Atsushi Manabe

Efficacy and safety of oral estriol for managing postmenopausal symptoms.

OBJECTIVE to assess the therapeutic efficacy and safety of oral estriol for the treatment of climacteric symptoms in postmenopausal women. METHODS 68 postmenopausal women with climacteric symptoms received oral estriol, 2 mg/day, daily for 12 months. We evaluated the degree of climacteric complaints with estriol therapy; serum levels of gonadotropins, estradiol (E2) and lipids; biochemical markers of bone metabolism; blood pressure; and side effects both at baseline and during treatment. Climacteric symptoms were assessed according to the menopausal index (MI), a version of the Kupperman index that had been modified for Japanese women. RESULTS oral estriol therapy significantly reduced total MI scores. The greatest relief was noted for hot flushes, night sweats, and insomnia. Estriol treatment significantly lowered serum follicle stimulating hormone (FSH) and luteinizing hormone (LH) concentrations but did not affect any of the other parameters (lipids, bone, liver and blood pressure) during the study period. Slightly vaginal bleeding occurred in 14.3% of those who underwent natural menopausal women. Histologic evaluation of the endometrium and ultrasound assessment of the breasts following 12 months of estriol treatment found normal results in all women. CONCLUSION Estriol is a safe and effective alternative for relieving climacteric symptoms in postmenopausal Japanese women.

Ovarian tumors of low malignant potential: transvaginal Doppler ultrasound features.

Twenty-nine patients with ovarian tumors were studied with transvaginal Doppler ultrasound before surgery. After surgery, pathological examination revealed that 26 tumors were benign and 3 were of low malignant potential (LMP). B-mode sonography, computed tomography, and magnetic resonance imaging showed no positive findings for malignancy in these 3 cases of LMP. Serum levels of the CA-125, tissue polypeptide antigen, and carcinoembryonic antigen were also within the normal range. Blood flow velocity waveforms were evaluated by the calculation of the resistance index (RI). There was a significant difference between the RI value (0.818 +/- 0.223) in benign tumors and that (0.418 +/- 0.072) in LMP (P less than 0.01). When the 0.56 (mean of LMP tumor RI value + 2SD) was considered as the cutoff value of RI, the sensitivity was 100% and the specificity was 88.5%. Transvaginal Doppler ultrasound provides a useful diagnostic information for the differentiation of benign and LMP ovarian tumors before surgery.

An accurate antenatal diagnosis of vasa previa with transvaginal color Doppler ultrasonography

We describe a case of vasa previa diagnosed antenatally with transvaginal color Doppler ultrasonography. The diagnosis was confirmed at cesarean delivery. The benefits and advantages of the use of transvaginal color Doppler ultrasonography to diagnose vasa previa in utero are discussed.

Three-Dimensional Sonographic Features of Placental Abnormalities

Objective: To describe three-dimensional (3D) sonographic features of placental abnormalities in utero. Methods: A total of 6 cases with placental abnormalities (1 chorioangioma, 1 subchorionic hematoma, 2 placental cysts, and 2 subplacental fibromas) from 22 to 34 weeks of gestation were studied with transabdominal 3D sonography. Results: Placental abnormalities could be easily imaged with both two-dimensional (2D) and 3D sonography; however, visualization of the continuity and curvature of structures was more easily accomplished with 3D sonography. In the case with chorioangioma, the thick and rough surface of the tumor was clearly depicted. With the use of color Doppler ultrasound, only a case of chorioangioma was shown to have abundant blood flow within the tumor. In cases with placental cyst and subchorionic hematoma, the wall of the cyst becomes a transparent-like structure, so internal textures can be clearly identified. In the case with subplacental fibroma, the location in relation to the placenta was clearly recognized. Conclusion: These results suggest that 3D sonography has the potential to be a supplement to 2D sonography and color Doppler ultrasound in identifying placental masses and provides a novel means of visualizing placental abnormalities in utero.

Longitudinal Doppler ultrasonographic assessment of alterations in regional vascular resistance of arteries in normal and growth-retarded fetuses

The objective of this longitudinal study was to evaluate alterations in regional vascular resistance of arteries with advancing gestation in normal and growth-retarded fetuses. Color Doppler flow imaging and pulsed Doppler ultrasonographic assessments were performed on 13 normal and 7 growth-retarded fetuses, ranging from 15 to 40 weeks menstrual age. The pulsatility index was calculated for middle cerebral artery, descending aorta, splenic artery, renal artery, femoral artery and umbilical artery, respectively. Optimal models for these pulsatility index values were determined by regression analysis. A normal range of the pulsatility index for each artery generated in the normal fetuses. In the middle cerebral artery, the models showed a parabolic pattern during pregnancy in the two groups and the predicted pulsatility index values in growth-retarded fetuses were always lower than those in the normal fetuses, especially late in pregnancy. In the renal artery, the predicted pulsatility index values in growth-retarded fetuses were higher than those in normal fetuses near term. In other arteries, the predicted pulsatility index values showed their own specific patterns and there were no significant differences in predicted pulsatility index values in the two groups. In conclusion, alterations in regional vascular resistance of arteries with advancing menstrual age occur evidenced in both normal and growth-retarded fetuses.

New pelvic sonoangiography for detection of endometrial carcinoma: A preliminary report

Pelvic sonoangiography (PSAG) using transvaginal color Doppler was done on 16 postmenopausal patients with abnormal uterine bleeding. Seven women had no endometrial carcinoma and nine had carcinoma. No flow was detected around and within the endometrium in noncancer patients. PSAG showed a feeder artery (blood flow with pulsation that runs into and clings to the tumor) in all patients with endometrial carcinoma, and intratumor blood flow (a mixture of pulsating and constant flow within the tumor) was evident in 7 of 9 patients with endometrial carcinoma. These findings were confirmed by conventional pelvic angiography. In the diagnostic evaluation of PSAG for endometrial carcinoma, both sensitivity and specificity were 100%. We conclude that PSAG with transvaginal color Doppler can be used to detect endometrial carcinoma in postmenopausal women with abnormal uterine bleeding and that this method might be applicable to selecting patients who really require diagnostic surgery for endometrial cancer.

Detection of Small-for-Gestational-Age Infants with Poor Perinatal Outcomes Using Individualized Growth Assessment

Objective: Our objective was to evaluate individualized growth assessment using the Rossavik growth model for detection of small-for-gestational-age (SGA) infants with a poor perinatal outcome. Methods: Rossavik growth models derived from second-trimester ultrasound measurements were used to predict birth characteristics of 47 singleton SGA infants. Individual fetal growth curve standards for head and abdominal circumference, and weight were determined from the data of two scans obtained before 25 weeks’ menstrual age and separated by an interval of at least 5 weeks. Comparisons between actual and predicted birth characteristics were expressed by the Growth Potential Realization Index (GPRI) and Neonatal Growth Assessment Score (NGAS). The proportions of perinatal outcomes [mechanical delivery, low Apgar score, abnormal fetal heart rate (FHR) patterns, neonatal acidosis, meconium staining of amniotic fluid, neonatal intensive care unit (NICU) admission and maternal complications] were compared between SGA infants with normal NGAS and those with abnormal NGAS. Results: Of the 47 fetuses studied, 27 had normal growth outcomes at birth and 20 showed evidence of intrauterine growth restriction, based on NGAS. There were significant increases in mechanical deliveries, abnormal FHR patterns and meconium staining of amniotic fluid in cases of growth-restricted neonates, determined using the NGAS classification, when compared with events related to normally grown infants. However, there were no significant differences in low Apgar score, neonatal acidosis, NICU admission and maternal complications between the 2 groups. Conclusion: Individualized growth assessment should be useful for detection of SGA infants with poor perinatal outcomes.

Subclassification of small-for-gestational-age fetus using fetal Doppler velocimetry.

Our purpose was to determine whether small-for-gestational-age (SGA) fetus can be divided to subclassified groups using fetal Doppler velocimetry. Fifty-four pregnant women with SGA infant delivered after 37 weeks of gestation were studied. After 24 weeks of gestation, fetal middle cerebral artery puslatility index (MCAPI) and umbilical artery pulsatility index (UAPI) were measured at 2- to 3-week intervals using Doppler ultrasound. Perinatal outcomes [operative delivery due to fetal distress, abnormal fetal heart rate (FHR) pattern, meconium staining, low Apgar score (<7), neonatal acidosis (umbilical artery blood pH <7.15), neonatal intensive care unit (NICU) admission due to neonatal asphyxia, and decreased amniotic fluid] were compared in subclassified SGA groups using fetal Doppler velocimetry. The number of SGA fetuses with normal MCAPI and UAPI (normal SGA group) was 39, and those with significantly low MCAPI but normal UAPI (eventful SGA group) 15, respectively. Birth age and birth weights in the eventful SGA group were significantly earlier and lower than those in the normal SGA group, respectively (p < 0.05, and p < 0.005). There were significant increases in operative deliveries, abnormal FHR patterns and decreased amniotic fluid in eventful SGA group, when compared with events related to normal SGA group. However, there were no significant differences in meconium staining of amniotic fluid, low Apgar score, neonatal acidosis, and NICU admission between the two groups. These results suggest that SGA fetus with abnormally low MCAPI but normal UAPI has more poor perinatal outcomes, compared with that with normal MCAPI and UAPI.

Visualization of Fetal Genitalia by Three- Dimensional Ultrasonography in the Second and Third Trimesters

Ninety-five normal fetuses from 14 to 40 weeks of gestation were studied with a specially developed abdominal three-dimensional ultrasonographic 3.5 MHz transducer (Aloka ASU-1000B, Aloka, Tokyo, Japan) connected to an ultrasonographic device (Aloka SSD-1700). This imaging system can provide conventional two-dimensional ultrasonographic images and also can generate within seconds highquality, three-dimensional images in the surface and transparent modes without an external workstation. Subjects with multiple pregnancies or molar pregnancies were excluded from the study. Gestational age was estimated from the first day of the last menstrual period and confirmed by first trimester and early second trimester ultrasonographic examinations. Birth weights in normal fetuses were within normal ranges (between the 10th and 90th percentiles) of the standard growth curve for Japanese people. After birth, no congenital malformations or genetic disorders were found in any neonate. The study was approved by the local ethical committee of Shimane Medical University, and standardized informed consent was obtained from each mother. A three-dimensional image is built by selecting a region of interest from a two-dimensional image and superimposing on it a volume box defined by the examiner. The crystal of the transducer then sweeps mechanically through a 60 degree angle over the selected two-dimensional region. Within 5 s, the outlined volume is automatically scanned, and a sculpturelike three-dimensional image is displayed simultaneously on the screen. At present we use a 128 MB removable hard disk drive for the permanent storage of three-dimensional images. For each gestational age interval we recorded the number of cases in which fetal genitalia were adequately evaluated, and we calcuated the percentage of these structures visualized at each interval using twoand three-dimensional ultrasonography. First, one examiner recorded the number of cases in which fetal genitalia had been adequately seen using twodimensional ultrasonography, then another examiner recorded the number of cases seen using threedimensional ultrasonography without knowing the results of the two-dimensional study. Determination of fetal genital visualization (both in twoand threedimensional ultrasonography) was made prospectively at the time of scanning. Complete visualization of fetal genitalia by twoand threedimensional ultrasonography was compared using Fisher’s exact test. P < 0.05 was considered statistically significant. The overall percentage of fetal genitalia visualization for the entire population using threedimensional ultrasonography was 38%, whereas that with two-dimensional ultrasonography was 95% (P < 0.05). When the sex was identified, it was correct in all cases using twoand threedimensional ultrasonography. The percentage of Received May 12, 1997, from the Department of Obstetrics and Gynecology, Shimane Medical University, Izumo, Japan. Revised manuscript accepted for publication November 4, l997. Address correspondence and reprint requests to Toshiyuki Hata, MD, PhD, Department of Obstetrics and Gynecology, Shimane Medical University, Izumo 693, Japan.

Fetal circulatory system in growth-retarded fetus with late decelerations and oligohydramnios

We present 4 cases of growth-retarded fetuses with fetal heart rate late decelerations and oligohydramnios. Doppler ultrasound revealed significantly decreased pulsatility index (PI) values of the middle cerebral artery; however, the PI values of the renal artery, femoral artery and umbilical artery were within normal ranges in all fetuses. Relative redistributions in the fetal circulatory system were shown with fetal hypoxemia without acidosis.