise with TAUS-guided biofeedback (BIO+EXE), exercise (EXE), and control (CON) groups. INTERVENTIONS: The BIO+EXE and EXE groups underwent an 8-week exercise program, with the BIO+EXE group receiving additional TAUS-guided biofeedback for PFM training during the first 4 weeks. The CON group only received a pelvic educational session. MAIN OUTCOME MEASURES: Primary outcomes included self-reported pain (numeric rating scale) and disability (pelvic girdle questionnaire). Secondary outcomes included functional tests (active straight leg raising [ASLR] fatigue, timed up-and-go, and 6-meter walking tests) and muscle contractibility indicated by muscle thickness changes for abdominal muscles and bladder base displacement for PFM (ultrasonographic measures). RESULTS: The BIO+EXE group had lower pain [1.8 (1.5) vs. 4.4 (1.5), mean difference -2.6, 95% confidence interval (CI) -3.9 to -1.2] and disability [14% (10) vs. 28% (21), mean difference -14, 95% CI -25 to -2] and faster walking speed [3.1 seconds (1) vs. 3.3 seconds (1), mean difference -0.2, 95% CI -1.0 to -0.2] than the CON group. The EXE group only had lower pain intensity compared to the CON group [2.7 (2.0) vs. 4.4 (1.5), mean difference -1.7, 95% CI -3.1 to -0.4]. No significant differences were observed among groups in timed up-and-go, ASLR fatigue, or muscle contractibility. CONCLUSIONS: Integrated training for PFM and stabilization with TAUS-guided biofeedback seems to be beneficial for reducing pain and disability in postpartum women with PPGP. CONTRIBUTION OF THE PAPER.

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OBJECTIVE: To evaluate the performance of maternal factors, biophysical and biochemical markers at 11-13 + 6 weeks' gestation in the prediction of gestational diabetes mellitus with or without large for gestational age (GDM ± LGA) fetus and great obstetrical syndromes (GOS) among singleton pregnancy following in-vitro fertilisation (IVF)/embryo transfer (ET). MATERIALS AND METHODS: A prospective cohort study was conducted between December 2017 and January 2020 including patients who underwent IVF/ET. Maternal mean arterial pressure (MAP), ultrasound markers including placental volume, vascularisation index (VI), flow index (FI) and vascularisation flow index (VFI), mean uterine artery pulsatility index (mUtPI) and biochemical markers including placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured at 11-13 + 6 weeks' gestation. Logistic regression analysis was performed to determine the significant predictors of complications. RESULTS: Among 123 included pregnancies, 38 (30.9%) had GDM ± LGA fetus and 28 (22.8%) had GOS. The median maternal height and body mass index were significantly higher in women with GDM ± LGA fetus. Multivariate logistic regression analysis demonstrated that in the prediction of GDM ± LGA fetus and GOS, there were significant independent contributions from FI MoM (area under curve (AUROC) of 0.610, 95% CI 0.492-0.727; p = 0.062) and MAP MoM (AUROC of 0.645, 95% CI 0.510-0.779; p = 0.026), respectively. CONCLUSION: FI and MAP are independent predictors for GDM ± LGA fetus and GOS, respectively. However, they have low predictive value. There is a need to identify more specific novel biomarkers in differentiating IVF/ET pregnancies that are at a higher risk of developing complications.

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OBJECTIVES: To compare fetal pulmonary artery Doppler parameters between pregnant women with asthma and healthy pregnant women. METHODS: This prospective, cross-sectional study was conducted on 50 pregnant women diagnosed with asthma and 61 healthy pregnant women. Fetal pulmonary artery Doppler parameters and the fetal main pulmonary artery acceleration time/ejection time (PATET) ratio were compared between the study and control groups. Thereafter, the study group was divided into two subgroups as non-severe and severe asthma. PATET ratio was compared between the subgroups. RESULTS: The fetal main pulmonary artery acceleration time was 25 ms in pregnant women with asthma and 33 ms in the healthy group, indicating a statistically significant difference (p=0.001). The acceleration time/ejection time ratio was statistically lower in the asthma group (0.185 vs. 0.240, p<0.001). The acceleration time/ejection time ratio was 0.172 in patients with severe asthma and 0.195 ms in the non-severe study group (p=0.156). In the maternal asthma group, the PATET ratio of those who went to the NICU due to respiratory distress was also 0.188, and the PATET ratio of those who went to the NICU for other reasons was 0.269 (p=0.053). CONCLUSIONS: Fetal pulmonary artery acceleration time and PATET decreased statistically in pregnant women with severe or non-severe asthma. Maternal asthma is associated with changes in pulmonary Doppler parameters in the fetus.

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Obesity rates are increasing world-wide with most of the increase in women of the reproductive age group. While recognised as an important contributor to non-communicable diseases, pregnant women with obesity are particularly at risk of not only maternal and pregnant complications but also have an increased risk of congenital malformations. Furthermore, pregnant obese women are more likely to be older and therefore at a greater risk of aneuploidy. Prenatal diagnosis in these women especially those who are morbidly obese is challenging due not only to their weight but the implications of the increase adiposity on biochemical markers of aneuploidy. In this review we discuss the current challenges in providing prenatal diagnosis for these women including those related to the ergonomics of ultrasound and those inherent in them because of their obesity. Appropriate counselling for these women should include the lower sensitivity of the tests, the difficulties in performing some of the procedures (imaging and invasive testing) as well as the increased risk of structural abnormalities related to their obesity.

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OBJECTIVES: Women with chronic rheumatic disease (CRD) are at greater risk of foetal growth restriction than their healthy peers. T2*-weighted magnetic resonance imaging of placenta (T2*P-MRI) is superior to conventional ultrasonography in predicting birth weight and works as a proxy metabolic mirror of the placental function. We aimed to compare T2*P-MRI in pregnant women with CRD and healthy controls. In addition, we aimed to investigate the correlation between T2*P-MRI and birth weight. METHODS: Using a General Electric (GE) 1.5 Tesla, we consecutively performed T2*-weighted placental MRI in 10 women with CRD and 18 healthy controls at gestational week (GW)24 and GW32. We prospectively collected clinical parameters during pregnancy including birth outcome and placental weight. RESULTS: Women with CRD had significantly lower T2*P-MRI values at GW24 than healthy controls (median T2*(IQR) 92.1 ms (81.6; 122.4) versus 118.6 ms (105.1; 129.1), p = 0.03). T2*P-MRI values at GW24 showed a significant correlation with birth weight, as the T2*P-MRI value was reduced in all four pregnancies complicated by SGA at birth. Three out of four pregnancies complicated by SGA at birth remained undetected by routine antenatal ultrasound. CONCLUSION: This study demonstrates reduced T2*P-MRI values and a high proportion of SGA at birth in CRD pregnancies compared to controls, suggesting an increased risk of placental dysfunction in CRD pregnancies. T2*P-MRI may have the potential to focus clinical vigilance by identifying pregnancies at risk of SGA as early as GW24. Key Points • Placenta-related causes of foetal growth restriction in women with rheumatic disease remain to be investigated. • T2*P-MRI values at gestational week 24 predicted foetuses small for gestational age at birth. • T2*P-MRI may indicate pregnant women with chronic rheumatic disease (CRD) in need of treatment optimization.

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OBJECTIVES: A recent randomized controlled trial of first-trimester anatomy ultrasound in obese women found some advantages to using this technique in this population, but some aspects of feasibility were not clear, such as whether first-trimester ultrasound can be brought outside of a research setting. The learning curve for first-trimester anatomy has been described in the general population, but a learning curve has not been described for this technique in obese patients. This study sought to describe a learning curve for first-trimester anatomy ultrasounds in obese patients with an operator familiar with the basics of first-trimester imaging. DESIGN: This was a secondary analysis of the EASE-O pilot randomized controlled trial (NCT04639973), which recruited 128 women with a BMI ≥35 kg/m2 and randomized them into two groups based on the timing of the first evaluation of fetal anatomy, to compare the completion rate of first- and second-trimester anatomy ultrasound. PARTICIPANTS: Pregnant women with a BMI ≥35 kg/m2 participated in the study. SETTING: Between January 2021 and February 2022, the study was conducted at maternal-fetal medicine clinics in Houston, TX, USA. METHODS: This secondary analysis evaluated data on the completion rate of first-trimester scans from the parent trial. Scans were grouped into bin sizes of 3, and prop_model for R version 4.2.0 for Windows was used to generate a learning curve across the first 60 scans. RESULTS: The parent study included 60 scans performed by one imager who had previously only done first-trimester scans in lean patients for limited anatomy. The probability of a complete scan increased over 60 scans from 0.38 to 0.69; 29 scans were required to reach the final probability, after which only marginal improvement followed. LIMITATIONS: The major limitation is the inclusion of only one operator for this curve. CONCLUSIONS: For an ultrasound operator with basic familiarity in first-trimester imaging, approximately 30 scans are needed to acquire a completion rate of 70% for detailed first-trimester anatomy in women with BMI ≥35 kg/m2. This can be used in education and training programs focused on imaging in the first trimester.

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OBJECTIVES: To synthesize the current evidence of maternal point-of-care ultrasound (POCUS) in obstetrics. A scoping review was conducted using PubMed, Clinicaltrials.gov, and the Cochrane library from inception through October 2023. METHODS: Studies were eligible for inclusion if they described the use of POCUS among obstetric or postpartum patients. Two authors independently screened all abstracts. Quantitative, qualitative, and mixed-methods studies were eligible for inclusion. Case reports of single cases, review articles, and expert opinion articles were excluded. Studies describing detailed maternal nonobstetric sonograms or maternal first trimester sonograms to confirm viability and rule out ectopic pregnancy were also excluded. Data were tabulated using Microsoft Excel and summarized using a narrative review and descriptive statistics. RESULTS: A total of 689 publications were identified through the search strategy and 12 studies met the inclusion criteria. Nine studies evaluated the use of lung POCUS in obstetrics in different clinical scenarios. Lung ultrasound (LUS) findings in preeclampsia showed an excellent ability to detect pulmonary edema (area under the receiver operating characteristic 0.961) and findings were correlated with clinical evidence of respiratory distress (21 of 57 [37%] versus 14 of 109 [13%]; P = .001). Three studies evaluated abdominal POCUS, two of the inferior vena cava (IVC) to predict postspinal anesthesia hypotension (PSAH) and fluid receptivity and one to assess the rate of ascites in patients with preeclampsia. Patients with PSAH had higher IVC collapsibility (area under the curve = 0.950, P < .001) and, in patients with severe preeclampsia, there is a high rate of ascites (52%) associated with increased risk of adverse outcomes. There were no studies on the use of subjective cardiac POCUS. CONCLUSION: POCUS use in the management of high-risk obstetrics has increased. LUS has been the most studied modality and appears to have a potential role in the setting of preeclampsia complicated by pulmonary edema. Cardiac and abdominal POCUS have not been well studied. Trials are needed to evaluate its clinical applicability, reliability, and technique standardization before widespread use.

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OBJECTIVES: We aimed to evaluate feto-maternal blood flow parameters using Doppler ultrasonography (USG) in pregnant women with intrahepatic cholestasis of pregnancy (ICP) and the effect of ursodeoxycholic acid (UDCA) treatment on these parameters. MATERIAL AND METHODS: This prospective cohort study was performed at Dr. Sami Ulus Women's and Children's Health Teaching and Research Hospital, in Turkey between September 2022 and February 2023. Sixty pregnant women, 30 with ICP disease and 30 healthy women were included in the study. Obstetric Doppler parameters were measured by USG at diagnosis and after 48 hours of UDCA treatment for the ICP group. RESULTS: The obstetric Doppler parameters did not significantly differ in the ICP group and the healthy control group. The Doppler findings were similar after UDCA treatment in the ICP group. Gestational week at delivery and birth weight were lower in the ICP group in our study. CONCLUSIONS: We demonstrated that pregnant women with ICP had similar obstetric Doppler parameters when compared with healthy pregnant women and that the UDCA agent used for treatment of ICP disease did not affect these parameters.

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This study's aim is to describe the imaging findings in pregnant patients undergoing emergent MRI for suspected acute appendicitis, and the various alternative diagnoses seen on those MRI scans. This is a single center retrospective analysis in which we assessed the imaging, clinical and pathological data for all consecutive pregnant patients who underwent emergent MRI for suspected acute appendicitis between April 2013 and June 2021. Out of 167 patients, 35 patients (20.9%) were diagnosed with acute appendicitis on MRI. Thirty patients (18%) were diagnosed with an alternative diagnosis on MRI: 17/30 (56.7%) patients had a gynecological source of abdominal pain (e.g. ectopic pregnancy, red degeneration of a leiomyoma); 8 patients (26.7%) had urological findings such as pyelonephritis; and 6 patients (20%) had gastrointestinal diagnoses (e.g. abdominal wall hernia or inflammatory bowel disease). Our conclusions are that MRI is a good diagnostic tool in the pregnant patient, not only in diagnosing acute appendicitis, but also in providing information on alternative diagnoses to acute abdominal pain. Our findings show the various differential diagnoses on emergent MRI in pregnant patients with suspected acute appendicitis, which may assist clinicians and radiologists is patient assessment and imaging utilization.

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BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is characterized by skin pruritus, elevated liver enzymes, and increased serum total bile acids. Several previous studies have revealed that the fasting and ejection volumes of the gallbladder in cholestasis of pregnancy are greater than those in normal pregnancy. The goal of this study was to explore the gallbladder volume and evaluate the diagnostic and prognostic value of ultrasound in ICP. METHODS: We prospectively recruited a cohort of 60 ICP patients at the First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China from January 2020 to December 2021 and compared their data with those from healthy pregnant women (n = 60). The gallbladder volume was evaluated by real-time ultrasound examination after overnight fasting and at 30, 60, 120, and 180 min after a liquid test meal of 200 mL, and the ejection fraction was calculated. Continuous data between two groups were compared by Student's t test. Differences were considered significant for p < 0.05. The diagnostic and prognostic value of the volume and ejection function of the gallbladder was analyzed by the receiver operating characteristic (ROC) curve. RESULTS: The ICP group had significantly higher gallbladder basal volume (43.49 ± 1.34 cm3 vs. 26.66 ± 0.83 cm3, p < 0.01) and higher ejection fraction compared with the healthy group. The ejection fraction higher than 54.55% at 120 min might predict ICP diagnosis with 96.67% sensitivity and 88.33% specificity, and an AUC of 0.9739 (95% CI 0.9521-0.9956), while the gallbladder volume higher than 12.52 cm3 at 60 min might predict ICP severity with 59.18% sensitivity and 72.73% specificity, and an AUC of 0.7319 (95% CI 0.5787-0.8852). CONCLUSION: Our results indicate abnormal volume and ejection function of the gallbladder in patients with ICP. The ejection fraction at 120 min can assist in the diagnosis if ICP exists, and the gallbladder volume at 60 min may assess the degree of severity of ICP.

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Diagnosis of intrahepatic cholestasis of pregnancy (ICP) is often decided upon with typical pruritus supported by elevated serum bile acid levels. However, there is confusion regarding the absolute reference range for serum bile acid . To confirm the utility of Placental Strain Ratio (PSR) measurement as a marker for the diagnosis of ICP and to reveal the extent to which it is correlated with serum bile acid concentration. A case-control study was conducted. The case group included 29 patients who were admitted to our hospital in the second or third trimester of pregnancy with typical itching and were clinically diagnosed with ICP with >10 mmol/L serum bile acid. The first 45 pregnant women were assigned to a control group. Real-time tissue elastography software was used for ultrasound assessment of all pregnant placentas. Software was used to estimate the SR values. Biochemical liver function parameters, hemograms, serum bile acid levels, and SR values were compared between these groups. PSR was found to predict the development of cholestasis with poor discrimination (area under the curve [AUC] = 0.524; 95% CI = 0.399-0.646). The optimal threshold value with the best sensitivity and specificity rates was calculated to be 0.46 PSR. ICP developed significantly more frequently in the low PSR group than in the high PSR group (60% vs 29.3%, P  = .05, odds ratios [OR] = 0.276, 95% CI = 0.069-1.105). No correlation was found between the PSR and bile acid levels (rho = -0.029, P  = .816). PSR values can support the diagnosis of ICP, predict serum bile acid levels, and can be used as soft markers.

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