Obstetrical Ultrasound Cases

1
Obstetrical Ultrasound Cases

• Douglas Richards, M.D.
• Maternal Fetal Medicine
• University of Florida

2
Richards Presentations on the Web

• www.obgyn.ufl.edu
• Click on ultrasound then
• Hot Seats Podium 2009 or
• Hot Seats Answers 2009
• You must have Power Point installed on your
  computer to run

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Case 1

• Heart displaced to right of chest (top of
  screen)
• Stomach in posterior left chest
• Left lobe of liver in anterior left chest
• Bowel fills remainder of left chest
• Right lung (behind heart) is small
• Intrahepatic umbilical vein displaced to side of
  hernia

Clinical correlation

• Other common findings include polyhydramnios
  (50 of cases)
• Most infants have severe respiratory
  insufficiency
• Many need ECMO
• Predictors of poor outcome include
• Small lung/ head ratio
• Associated cardiac or other anomalies
• Abnormal karyotype
• Premature delivery

Diagnosis
Left- sided diaphragmatic hernia
4
Case 2 a
Significant findings

• Head lemon shaped (frontal narrowing)
• Mild dilation of lateral ventricles
• Cysterna magna obliterated. This is part of the
  Chiari type II malformation or banana sign
  (arrows)

Clinical correlation

• Intracranial findings usually more obvious than
  defect in spine
• The lemon sign often not seen after about 24
  weeks
• In spite of ventriculomegaly, BPD usually less
  than average. Head enlarges after birth and
  repair of the spine defect- Shunting often needed

Diagnosis
Intracranial findings with spina bifida
5
Case 2(b)
Significant findings

• Transverse of spine shows widening of posterior
  echocenters arrows
• Irregular neural elements between posterior
  echocenters. No skin cover, no MMC sac in this
  case
• Coronal of spine shows hole. Slight widening
  of rows of posterior echocenters

• Spina bifida comprises half of neural tube
  defects
• Ultrasound level of defect roughly correlates
  with neurologic outcome
• Associated with an elevated maternal serum AFP
• Incidence reduced by maternal folic acid
  ingestion before conception and early pregnancy
• Usually delivered by cesarean before labor

Diagnosis
Spine findings with spina bifida
6
Case 3
Significant findings

• Large midline posterior fossa cyst communicates
  with 4th ventricle
• Hypoplastic, widely-separated cerebellar
  hemispheres
• Absent cerebellar vermis
• Dilated lateral ventricles (not shown)

Clinical correlation

• Associated CNS malformations or genetic
  syndromes common
• 35 mortality- depends on associated
  malformations or syndrome
• 1/3 of survivors have IQ 80
• A small cyst under the cerebellum may not be
  pathologic

Diagnosis
Dandy Walker malformation
7
Case 4 (a)
Significant findings

• Severely shortened long bones
• Long bones malformed- may be bowed or have
  telephone receiver shape
• Redundant soft tissues
• Fingers short and sausage shaped

Clinical correlation

• Most common lethal skeletal dysplasia
• Uniformly fatal- respiratory insufficiency
• Macrocrania may make vaginal delivery
  impossible
• Almost all cases sporadic

Diagnosis
Abnormal limbs in thanatophoric dysplasia
8
Case 4 (b)
Significant findings

• Very narrow chest
• Chest/abdomen transition is bell- shaped
• Small lungs

Clinical correlation

• Skeletal dysplasias with small chest usually
  lethal
• Thanatophoric dysplasia
• Short rib- polydactyly syndrome
• Homozygous achondroplasia
• Asphyxiating thoracic dysplasia (Jeune)
• Campomelic dysplasia
• Chondroectodermal dysplasia

Diagnosis
Hypoplastic chest in thanatophoric dysplasia
9
Case 4 (c)
Significant findings
Coronal view of head, showing cloverleaf pattern
Clinical correlation
Diagnosis

• Caused by premature closure of cranial sutures
• Seen in 15 of thanatophoric dysplasia
• Other, sporadic syndromes include Crouzon,
  Pfeiffer, Carpenter, and Apert

Cloverleaf skull in thanatophoric
dysplasia kleeblattschadel
10
Case 5
Significant findings

• Non- communicating cysts of varying sizes
  filling kidney

Clinical correlation

• Sporadic occurrence
• Usually unilateral. If so, good outcome
• Kidney may be very large significant abdominal
  mass, or may be smaller than a normal kidney
• May be segmental, but most often the entire
  kidney is non-functional

Diagnosis
Multicystic dysplastic kidney
11
Case 6
Significant findings

• The fetal membranes have funneled almost all the
  way down the cervix, leaving a very short closed
  portion.

Clinical correlation

• A short cervix in the second trimester predicts
  a high risk of preterm delivery
• Benefit of cerclage controversial
• Cervix is best visualized by transvaginal
  ultrasound

Diagnosis
Membrane funneling in cervix
12
Case 7a (video clip)
Significant findings

• Uterus filled with small cysts (hasnt looked
  like a snowstorm since 1970s!)
• Tissue is quite vascular

Clinical correlation

• Usually presents around 10-14 weeks with
  hyperemesis, size dates, bleeding
• Prompt suction evacuation is indicated
• Follow bHCG levels for one year. If they dont
  fall normally, patient may need chemo for
  gestational trophoblastic neoplasia
• Effective contraception very important
• 46XX - Empty egg fertilized by single sperm
  with reduplication of the haploid karyotype

Diagnosis
Molar pregnancy (hydatidiform mole)
13
Case 7b
Significant findings

• Large ovaries, filled with prominent cysts
• Similar in appearance to multiple cysts seen in
  ovulation induction with gonadotropins

Clinical correlation

• Found in patients with hydatidiform mole
• Results from high levels of gonadotropins- HCG
  in the case of a mole
• Spontaneous resolution once the gestational
  trophoblastic disease has been treated and HCG
  returns to normal

Diagnosis
Theca lutein cysts (with mole)
14
Case 8 (a)
Significant findings

• No intrauterine gestational sac
• No hemoperitoneum in this case

• An intrauterine gestational sac should always
  be seen if the ßHCG is above 1,500 mIU/ml
• Be careful to not confuse a pseudogestational
  sac with a true sac. A true sac has a double
  sac sign- an inner trophoblastic rim surrounded
  by the endometrial lining
• Evaluate for hemoperitoneum when ectopic is
  suspected.
• Blood looks different than peritoneal fluid- it
  contains clumps of clotted blood and the liquid
  component is echogenic.

Diagnosis
Unruptured ectopic pregnancy
15
Case 8 (b)
Significant findings

• Normal right ovary- (O)
• Ectopic pregnancy (E) with a gestational sac,
  yolk sac, and tiny embryo. It is adjacent to,
  but clearly separate from, the right ovary

e
O
Clinical correlation

• If 1,500 and dont see IUP pt needs clinical
  evaluation at that time (Completed abortion vs
  ectopic)
• Can often see gestational sac or obvious
  findings of ectopic at lower levels
• If follow bHCG levels
• Completed abortion falls
• Live IUP doubles in 48 hours
• Ectopic- variable

Diagnosis
Ectopic pregnancy with a live embryo
16
Case 9
Significant findings

• Head enlarged
• Lateral ventricles markedly dilated
• Dangling choroid plexus
• Normal brainstem, cerebellum and posterior fossa
• Blown out 3rd ventricle communicates freely
  with lateral ventricles.

Clinical correlation

• Aqueductal stenosis one of many causes of
  hydrocephalus (others include NTD, DWM,
  holoprosencephaly, CMV infection, v. of Galen,
  etc)
• 10- 50 have IQ in the normal range
• Prognosis not predictable with prenatal
  ultrasound findings
• Head may become enormous
• Deliver by cesarean after 35 weeks gestation
  when pulmonary maturity documented

Diagnosis
Severe hydrocephalus (Aqueductal stenosis)
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Case 10
Significant findings

• Free-floating loops of bowel anterior to fetal
  abdomen
• Not covered by membrane (in contrast to
  omphalocele)
• Defect to right of umbilical cord insertion
• Thickened bowel wall
• Stomach often dilated from relative obstruction
  (not in this case)

Clinical correlation

• Usually no associated anomalies outside GI tract
• IUGR common
• Non-reassuring fetal heart rate patterns common
• 5 mortality
• Stillbirth, bowel infarction, sepsis
• Vaginal delivery OK to try, but cesarean common
• About half require silo rather than primary
  closure

Diagnosis
Gastroschisis
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Case 11
Significant findings

• Umbilical vessel runs through membranes across
  internal cervical os
• Requires vellamentous cord insertion (ie inserts
  into membranes) or succenturiate lobe of placenta

Clinical correlation

• Very high mortality if not recognized prenatally
  (fetal exsanguination when membranes rupture)
• Umbilical vessels subject to compression by
  fetal head
• Look for vasa previa if low-lying placenta or
  loops of cord noted in lower uterus
• Confirm with transvaginal color Doppler

Diagnosis
Vasa previa
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Case 12
Significant findings

• Large echogenic mass involves entire left lung
• Heart displaced to the right
• Diaphragm depressed
• Polyhydramnios

Clinical correlation

• Three types of CCAM
• I- 2-10 cm cysts
• II- cysts
• III- Individual cysts not visible, very small
  cysts give strongly echogenic appearance to
  tissue
• Type III most likely to cause hydrops and
  neonatal compromise

Diagnosis
Congenital cystic adenomatoid malformation (Type
III)
20
Case 13
Significant findings

• First image shows low- resistance flow (good
  forward flow in diastole)
• Second image shows reverse diastolic flow

Clinical correlation

• High umbilical resistance (low or reversed
  diastolic flow) associated with an increased rate
  of IUGR and other problems from placental
  insufficiency
• In an IUGR fetus with absent or reverse
  diastolic flow, delivery is indicated if near
  term. In preterm, careful surveillance to
  prevent intrauterine asphyxia or death

Diagnosis
Abnormal umbilical blood flow pattern (2ond panel)
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Case 14
Significant findings

• Large membrane-covered sac arising from
  abdominal wall defect
• Omphalocele sac filled with fetal liver
• Cord inserts into sac (not shown)

Clinical correlation

• Prognosis depends on associated malformations
• 80 have other anomalies- esp cardiac
• 30 have abnormal karyotype
• Size of defect often appears larger in second
  trimester than at term
• Delivery by cesarean section if liver in
  omphalocele sac

Diagnosis
Omphalocele
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Case 15 (video clip)
Significant findings

• No membrane separating twins
• Neither twin stuck to uterine wall
• Not conjoined
• Cords intertwined (not shown)

Clinical correlation

• Only 2 of monozygotic twins are monoamniotic
• Division occurs 8-14 days after ovulation
• Cords knotted together in almost all cases
• Very high mortality, therefore careful
  monitoring in third trimester
• If no membrane seen- look for diamniotic with
  twin-to- twin transfusion. Membrane is closely
  applied to stuck twin

Diagnosis
Monoamniotic twins
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Case 16
Significant findings

• Significantly dilated ureter (ur)
• Kidney (K) is hydronephotic with dilated renal
  pelvis and calyces
• Bladder is not enlarged

k
ur
Clinical correlation

• Dilated upper urinary tract with normal bladder
  most commonly due to reflux
• Vesicouretero junction obstruction is possible,
  but less common. Often has ureterocele
• Hydronephrosis usually doesnt affect pregnancy
  management- pre term delivery or fetal surgery
  not considered
• Usually good outcome if prompt postnatal care

Diagnosis
Vesicoureteral reflux
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Case 17
Significant findings

• Polyhydramnios (not shown here)
• Dilated stomach and proximal duodenum (double
  bubble)

Clinical correlation

• 30 of fetuses with duodenal atresia have Down
  syndrome
• Relatively few Down syndrome fetuses have
  duodenal atresia
• Often causes severe polyhydramnios
• Surgical repair usually uncomplicated

Diagnosis
Duodenal atresia
25
Case 18
Significant findings

• Thick, anechoic layer between soft tissue of
  neck and skin

12 week fetus
Clinical correlation

• Standardized measurement used in conjunction
  with maternal serum (high B-HCG, low pregnancy
  associated plasma protein-A) as first trimester
  aneuploidy screen
• This screening detects about 85 of trisomy 21,
  most trisomy 18 and 13 with 5 screen positive
  rate
• Nasal bone present in this fetus. Absent nasal
  bone is a marker for TS 21.

Diagnosis
Thick nuchal translucency
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Case 19

• Calvarium not seen
• BPD cannot be measured
• Head ends above level of the eyes
• Eyes appear prominent- frog eyes
• May have angiomatous stroma above the base of
  the skull that degenerates in the second
  trimester leaving the typical anencephaly
  appearance

Clinical correlation

• Comprises about half of neural tube defects
• Multifactorial causation
• Family history
• Folate deficiency
• Valproic acid, Tegretal
• Polyhydramnios frequent (abnormal swallowing)
• Failure to go into labor (absent pituitary
  hormones)
• Lethal in early life

Diagnosis
Anencephaly
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Case 20 (Video clip)
Significant findings

• Transvaginal view showing embryo within the
  gestational sac. There is a clot in the
  endometrial cavity

Clinical correlation

• Spontaneous abortion occurs in
• 15 of all recognized pregnancies
• 3 if no symptoms and normal ultrasound
• 5 if bleeding and normal ultrasound
• 15 If bleeding and intrauterine clot

Diagnosis
First trimester intrauterine clot outside the
gestational sac
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Case 21
Significant findings

• 1/3 of the placenta shown here composed of clot
  from placental separation
• Blood from the margin of the placenta may lodge
  between the chorion and uterine wall (a
  subchorionic hematoma)
• A normal ultrasound doesnt exclude abruption-
  all the blood may have passed

Clinical correlation

• Major risk factors for abruption include
• Smoking
• Hypertension
• Smoking and cocaine use
• Blunt abdominal trauma
• Usually presents with bleeding, abdominal pain,
  hypertonic uterine contractions
• May cause fetal distress, maternal DIC

Diagnosis
Abruption with retroplacental hematoma
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Case 22
Significant findings

• Dilation of renal pelvis
• AP measurement in axial view, abnormal if
• 4 mm AP up to 32 weeks
• 7 mm AP beyond 32 weeks
• Normal contralateral kidney, bladder filling,
  and amniotic fluid
• Ureters not dilated

Clinical correlation

• Cutoffs listed above picked to maximize
  sensitivity to detect newborns with significant
  disease
• Many fetuses with mild hydronephrosis become
  normal after birth (decreased urine output)
• A weak marker for Trisomy 21

Diagnosis
UPJ obstruction
30
Case 23
Significant findings

• Easiest to diagnose with color Doppler as
  umbilical arteries sweep around bladder (Bl)
• Cross section of the cord demonstrates two
  vessels (arrows)- more difficult to see in early
  second trimester or obese woman

Bl

• 1 of all pregnancies
• 20 with SUA have other malformations
• A risk factor for aneuploidy (half of trisomy 18
  have SUA), but usually aneuploid fetuses have
  other findings as well
• Increased rate of IUGR, prematurity

Diagnosis
Single umbilical artery
31
Case 24
Significant findings

• No amniotic fluid
• Hypoplastic, distorted chest
• Look for presence of kidneys, bladder filling
• Evaluate for abnormal appearing placenta,
  high-resistance umbilical artery flow

Diagnosis
Clinical correlation

• Second trimester anhydramnios
• Differential includes
• Bilat renal agenesis or other urinary tract abn
• Premature rupture of membranes
• Severe placental insufficiency

• Usually lethal (Oligohydrdamnios sequence)
  cause of death is pulmonary hypoplasia
• First trimester amniotic fluid doesnt depend on
  renal function- can be normal with BRA
• Unilateral agenesis 10 x more common
• BRA usually sporadic. There are autosomal
  dominant forms sono kidneys of close family
  members

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Case 25 (one patient)
Significant findings

• Thick nuchal skin
• Absent or hypoplastic nasal bone
• Atrioventricular septal defect
• Echogenic bowel
• Echogenic intracardiac focus
• Clinodactyly and hypoplastic middle phalynx 5th
  digit
• Other TS 21 markers (not shown)
• Short humerus or femur
• Pyelectasis

Diagnosis
Trisomy 21
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Case 26
Significant findings

• Small cranium if significant brain extruded
• Defect in occiput through which most of the
  brain protrudes. The brain is within an
  encephalocele sac

Clinical correlation

• Least common form of neural tube defect (5)
• 80 are occipital
• Associated with an elevated maternal serum AFP
• Prognosis depends on the amount of brain tissue
  within the encephalocele. An occipital
  meningocele, with no extruded brain tissue
  compatible with a good prognosis

Diagnosis
Encephalocele
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Case 27
Significant findings

• Absence of hypoechoic layer of myometrium
  between placenta and bladder wall
• Vascular lacunae in placenta in same area
• May invade into or through bladder wall

Clinical correlation

• Risk factors include placenta previa and prior
  uterine surgery (esp. cesarean, myomectomy)
• If placenta previa and multiple prior cesareans,
  incidence as high as 40
• Important to diagnose before birth so that
  surgeons can make preparations for hysterectomy,
  difficult bladder dissection, severe hemorrhage
• Sono to screen, MRI to confirm if ultrasound
  uncertain

Diagnosis
Placenta percreta
35
Case 28
Significant findings

• Donor twin (d) stuck to anterior uterine wall.
  Thin membrane adherent to fetus because of
  severe oligohydramnios
• Polyhydramnios in sac of recipient (r)
• Enlarged bladder in recipient

d
r
Clinical correlation

• TTTS occurs in about 1/7 of monochorionic twin
  pregnancies (never in dichorionic)
• Severe cases usually manifest at 16-20 weeks
• Other findings- large/empty bladders, myocardial
  hypertrophy (recipient), hydrops (usually in
  recipient twin first), abnormal Doppler studies
• 80 mortality when early, severe
• Preterm delivery (severe polyhydramnios)
• Volume overload (recipient) or inadequate
  circulation (donor)
• Treatments- Repeated reduction amniocentesis or
  laser coagulation of connecting vessels

Diagnosis
Twin-to-twin transfusion syndrome
36
Case 29
Significant findings

• Large posterior nuchal cystic hygroma
• Skin edema
• This fetus had generalized hydrops

Clinical correlation

• 80 of fetuses with cystic hygroma have
  aneuploidy (most commonly Turner syndrome)
• Causes the webbed neck seen in neonates with
  Turner syndrome
• Cystic hygroma and overt hydrops has 100 fetal
  mortality- usually before 24 weeks
• Over 100 causes of hydrops- include aneuploidy,
  severe anemia from alloimmunization or
  parvovirus, fetomaternal hemorrhage, structural
  heart defect, TORCH, fetal brady or
  tachyarrhythmia, AVM

Diagnosis
Cystic hygroma with hydrops, 45 X karyotype
37
Case 30
Significant findings

• Anhydramnios
• Very large bladder
• Hydronephrosis, dilated ureters
• Echogenic or cystic renal parenchyma (not shown
  here)
• Small fetal chest due to hypoplastic lungs

Clinical correlation

• Normal amniotic fluid after 14 weeks requires
  fetal urine contribution
• If complete obstruction, newborn dies of
  pulmonary hypoplasia, renal dysplasia
• Prognosis better if fetus maintains normal
  amniotic fluid-signifies incomplete obstruction
• Placement of vesicoamniotic shunt can sometimes
  prevent lethal pulmonary hypoplasia

Diagnosis
Bladder outlet obstruction
38
Case 31
Significant findings

• Sagittal view shows placenta over region of
  cervix
• The anterior myometrium appears intact, no large
  venous sinuses in the placenta- thus placenta
  acreta is not suspected

Clinical correlation

• Major risk factors for placenta previa include
• Multiparity
• Prior cesarean or other uterine surgery
• 80 of cases of placenta previa diagnosed before
  18 weeks resolve
• Unlikely to resolve if persists into third
  trimester or if central previa
• Careful transvaginal or transperineal ultrasound
  helps exclude false and negatives
• 15 need hysterectomy at time of cesarean

Diagnosis
Placenta previa
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Case 32 (a)
Significant findings

• Thick membrane
• Lambda (twin peak) sign (arrow)
• Separate or fused placentas
• Same or unlike sex

Clinical correlation
Diagnosis

• Usually dizogotic (always if unlike sex)
• Can be monozygotic with very early division

Dichorionic twins
40
Case 32 (b)
Significant findings

• Thin whispy membrane
• No lambda sign
• Always one placenta
• Always same sex

Clinical correlation

• Of monozygotic twins, time of division determines
  number of chorions/ amnions
• 0-3 days Dichorionic/ diamniotic
• 4-8 days Monochorionic/ diamniotic
• 8-13 days Monochorionic/ monoamniotic
• 13 days Conjoined twins
• Monochorionic twins increased risk for
• Fetal anomalies
• 15 twin to twin transfusion
• IUGR
• Villamentous cord insertion
• Fetal death

Diagnosis
Monochorionic twins
41
Case 33
Significant findings

• Small LV
• Very small ascending aorta (not shown)
• Retrograde filling of the aortic arch through
  ductus (not shown)

Clinical correlation

• Evaluate for other malformations, offer
  amniocentesis for karyotype
• Usually stable fetal course
• Requires PGE at birth to keep ductus open
• Staged Norwood procedure- long term survival
  40-70

Diagnosis
Hypoplastic left heart syndrome
42
Case 34 (a)
Significant findings

• Clenched fist, overriding index finger
• VSD
• Rocker bottom foot

Clinical correlation

• Second most common trisomy (after Trisomy 21)
• Second trimester Tri- screen detects many cases
  (all analytes low)
• Early neonatal death

Diagnosis
Trisomy 18
43
Case 34(b)
Significant findings

• Choroid plexus cyst
• Strawberry shaped head (brachycephaly, frontal
  narrowing).

Clinical correlation

• Isolated CP cyst seen in about 1-2 of normal
  fetuses
• Resolve spontaneously by 26 weeks- no sequellae
• 2 of fetuses with CP cysts have trisomy 18.
  There are almost always other signs.
• Most trisomy 18 fetuses have brachycephaly

Diagnosis
Trisomy 18
44
Significant findings
Case 34(c)

• Small lower jaw
• Absent nasal bone

Clinical correlation

• ANB seen in trisomy 21 as well
• To dx micrognathia critical that true sagittal
  image obtained
• Other genetic syndromes with micrognathia
• Pierre Robin sequence
• Cornelia- De Lange syndrome
• Russell-Silver syndrome
• Miller- Diecker syndrome
• Diastrophic dysplasia
• Severe micrognathia (e.g. with P.R. sequence)
  can cause airway emergency at birth

Diagnosis
Trisomy 18
45
Case 35 (video clip)
Significant findings

• Amorphous embryo with no fetal heart activity
• No yolk sac seen

Clinical correlation

• Cardiac activity usually seen at about 5 weeks
  (menstrual) as a pulsation adjacent to the yolk
  sac.
• Can confidently diagnose embryonic death if
  fetal pole measures 5 mm (with good equipment)
  and no cardiac activity
• Management can be expectant, dilation and
  evacuation, or medical evacuation with misoprostol

Diagnosis
Embryonic death
46
Case 36
Significant findings

• Brachycephaly, small head
• Undivided lateral ventricle
• Cerebral cortex not divided
• Bulbous thalamus (Th)
• Proboscis arises above level of orbits (not shown
  her)

Th
Clinical correlation

• Failure of cleavage of the prosencephalon
• Defects in brain and face
• Alobar form incompatible with prolonged
  postnatal life
• Most are sporadic, 20 trisomy 13, some are
  autosomal dominant with variable penetrance

Diagnosis
Alobar holoprosencephaly
47
Case 37
Significant findings

• Enlarged, echogenic kidneys
• Cysts are not visible sonographically (1-2 mm)
• Anhydramnios
• Narrow chest from pulmonary hypoplasia

Clinical correlation

• Autosomal recessive inheritance
• Age of onset varies
• Prenatal onset with anhydramnios is lethal- death
  due to pulmonary hypoplasia
• Most have renal failure within first few years
  of life

Diagnosis
Infantile polycystic kidney disease
48
Case 38
Significant findings

• Stomach not seen in left upper abdomen (should
  always be visualized after first trimester)

Clinical correlation

• Severe polyhydramnios may lead to preterm labor,
  severe discomfort, maternal respiratory distress-
  reduction amniocentesis can be done
• Esophageal atresia usually associated with TE
  fistula. Fistula connects distal esophagus with
  trachea in 90 of cases

Diagnosis
Esophageal atresia
49
Case 39
Significant findings

• Transverse view at the uterine fundus with and
  ectopic pregnancy in the left interstial portion
  of the tube
• Note the trophoblastic rim
• The pregnancy is eccentric within the uterus
• There is a thin rim (

Clinical correlation
Diagnosis

• About 2 of all ectoptic pregnancies
• Because myometrium can expand, can grow longer
  before rupture than tubal ectopic
• Chance of catestropic bleeding if ruptures
  because of abundant blood supply of myometrium

Interstitial (cornual) ectopic pregnancy
50
Case 40
Significant findings

• Well circumscribed echogenic mass in lower lobe
  of left lung
• Mass receives blood supply from aorta (not
  shown)
• No polyhydramnios (in this case)

Clinical correlation

• Derives from embryonic foregut
• Intralobar or extralobar, depending on if it
  arises before or after development of the pleura
• Extralobar usually found between lower lobe and
  diaphragm
• Many other potential sites- some below diaphragm
• Polyhydramnios frequent
• May need immediate respiratory support

Diagnosis
Pulmonary sequestration