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302
WOMEN’S IMAGING
Introduction
Diabetes mellitus (DM) is due to impaired carbohydrate metabo-
lism secondary to defective insulin secretion or function and is one
of the most prevalent endocrine disorders worldwide. DM is classi-
cally categorized into type 1 and type 2 on the basis of epidemiology,
RG • Volume 42 Number 1 Aboughalia et al 303
Figure 2. Chart shows that complex pathogenic mechanisms initiated by diabetes induce hyperglycemia
in pregnancy and are involved in causing diabetic embryopathy, fetopathy, and pregnancy complications.
AGE = advanced glycosylation end product, IUGR = intrauterine growth restriction.
and thickening of the basal trophoblast mem- tion of the fetal weight, diagnosis of congenital
brane, which cumulatively result in fetal hypoxia malformations, and monitoring of pregnancy in
(Fig 2). general. Since maternal diabetes is considered
The timing during which the previously de- a high-risk condition, the American Institute of
scribed sequences are initiated is highly correlated Ultrasound in Medicine (AIUM) recommends
with different maternal and fetal complications. performing detailed diagnostic obstetric second-
Metabolic derangements in early pregnancy, trimester anatomy US in a referral center where
typically before the 7th week of gestation, lead to personnel have expertise in obstetric US. Fetal
blastogenic malformations, spontaneous abor- structures evaluated during a detailed second-
tions, and multiorgan and syndromic malforma- trimester US examination in high-risk pregnancy
tions. On the other hand, the development of compared with those in a standard examination
such metabolic alterations later in pregnancy is are detailed in Table 1 (10). Fetal evaluation
associated with increased risk of macrosomia and should also be tailored further on the basis of any
isolated fetal anomalies (8). In addition, abnor- findings on the anatomic image. For example,
malities of organogenesis and placentation play a fetal echocardiography may be warranted if a
major role in second-trimester pregnancy loss (9). cardiac defect is suspected. Routine inclusion of
fetal echocardiography is recommended only in
Role of US patients with preexisting DM, according to the
The role of US in the management of diabetic most recent AIUM guidelines (11). Some authors
pregnancies is well established. US is routinely advocate for serial US follow-up for assessment of
used for assessment of fetal biometry and estima- fetal growth and amniotic fluid volume, especially
RG • Volume 42 Number 1 Aboughalia et al 305
Complications Description
Fetal complications
Congenital anomalies Nervous system: NTDs, holoprosencephaly-caudal dysgenesis
Heart and great vessels: VSD, conotruncal abnormalities
Genitourinary system: renal agenesis, UTD, MCDK, duplex kidney
Skeletal system: preaxial polydactyly, syndactyly, and radial ray
anomalies
Fetal lung maturity Maternal hyperglycemia interferes with corticosteroid therapy,
delaying lung maturation
Fetal growth Accelerated growth is usually apparent by the late second trimes-
ter, with a disproportionate increase in abdominal and head
circumferences; in addition, there is subcutaneous fat deposition
Miscellaneous Spontaneous abortion increases with poor glycemic control
Stillbirth is four times more common
Metabolic derangements and respiratory distress syndrome are
more frequent in infants of diabetic mothers
Maternal complications
Preeclampsia Diabetes increases the risk of preeclampsia, which correlates with
the extent of glycemic control (up to 18%); this in turn might
be associated with severe obstetric complications, including
HELLP syndrome
Placental abruption: placental detachment before delivery of the fetus
Cesarean delivery The main indication for cesarean delivery is macrosomia to avoid
shoulder dystocia
Long-term sequelae of cesarean delivery include increased risk of
abnormal placentation, as well as uterine dehiscence and rup-
ture in subsequent pregnancies
Other complications
Placental thickening Thick placenta independently associated with adverse pregnancy
and early maturation outcomes
Amniotic fluid volume Second most common cause of polyhydramnios
Oligohydramnios might be seen if there is long-standing diabetes
or associated maternal hypertension
Umbilical cord SUA affects up to 6% of infants of diabetic mothers
Associated with increased frequency of growth retardation and
preterm delivery
Note.— MCDK = multicyclic dysplastic kidney, NTD = neural tube defect, SUA = single
umbilical artery, TA = truncus arteriosus, TGA = transposition of the great vessels, UTD =
urinary tract dilatation, VSD = ventricular septal defect.
At first-trimester US, caudal dysgenesis is sug- and amniotic fluid volume. Predelivery US is rec-
gested when small crown-rump length, increased ommended to assess fetal presentation, as malpre-
nuchal translucency, and lower spine protuber- sentations are common in caudal dysgenesis (21).
ance are detected (19). The definitive diagnosis is Infants of diabetic mothers are at increased risk
made at second-trimester US with demonstration for other central nervous system (CNS) anoma-
of abrupt termination of the spine. The fetal lower lies. In 2008, Correa et al (22) published a large
extremities may show characteristic positioning U.S.-based multicenter study with 13 030 patients
with hip abduction and knee flexion, called the that focused on analysis of the frequency of birth
cross-leg tailor position or Buddha pose. The iliac defects in diabetes (22). The authors highlighted
wings may be fused, yielding a shieldlike appear- the increased risk for congenital CNS anomalies
ance of the pelvic bones (Fig 3, Movie 1) (20). in diabetic pregnancies, particularly anencephaly,
MRI can better delineate the level of caudal dys- encephalocele, and holoprosencephaly. The odds
genesis, associated spinal cord abnormalities, and ratio was higher in mothers with pregestational
other accompanying anomalies. US follow-up is DM in comparison with those with GDM. For
recommend for evaluation of interval fetal growth example, the odds ratio for the presence of anen-
RG • Volume 42 Number 1 Aboughalia et al 307
Figure 3. Caudal dysgenesis. (A) Longitudinal gray-scale US image (sagittal orientation) shows a fetus at 23 weeks gestational age
(GA) with absence of caudal spinal elements in the lumbosacral region (arrow). (B) Transverse gray-scale US image of the same fetus
as in A shows associated abnormal approximation of the iliac bones (arrows). (C) Frontal radiograph of a different aborted fetus
shows premature truncation of the vertebral column at the L3 level (*). Note the shieldlike appearance of the pelvic bones (arrow).
(D) Sagittal T2-weighted MR image of the lumbosacral region in a different 1-day-old neonate shows premature truncation of the
spinal column with agenesis of the distal sacral elements (arrow). (E) Photograph of an aborted fetus with caudal dysgenesis shows
a foreshortened left leg with contracture of the ankle joint (arrow), highlighting the frequent association of caudal dysgenesis with
developmental abnormalities of the lower extremities. (F) Clinical photograph of a different aborted fetus with caudal dysgenesis
shows absence of an external anal opening in an imperforate anus (arrow).
cephaly in pregestational DM versus GDM was regions (Fig 6, Movie 3). On the basis of the con-
3.39 versus 1.33, and for encephalocele was 2.09 tents, a protrusion containing only meninges and
versus 1.82, respectively (22). Another large-popu- cerebrospinal fluid is called a meningocele, while
lation European study by Garne et al (23) in 2012 the presence of brain tissue in the sac content is
confirmed the increased risk of CNS anomalies known as an encephalomeningocele. Encephalo-
in the context of pregestational diabetes, with an cele outcome depends on its content and loca-
overall odds ratio of 1.23 for any CNS anomaly, tion, and cesarean delivery is often pursued to
particularly for encephalocele (odds ratio, 3.22) avoid injury of the intracranial structure at the
and anencephaly (odds ratio, 1.9). time of delivery (24,25).
Anencephaly is a lethal anomaly describing ab- Holoprosencephaly refers to a spectrum of
sent major portions of the brain, skull, and scalp brain malformations that affect the developing
above the orbits (Fig 4). Exencephaly describes prosencephalon (forebrain), characterized by
abnormally formed brain tissue without the pres- varying degrees of failed cleavage of the cerebral
ence of a calvarium and can be diagnosed with hemispheres and deep gray matter nuclei. Three
100% confidence at the time of nuchal trans- classic subtypes are described: alobar, semilobar,
lucency screening. This is considered an earlier and lobar holoprosencephaly (Fig 7, Table 3). No
stage of anencephaly, with further destruction of fetal intervention is indicated, and termination
the brain tissue due to absence of the protective can be offered given the grave sequelae of the
calvarium, eventually leading to anencephaly (Fig disease and the high mortality observed in severe
5, Movie 2) (24). cases of holoprosencephaly (26).
Encephalocele refers to protrusion of intracra-
nial structures through a defect in the skull, most Cardiac Anomalies.—Infants of women with pre-
commonly occurring in the occipital or frontal gestational DM have a two to five times increased
308 January-February 2022 radiographics.rsna.org
Figure 4. Anencephaly. (A) Longitudinal gray-scale US image (sagittal orientation) of a fetus at 11 weeks 6 days GA shows lack
of brain development, with only a small amount of tissue above the orbits (arrow). (B) Coronal gray-scale US image of the face
of another fetus shows the characteristic “frog eye” appearance of the fetal head due to lack of brain matter development above
the orbits (arrows). (C) Clinical photograph of an aborted fetus shows total absence of the calvarium superior to the orbits with a
diminutive misshaped skull.
risk of congenital heart disease, the most com- relationship is best evaluated by using the outflow
mon of which is atrioventricular septal defects tract projections, highlighting the origin and
according to a systematic review by Simeone et orientation of the great vessels. Thus, they are of
al (27). This risk is highest in women who receive great value in the assessment of the conotruncal
insulin therapy at the time of conception and anomalies (29).
lower in women who develop gestational diabetes The essential underlying abnormality in
later in pregnancy (27). The risk for conotruncal patients with tetralogy of Fallot is underdevel-
cardiac anomalies, including truncus arteriosus, opment of the pulmonary infundibulum with a
double-outlet right ventricle, transposition of the resultant constellation of abnormalities includ-
great vessels, and tetralogy of Fallot, is statisti- ing right ventricular outflow stenosis, ventricu-
cally significantly higher when compared with lar septal defect with an overriding aorta, and
that for other cardiac anomalies. The proposed later development of secondary right ventricular
theory for this difference is hyperglycemia- hypertrophy. In truncus arteriosus, there is a
induced neural crest cell death affecting the common arterial trunk instead of a separate
morphogenesis of the developing heart (28). aorta and pulmonary artery (Fig 8). On the other
Understanding the sonographic relationship hand, transposition of the great vessels describes
among the pulmonary and aortic arteries at fetal reversed relationship between the pulmonary ar-
US assessment is key to diagnose conotruncal tery and aorta with secondary ventriculo-arterial
anomalies. Normally, the main pulmonary artery discordance (Fig 9). Double-outlet right ventricle
lies to the left of the ascending aorta, and the is another anomaly in which a major portion of
right pulmonary artery courses posterior to the the aorta arises from the right ventricle, in addi-
ascending aorta and below the aortic arch. This tion to the pulmonary artery (29).
RG • Volume 42 Number 1 Aboughalia et al 309
Figure 6. Meningoencephalocele. (A) Transabdominal transverse gray-scale US image shows an ex-
tracranial complex cystic structure consisting of herniating meninges and cerebrospinal fluid commu-
nicating with the skull cavity through a calvarial defect (arrow). The complex nature of the cystic lesion
suggests the presence of brain parenchyma within the hernia sac. (B) Clinical photograph of a different
neonate shows a large skin-covered circumscribed bulge in the occipital region, compatible with an
encephalocele.
Figure 7. Alobar holoprosencephaly in a fetus at 23 weeks 3 days GA. (A) Transabdominal transverse gray-scale US image shows
fused thalami (arrow) and an enlarged posterior midline fluid space (*). (B) Axial T2-weighted MR image shows the enlarged pos-
terior midline fluid space (*). (C) Axial T2-weighted MR image at the level of the orbits shows thalamic fusion (arrow). Fetal hypo-
telorism is additionally noted (*).
Structure
Finally, it is also important to highlight that (Fig 12), and duplicated collecting system (Fig
these infants are prone to develop hypertrophic 13) (36). Prenatal US plays an important role
cardiomyopathy, which is noted in up to 30% of in the assessment of fetal kidneys and collect-
infants of diabetic mothers at echocardiography. ing system dilatation. The Society for Pedi-
This condition manifests postnatally with respi- atric Urology, in consensus with the AIUM
ratory distress, and in up to 12% of cases it can and ACOG, published guidelines for a UTD
manifest as heart failure, requiring supportive classification system, which aims to unify the
therapy (30). sonographic nomenclature and classification for
UTD while standardizing imaging evaluation
Renal Anomalies.—Congenital abnormalities of and postnatal follow-up. Factors governing this
the kidney and urinary tract (CAKUT) account classification include anterior-posterior renal
for up to 20% of all prenatally detected birth pelvic diameter, calyceal dilatation, renal paren-
defects and 50% of pediatric chronic kidney chymal abnormalities, ureteral dilatation, and
disease cases (31,32). CAKUT are commonly bladder abnormalities (37). Based on the UTD
subdivided into three categories according to classification, fetuses with a dilated ureter in the
their embryologic origin: renal parenchymal context of collecting system dilatation are at in-
malformations, anomalies of renal embryonic creased risk for developing postnatal uropathies,
migration, and outflow abnormalities (33). The and hence the anomaly is classified as UTD
risk of CAKUT increases by 50% in diabetic A2–3. These patients require follow-up prenatal
pregnancies regardless of diabetes subtype, with imaging as well as postnatal US and consulta-
a higher risk in pregestational DM (34). It is tion by a pediatric urologist. A full discussion
suggested that the teratogenic effect of hypergly- of the UTD classifications and guidelines are
cemia on renal development mainly affects the beyond the scope of this article, and we refer the
ureteric branching during morphogenesis and reader to the review article by Nguyen et al (37).
nephrogenesis (35).
The most commonly encountered CAKUT Musculoskeletal Anomalies.—Polydactyly
in infants of diabetic mothers include renal (supernumerary digits) is an uncommon find-
agenesis (Fig 10), urinary tract dilatation ing during fetal evaluation. It can be isolated
(UTD) (Fig 11), multicystic dysplastic kidneys or syndromic, such as with Ellis-van Crev-
RG • Volume 42 Number 1 Aboughalia et al 311
Figures 10–13. (10) Unilateral renal agenesis in a fetus at 20 weeks 4 days GA. (10A) Transabdominal transverse gray-scale US im-
age at the level of the renal fossa shows absence of the left kidney (*). (10B) Longitudinal gray-scale US image (coronal orientation)
shows again an empty renal fossa with an elongated adrenal gland (arrow). (10C) Coronal color Doppler US image shows absence
of the left renal artery (*), the expected location of the origin of the renal artery from the aorta. (11) UTD in a fetus at 33 weeks 3
days GA. Longitudinal gray-scale US image (coronal orientation) shows dilatation of the right renal pelvis (measuring up to 16 mm)
and of the central and peripheral calyces (arrow), corresponding to UTD A2–3. (12) Multicystic dysplastic kidney. (12A) Transverse
gray-scale US image of a fetus at 32 weeks 1 day GA shows bilateral enlarged cystic kidneys with an echogenic cortex, multiple small
cysts (arrows), and a dilated renal pelvis (P). (12B) Gross pathology photograph of the kidney from a different 22-week-old aborted
fetus shows a multicystic appearance with lack of corticomedullary differentiation. (13) Duplicated renal collecting system in a
fetus at 29 weeks 6 days GA. (13A) Longitudinal gray-scale US image (coronal orientation) shows left renal duplication with renal
pelvis dilatation, parenchymal thinning, and ureteral dilatation (calipers) of the upper moiety (UM), as well as dilatation of the lower
moiety (LM). (13B) Longitudinal gray-scale US image (coronal orientation) of the bladder shows an associated ureterocele (arrow).
eld syndrome or trisomy 13. Adam et al (38) anomalies and tibial hemimelia (partial or com-
evaluated 18 fetuses with diabetic embryopathy plete absence of the tibia) (38). In the literature,
and polydactyly in an attempt to establish any a radial ray spectrum of anomalies involving
association between polydactyly and diabetic the radius, radial carpal bones, or thumb is also
embryopathy and found that proximally placed described in the context of diabetic pregnancies
preaxial hallucal polydactyly (an additional digit (Fig 14, Movie 4) (39). The oculoauriculoverte-
along the radial side of the hand) is linked to bral sequence, previously known as Goldenhar
diabetic embryopathy. This relationship is stron- syndrome, defined as defects in anatomic struc-
ger if there are associated spine segmentation tures arising from the first and second branchial
312 January-February 2022 radiographics.rsna.org
arches, with variable abnormalities of the eyes, tion. This effect can be noted as early as in the
ears, and vertebral column, is also known to be second trimester of pregnancy, with a dispropor-
associated with radial ray anomalies and diabetic tionate increase in the fetal abdominal and head
embryopathy (40). circumferences, and associated subcutaneous fat
deposition.
Delayed Lung Maturity Both maternal and fetal morbidity increase
Lung immaturity is a major determinant of with increasing EFW (45). According to the
perinatal morbidity and mortality. In diabetic ACOG practice bulletin summary, the risk
pregnancies, lung maturity is delayed, thought of developing a large for GA fetus is 29% in
to be linked to inhibition of surfactant secretion women with diet-controlled GDM, 30% in
by type 2 pneumocytes secondary to hypergly- women with medication-controlled GDM, and
cemia (41). Lung maturity is primarily assessed 38% in women with preexisting diabetes (44).
by measurement of the concentration of vari- Disproportionate deposition of fat around the
ous surfactant by-products, including lecithin, fetal shoulders is responsible for the higher inci-
sphingomyelin, and phosphatidylglycerol within dence of shoulder dystocia in infants of diabetic
the amniotic fluid. However, amniocentesis also mothers (46). Thus, the ACOG guidelines sug-
carries the risk of membrane rupture, direct gest offering cesarean delivery to mothers with
fetal injury, infection, and fetal loss (42). The diabetes when the estimated fetal weight is more
use of MRI has been investigated as a means than 4500 g, in comparison with mothers with-
for lung maturity assessment. Fetal lung sig- out diabetes where cesarean delivery is offered
nal intensity gradually changes over gestation when the estimated fetal weight is greater than
and is a potential marker for lung maturity. 5000 g. In addition to shoulder dystocia, fetuses
Several groups have reported on the validity of of diabetic women are also at increased risk for
the lung-to-liver signal intensity ratio (LLSIR), clavicular and humeral fractures and brachial
which has a linear relationship to GA in normal plexus palsy regardless of fetal weight at birth
fetuses. However, the exact LLSIRs at different (Fig 16) (47).
gestational ages are still to be validated in large Several studies have investigated the accuracy
normative studies (42,43). of various imaging modalities in fetal weight
assessment. A systematic review by Cooma-
Fetal Growth Disorders rasamy et al (48) showed that the fetal biometric
Macrosomic and large for GA fetuses are measurements such as abdominal circumference
frequently encountered in diabetic pregnan- and EFW obtained at two-dimensional US are
cies. Fetal macrosomia is diagnosed when the not adequate predictors for increased postna-
estimated fetal body weight (EFW) is more tal weight. Other literature suggests a relatively
than 4000 g (Fig 15). On the other hand, large higher sensitivity of MRI for predicting large
for GA generally implies a birth weight greater fetal weight at birth compared with that of US
than or equal to the 90th percentile for a given (49), although the ACOG recommends further
GA according to the ACOG practice bulletin on research to justify performing MRI in this set-
macrosomia (44). Uncontrolled diabetes during ting (44).
pregnancy resulting in maternal hyperglycemia Diabetic pregnancy can be also associated
causes fetal hyperglycemia and stimulates fetal with fetal growth restriction (FGR), where EFW
insulin release and increases fetal fat deposi- is lower than the 10th percentile for GA, and is
RG • Volume 42 Number 1 Aboughalia et al 313
Figure 15. Large for GA fetus at 31 weeks GA. (A) Transverse gray-scale US image shows increased
abdominal circumference and EFW, with an EFW of 2413 g. (B) Graphs show that both abdominal cir-
cumference (left) and EFW (right) are greater than the 99th percentile for GA.
an established risk factor for perinatal morbid- Patients with pregestational DM are at increased
ity and mortality (50). FGR is primarily seen in risk for spontaneous abortion, especially in the
mothers with long-standing pregestational dia- context of poor glycemic control evidenced by
betes and is attributed to vasculopathy resulting elevated HbA1c levels, which can also manifest
in placental dysfunction and impairment of fetal as associated fetal congenital anomalies (Figs
growth (51). FGR can also be noted as a conse- 17, 18) (54). Infants of diabetic mothers are at
quence of diabetes-associated congenital mal- increased risk of preterm delivery (either spon-
formation and/or maternal hypertensive disease taneous or medically indicated), as well as still-
(52). Thus, it is recommended to pursue US birth (relative risk [RR] = 1.34) (55,56). Given
surveillance every 3–4 weeks once a diagnosis of the increased risk of stillbirth in this population,
FGR is established. Serial EFW measurements antenatal testing with nonstress test or biophysi-
over time can provide an overall picture of cal profile is recommended in the third trimes-
growth trajectory, allowing appropriate follow- ter. This, together with hyperglycemia-induced
up and intervention. Furthermore, Doppler delayed lung maturation, contributes to surfac-
US of the umbilical artery can be performed tant deficiency disease, manifesting at neonatal
to distinguish high-risk FGR and to assess for imaging as low lung volumes and diffuse granu-
deterioration over time. A full discussion of fetal lar opacities (Fig 19) (57). Other factors that
Doppler US evaluation is beyond the scope of contribute to perinatal asphyxia include neo-
this article. However, lack or reversal of diastolic natal cardiomyopathy and nephropathy. These
flow in the umbilical artery is associated with infants are also prone to metabolic disturbances
adverse prenatal outcomes (53). including hypoglycemia, hypocalcemia, and
hypomagnesemia (57). Given these increased
Perinatal Morbidity and Mortality risks of complication, neonates of women with
Diabetic pregnancies are associated with in- diabetes have increased risk of neonatal inten-
creased perinatal morbidity and mortality. sive care unit admissions.
314 January-February 2022 radiographics.rsna.org
Other Abnormalities
Placental Thickening
A thick placenta is independently associated
with adverse perinatal outcome including FGR
and need for emergency cesarean delivery (67).
DM is among the most common causes of pla-
cental thickening, in addition to toxoplasmosis,
other infections, rubella, cytomegalovirus, and
herpes simplex (TORCH) infection; triploidy;
and fetal hydrops. At US, placental thickness is
obtained through a perpendicular measurement
at the mid placenta, excluding the myometrium,
from the subplacental veins to the amniotic fluid
surface of the placenta (Fig 25). It is important
Figure 21. Marginal placental abruption. Trans- to recognize that myometrial contraction and
verse gray-scale US image of the uterus in a 26-week
pregnancy shows a large heterogeneous retropla- placental abruption are important pitfalls to be
cental hemorrhage at the uterine fundus (calipers). avoided during placental thickness assessment.
FH = fetal head. The reported thresholds for a thickened pla-
centa, measured as a perpendicular line extend-
ing from the subplacental veins to the amniotic
(Fig 21). Reported maternal complications of fluid at the midportion of the placenta while
placental abruption include hemorrhage, dis- excluding the myometrium, are 33 mm for an
seminated intravascular coagulation, and renal anterior placenta and 40 mm for a posterior
failure, while fetal complications include FGR placenta (68).
and preterm delivery (64).
Polyhydramnios
Complications Related to Delivery DM accounts for up to 20%–25% of pregnan-
DM is independently associated with an in- cies diagnosed with polyhydramnios, defined as
creased need for cesarean delivery. In a study by amniotic fluid index greater than 25 or a maxi-
Ehrenberg et al (65), the odds ratio of cesarean mum vertical pocket greater than 8 cm (Fig 26)
delivery is 1.8 in women with diet-controlled (69). Polyhydramnios is independently associ-
GDM, 3.2 in women with medication-con- ated with an increased risk of adverse pregnancy
trolled GDM, and 4.5 in women with preges- outcomes, including preterm labor, placental
tational DM (65). Although cesarean delivery abruption, and premature rupture of mem-
is considered a relatively safe procedure, there branes (70). In selected patients, amnioreduc-
is increased risk for the development of subse- tion might be pursued in light of amniotic fluid
quent complications, adding to the burden to index and clinical status, the details of which
any future pregnancy (Table 4, Figs 22–24). On are beyond the scope of this article. Prenatal
the other hand, attempted vaginal delivery, when normalization of hyperglycemia and symptom-
appropriate by institutional guidelines, might be atic management decrease the incidence of
complicated with cephalopelvic disproportion, polyhydramnios and can be used as a marker for
resulting in need for cesarean delivery; maternal glycemic control during pregnancy. Research by
vaginal and perineal lacerations; and fetal shoul- Dashe et al (71) has suggested that the amniotic
der dystocia (66). fluid index parallels the amniotic fluid glucose
316 January-February 2022 radiographics.rsna.org
level. Less commonly, oligohydramnios in dia- tion, and adverse neonatal outcomes (73). A
betic pregnancies is multifactorial and reflects suggested cause for SUA is decreased amount
long-standing DM, fetal renal abnormality, or of Wharton jelly, a gelatinous substance within
presence of maternal hypertension. the umbilical cord that surrounds the vessels
(74). SUA can be identified at both fetal US
Abnormalities of the Umbilical Cord and MRI. A transverse US image near the fetal
GDM is a known risk factor for the develop- insertion of the cord can better demonstrate an
ment of a single umbilical artery (SUA). Other SUA since the umbilical arteries commonly fuse
implicated risk factors include advanced mater- near the placental insertion site. In addition, a
nal age, smoking, pregestational diabetes, hyper- longitudinal image at the level of the urinary
tension, preeclampsia, and epilepsy (72). The bladder shows an SUA lateral to the urinary
risk for congenital anomalies (the most common bladder (Fig 27). Doppler US can further con-
of which are genitourinary and cardiovascular) firm this finding (72). In such cases, detailed
and chromosomal abnormalities is eight and fetal anatomy evaluation is recommended. Fetal
16 times higher in fetuses with an SUA, respec- echocardiography and karyotype analysis can be
tively. In addition, an SUA is associated with an pursued in cases that display associated congeni-
increased risk for prematurity, growth restric- tal anomalies. Increased risk of growth retarda-
RG • Volume 42 Number 1 Aboughalia et al 317
Figures 26–27. (26) Polyhydramnios. (26A) Transverse transabdominal US image shows a maximum vertical pocket of the amni-
otic fluid measuring up to 10.1 cm (calipers). The amniotic fluid index measured 27.1 cm (not shown). (26B) Sagittal T2-weighted
MR image in a different patient at 34 weeks gestation shows polyhydramnios as a large amount of fluid surrounding the fetus.
(27) Two-vessel umbilical cord. Transverse color Doppler US image of a fetus at 20 weeks GA at the level of the urinary bladder
shows a two-vessel umbilical cord with an SUA (arrow) in the left perivesical region.
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