Ana Monteagudo

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.

The diagnosis, treatment, and follow-up of cesarean scar pregnancy.

OBJECTIVE The diagnosis and treatment of cesarean scar pregnancy (CSP) is challenging. The objective of this study was to evaluate the diagnostic method, treatments, and long-term follow-up of CSP. STUDY DESIGN This is a retrospective case series of 26 patients between 6-14 postmenstrual weeks suspected to have CSP who were referred for diagnosis and treatment. The diagnosis was confirmed with transvaginal ultrasound. In 19 of the 26 patients the gestational sac was injected with 50 mg of methotrexate: 25 mg into the area of the embryo/fetus and 25 mg into the placental area; and an additional 25 mg was administered intramuscularly. Serial serum human chorionic gonadotropin determinations were obtained. Gestational sac volumes and vascularization were assessed by 3-dimensional ultrasound and used to monitor resolution of the injected site and outcome. RESULTS The 19 treated pregnancies were followed for 24-177 days. No complications were observed. After the treatment, typically, there was an initial increase in the human chorionic gonadotropin serum concentrations as well as in the volume of the gestational sac and their vascularization. After a variable time period mentioned elsewhere the values decreased, as expected. CONCLUSION Combined intramuscular and intragestational methotrexate injection treatment was successful in treating these CSP.

Transabdominal versus transcervical and transvaginal multifetal pregnancy reduction: International collaborative experience of more than one thousand cases * ** *

OBJECTIVES Two major approaches for multifetal pregnancy reduction have been developed over the past several years: transabdominal potassium chloride by injection and pelvic procedures by either transcervical aspiration or transvaginal potassium chloride injection or by an automated spring-loaded puncture device. The purpose of this study was to create the largest database from among the worlds largest centers to assess possible differences in efficacy and complication rates by transabdominal or transcervical or multifetal pregnancy reduction. STUDY DESIGN Data on over 1000 completed pregnancies that underwent multifetal pregnancy reduction by both methods from major centers with among the highest worldwide experience were combined. Transabdominal cases were divided temporally (1986 through 1991 and 1991 through 1993). RESULTS Transabdominal multifetal pregnancy reduction was successfully performed on 846 patients and transcervical or transvaginal on 238 patients. Transcervical or transvaginal reduction is performed earlier and starts and finishes with fewer embryos. In 12.6% of cases transcervical or transvaginal reduction left a singleton as opposed to 4.4% for transabdominal reduction. Pregnancy losses (up to 24 weeks) were observed in 13.1% of transcervical or transvaginal cases and in 16.2% of transabdominal cases early in the series and 8.8% of late transabdominal cases. Transcervical or transvaginal reduction may be safer very early in gestation and transabdominal safer later in the first trimester. Premature deliveries were comparable, with only about 5% delivered between 25 and 28 weeks. The smaller starting numbers for transcervical and transvaginal reduction may explain a slightly higher term delivery rate. The transabdominal route tends to reduce the fundal embryos and the transcervical and transvaginal the lower ones. The significance of this is not clear. CONCLUSIONS (1) Multifetal pregnancy reduction by either method is a relatively safe and efficient method for improving outcome in multifetal pregnancies. (2) More than 84% are delivered at > 33 weeks. (3) The experience and preference of the operator are probably the key determinants for an individual patient. (4) An inverse relationship of starting and finishing number to loss rates and gestational age at delivery suggests that there still is a cost of iatrogenic multifetal pregnancies, even if multifetal pregnancy reduction can be successfully performed.

Non‐surgical management of live ectopic pregnancy with ultrasound‐guided local injection: a case series

To describe a series of consecutive cases of live ectopic pregnancies managed with ultrasound‐guided local injection of methotrexate (MTX) or potassium chloride (KCl).

Cesarean scar pregnancy is a precursor of morbidly adherent placenta

To provide further sonographic, clinical and histological evidence that Cesarean scar pregnancy (CSP) is a precursor to and an early form of second‐ and third‐trimester morbidly adherent placenta (MAP).

Cesarean scar pregnancy and early placenta accreta share common histology

To determine, by evaluation of histological slides, images and descriptions of early (second‐trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Three and four-dimensional ultrasound in obstetrics and gynecology.

Purpose of review Developments in ultrasound in general, but even more so in three-dimensional ultrasound, parallel the growth in computing power and speed of computer technology. It is not surprising, therefore, that three-dimensional ultrasound technology is constantly evolving at a fast pace. The purpose of this article is to provide enhanced diagnostic capabilities for the obstetrical and gynecologic provider. Recent findings The most recent advances in three-dimensional ultrasound have to do with two main features. First, an increasingly fast acquisition speed, enabling quick sequences of fast moving organs such as the heart to be captured. Second, the increasing number of different display modalities, making understanding and analysis of normal anatomy and pathology easier for clinicians. Summary This article highlights a selected number of clinical situations in which three-dimensional ultrasound meaningfully enhances the contribution of this fast evolving diagnostic imaging tool.

Normal sonographic development of the central nervous system from the second trimester onwards using 2D, 3D and transvaginal sonography

The developmental changes of the fetal central nervous system (CNS) during the second and third trimesters, specifically the brain, relate mostly to changes in size. However, other changes do occur in the fetal brain during the second and third trimester such as: the union of the cerebellar hemispheres, development of the corpus callosum (CC), and increasing complexity of the cerebral cortex. These changes follow a well‐defined developmental timeline recognizable by sonography.

Simple ultrasound evaluation of the anal sphincter in female patients using a transvaginal transducer

Fecal incontinence affects 0.2% of women aged 15–64 years and about 1.3% of women over 64 years. Most cases are related to instrumental deliveries affecting the anal sphincter complex. We propose a simple technique using the generally available transvaginal transducer to evaluate the anal sphincter complex.

Performing a fetal anatomy scan at the time of first-trimester screening.

Over the past decade, prenatal diagnosis has shifted rapidly from the second trimester into the first trimester. Although the nuchal-translucency scan may detect a small proportion of fetal structural malformations, fetal anatomy is not routinely assessed until the fetal anatomical survey is performed in the second trimester between 18 and 22 weeks. The recent development of high-frequency transvaginal ultrasound transducers has led to vastly improved ultrasound resolution and improved visualization of fetal anatomy earlier in gestation. Several pilot studies of a first-trimester anatomic survey have reported detection rates comparable with those achieved in the routine second-trimester anatomic survey. As advanced ultrasound technology becomes more available, there is an urgent need to evaluate the diagnostic ability of a first-trimester anatomic survey and to determine the role of a first-trimester anatomic survey in the current screening paradigm.