Ultrasound Obstet. Gynecol. 7 (1996) 17 181 Ultrasonic features of intra-amniotic ‘unidentified debris’ at 14-16 weeks’ gestation .. Z. Zimmer and M. Bronshtein Department of Obstetrics and Gynecology, Rambam Medical Center, Ihe Rappaport Faculty of Medicine, ‘Technion-Israel Institute of Technology, Haifa, Israel Key words: ULTRASOUND, AMNIDTIC FLUID, EARLY PREGNANCY, ECHOGENIC MATERIAL ABSTRACT The objective of the study was to define the sonographic features of uarinus echogenic moterials which have been observed in the amniotic cavity of pregnancies in the early second trimester. The study population consisted of women who underwent a transvaginal ultrasound scan of pregnancy at 14-16 weeks’ gestotion. Quy experience in {65010 examinations performed in both low and high-risk pregnancies is reported; 249 cases of intracumniotic debris were identified in this population. Five different types of echogenic material were observed in the amniotic fluid: small floating particles. round structures, cystic structures, solid and semi-solid masses and highly echogenic material which looked like calcification. We conclude that intra amniotic echogenic material may be observed during early pregnancy. ls origin and clinical significance need further evaluation. INTRODUCTION The amniotic fluid changes from clear to turbid as gesta tion progresses. The presence of aa ultrasonographic echo. genic fluid is common in the third trimester and represents \ Turbid fluid may also be seen in cases of intrauterine bleeding. In early gestation, the amniotic fluid is usually clear, although amniochorionic separation, amniotic sheets ar placental bleeding may be observed", Ic iy uur experience that transvaginal ultrasound scan. ring with high-frequency transducers may disclose a variety of intra-amniotic echogenic material in early preg- nancy. The present study describes the ultrasonic features of this material and discus its possible sources. MATERIALS AND METHODS The reported cases represent our experience in 6500 patients who were referred for an ultrasound examination Correspondence: Dr E. 2, Zimmer, De 178 at 14-16 weeks’ gestation. The study population consisted cf both low. and high-risk women. A complete survey for {etal malformations was performed in all cases by one observer using a 6.5-MHz vaginal probe (Elscint 1000, Haita, Israel). The presence of intra-amniotic material was also recorded. Only cases in which no attachment of the echogenic material to the fetus was observed are presented This was doue in order ww exclude cases of possible amni- otic band syndrome. Five types of echogenic material were observed: (1) Small floating particles Vhe amnione fluid had a milky appearance, due to small flakes which look similar a the verniv af late gestation (Figure 1) (2) Round structures These structures of low-level echo: genicity contained small flakes and had a diameter of about 20 mm (Figure 2a)s ra Figure 1 Twin gestation. The membrane separates the clear fluid fof the normal fetus from the dense fluid of the anensephalie fetus vent of Obstetrics and Gynecology, Rambam Medical Center, Haifa $10%6, ral Received 25-7-95 Revised 19-1-96 Accepted 23-1-96Intra-amniotic ‘unidentified debris’ Zimmer and Bronshtein (3) Cystic structures Sonolucent, non-echogenic floating material was encircled by a membrane. The diameter was about 10 mm (Figure 2b}; (4) Solid and semi-solid material Bchogenic debris in a variety of shapes, sizes and echogenicity (Figure 3) The size ranged frou a few millineters w 50 nus (5) Highly echogenic material which resembled calcific ium This material, in many cases, lad a cing-like appearance of a few millimeters and resembled a yolk sac (Figure 4). It can also appear as.a calcified mass of up to 1S mm RESULTS There were 249 cases of intra-amniotic ‘unidentified deb- ris’ in the study population of 6500 patients. The number ‘of cases showing each type of debris and associated fetal anomalies is presented in Table 1 The outcome of pregnancies with the different groups of debris was favorable, except for those cases with a sono- graphic diagnosis of fetal malformations. Our ultrasound Unit serves asa referral center for many hospitals in Israel Therefore, data on pregnancy outcome were obtained by telephoning the patients, There were no cases of false diag: nosis of fetal anomaly. nor cases of gross pathology of the membranes. However, a detailed microscopic examination cof the membranes was nor performed. DISCUSSION “The presence of intea-amniotic echogenic material is are in early gestation and is usually associated with amniotic sheets, intrauterine synechiae or placental bleeding Another possible source is the normal process of exfolia tion of cells and derachment of cellalae Fragments frown fetal organs into the amniotic uid’. There are reports on Figure 2 Round steucture filled with small flakes (a). The circumference is marked by arrowheads, Cystle structure (b) marked by arrows Table 1 lis in che study population of 6500 patients The intra-amniowse ultrasonic findings and fetal anoma: Tntracamniatic Number of dings ‘aos Fetal anomali Small floating 2322 anencephalie fetuses particles Round structures 2 one fetus with hypoplastic left heart Cystic strvctures| 3. one fetus with hypoplastic left ‘heart and common ario- ventecular canal one fetus with cephalocele, Dandy-Walker malformation and omphalocele Solid and semi 206 —no-malformed fetuses solid material “Cakeification’ 15 one fetus with arthrogryposis ‘one fetus with calified material in the endocardium which dis appeared a¢ a later stage of pregnaney the sonographic depiction af feral pastric psuedomasses. It has been suggested that these masses are aggregates of such calls and fragments". In the present study, we observed ditterent types of intra-amniotic echogenic matertal. It 1s possible that some of the semi-solid and solid masses which wwe visualized were also aggregates of cells and membranes. The sonographic appearance of these aggregates probably reflects the amount of cells and the quantity of fluid. As the quantity of fluid decreases, the mass becomes more solid and in some cases becomes very echogenic, resembling. calcification. ‘The ‘milky’ appearance of floating flakes was observed in 22 of 23 anencephalic fetuses. As illustraced in Figure 1. which shows a twin gestation, the normal twin fetus had a clear amniotic fluid while the anencephalic twin fetus had a turbid amniotic fluid. Ultrasound in Obstetrics and Gynecology 179Intra-amniotic ‘unidentified debris? Figure 3 There are reports on the senogeaphic diagnosis of acrania, which turned out to be anencephaly when the fetuses were aborted several weeks later”. Kennedy and colleague which remnants of the neural tissue were observed in the amniotic fluid. It is therefore possible that shedding of the neural tissue is the source of the milky appearance of che amniotic fluid in anencephaly. All pregnancies of anen: cephalic fetuses were terminated. Therefore, we do not have a follow-up on the milky appearance of the amniotic fluid. Sonographers should be aware of other possible sources fof the milky appearance: (1) intrauterine bleeding after amniocentesis; (2) meconium may be present in the second half of pregnancy''; and (3) in some normal pregnancies such a picture may be elicited after 21 weeks’ gestation just by tilting and shaking the uterus. However, all our cases were detected in the early second trimester and had no history of amniocentesis, Therefore, a ‘milky’ appearance at this stage of pregnancy should alert the sonographers to the possibility of aneneephaly. The sonographic features of the round structures re sembled a hematoma, How such a hematoma appeared inside the amniotic cavity is still unclear. One possible explanation is that the hematoma originally formed at the ® reported on a fecus with no cranial vaule and 180 Ultrasound in Obstetrics and Gynecology Zimmer and Bronchtein Four different rypes of solid and semi-solid material, Two are calcified placental site, but afterwards detached and shifted into the amniotic uid. The cystic structures resembled intrauterine mem: branous cysts. These cysts, which originate from the sub- chorionic layer of the placenta, have previously bee observed in lace gestation". It is also possible that the cystic structures which we saw represented a stage of lique- faction of a hematoma, It may be speculated that these structures are a result of the detachment of omphalomes- enteric, umbilical cord or alantoid eysts into the amniotic fluid. Some of the cases of ‘calcified material had a ring-like appearance similar to a yolk sac. However, the yolk sac usually has a smooth border as opposed to the wide, irregular and crenated borders which were noted in our cases. Furthermore, the yolk sac is normally located out- side the amniotic cavity and is usually not visible after 14-16 weeks’ gestation. At present, we do not have an explanation for this unique appearance af the highly echo genic material. As stated, this study reports only on cases in which no connection could be observed between the intra-amniotic echogenic material and the fetus. Therefore, these cases differ from the well-known amniotic bande or fetal body stalk anomaliesIntra amniotic ‘wsidentified debris’ Figure 4 Cakified round structure ‘The ultrasonic appearance of the intra-amniotie debris and especially its echogenicity may depend on the resolu- sion of the ultrasound equipment and gain adjustment. Its, therefore important to note that all the cases presented in this study were evaluated by the same observer, who used In conclusion, depiction of intra-amniotic echogenic material has been previously reported in the second half of pregnancy. The present study, a sorgraphic observational report, has shown that various types of material may also be uuted it che early second trimester of pregnancy. The origin of these materials is not always clear and their clin cal importance therefore needs further evaluation, Zimmer and Dronsbtein REFERENCES 1, Grose, TL, Wolfson, R.N., Kuhnert, P.M. and Sokol, R. J (1985). Sonogeaphically detacted free flossing particles in amniotic fluid predict a mature lecithin sphingo-myelin ratio. J. Clin. Ultrasound, 13, 405-8 2. Mullin, T-J-, Gross, TL, and Wolfson, R. N. (1985). Ulta sound screening for fre floating particles and fetal lung mac rity. Obster. Gynecol, 66, 50-4 3. Brown, D.L, Polger, M., Clack, P.K., Bromley, B.S. and Doubilet, P. M. 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