Colin R. McArdle

A prospective study of the clinical outcome of femoral pseudoaneurysma and arteriovenous fistuals induced by arterial puncture

PURPOSE Although spontaneous thrombosis of femoral false aneurysms (FAs) and arteriovenous fistulas (AVFs) has been reported, the frequency of this occurrence is unknown. This prospective study was designed to establish the natural history of FA and AVF and to evaluate factors that might predict eventual thrombosis of these lesions. METHODS Twenty-two patients with either femoral FAs (n = 16) or AVFs (n = 6) induced by percutaneous arterial punctures were evaluated prospectively. After an initial duplex scan, all patients were monitored with serial scans, either in hospital or weekly as outpatients, depending on the stability of the process. Operative repair was performed for the following indications: (1) a greater than 100% increase in size of a FA by duplex scan, (2) the development of symptoms, or (3) continued patency of the lesion after 2 months of observation. RESULTS Nine of 16 FAs and four of six AVFs closed spontaneously; FAs greater than 6 cm3 (1.8 cm in diameter) required repair more often (p = 0.065). However, size was not an absolute predictor of the need for repair because two small aneurysms (1.6 and 0.7 cm3) remained patent, although both patients were discharged safely from the hospital, and two large aneurysms (13.2 and 10.7 cm3) thrombosed spontaneously. Three of seven patients whose aneurysms required repair received anticoagulation continuously from the time of catheterization until repair became necessary. None of the patients whose FAs closed spontaneously were receiving anticoagulants at the time of thrombosis (p = 0.02). Neither length of the FA neck, velocity in the FA cavity, size of original arterial puncture, nor velocity in the AVF correlated with thrombosis. CONCLUSIONS We conclude that (1) all FAs do not thrombose spontaneously and at least one third require surgical repair, (2) patients receiving continuous anticoagulation should undergo aneurysm repair, (3) discharge of patients with FAs less than 6 cm3 is safe (the majority of these FAs will eventually thrombose spontaneously), and (4) many AVFs close spontaneously and repair is not required unless symptoms or signs of progressive enlargement develop.

Ovulation induction in polycystic ovary syndrome with urinary follicle-stimulating hormone or human menopausal gonadotropin*†

In patients with polycystic ovarian disease (PCOD) ovulation was induced with a combination of human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) or with urinary follicle-stimulating hormone (uFSH; Metrodin, Serono Laboratories, Inc., Randolph, MA) alone. hMG/hCG and uFSH resulted in comparable rates of ovulation and conception in patients with PCOD. The incidence of hyperstimulation and the potential for multiple births appeared lower with uFSH. The fact that endogenous ovulation did not occur in hMG patients who had hCG withheld or in 3 of the 11 uFSH patients who had preovulatory levels of estradiol and follicles greater than 15 mm may imply that these similarly derived gonadotropins in some instances block endogenous ovulation.

The role of ultrasound in ovulation induction: a critical appraisal *

Twenty-five cycles induced by human menopausal gonadotropin (hMG) were serially studied by ultrasound. The developing follicles were observed up to and beyond human chorionic gonadotropin (hCG) administration. Ovulation as determined by subsequent pregnancy or a sustained elevation of basal temperature was seen in 18 of these cycles. Among these patients the follicular size ranged between 24 and 13 millimeters. No pregnancies occurred where the follicular size was below 15 mm. A shortened luteal phase was noted in three cycles where the follicular size was either 13 or 14 mm. Multiple follicles greater than 10 mm were observed in 14 of the ovulating cycles, but in no case did a multiple pregnancy occur. Fifteen millimeters is therefore suggested as a minimum size for satisfactory ovulation, but it does not appear that an optimum size exists. We conclude that ultrasound can play an important role in the monitoring of ovulation induction but does not replace the present methods.

The Simon Nitinol Filter: Evaluation by MR and Ultrasound

In this prospective blinded study of inferior vena caval (IVC) patency, 18 patients underwent 25 duplex ultrasound (US) and magnetic resonance (MR) angiography examinations over an eight-month period following Simon nitinol filter placement. Clinical examination for lower extremity venous stasis and plain abdominal radiography were also performed. Twenty-three of 24 MR ex aminations and 11 of 24 US examinations were judged technically adequate by the blinded observers. One technically adequate US exam was false positive for intraluminal caval thrombus. Thirteen technically inadequate US examinations missed 3 complete caval occlusions and 2 partial occlusions. MR identified all patients with complete or partial caval occlusion. The authors conclude that duplex US reliably confirms IVC patency only when strict criteria for technical adequacy and interpretation are met (good visualization of filter and IVC above and below filter). MR, although expensive, more reliably identifies nonoccluding intraluminal thrombus and caval occlu sion. It should be the noninvasive study of choice in symptomatic patients with venous stasis and patients with recurrent pulmonary emboli.

The diagnosis of ovarian hyperstimulation (OHS): the impact of ultrasound.

Eighty cycles induced by human menopausal gonadotropins in 45 women were studied with serial ultrasound examinations. The incidence of ovarian hyperstimulation (OHS) was 44%, considerably higher than in other series using similar induction protocols. This was probably due to the superior ability of ultrasound to detect ovarian enlargement and the withholding of human chorionic gonadotropin until at least one follicle had reached a minimum size of 15 mm. No difference was found between the mean urinary estrogen levels of those in whom mild or moderate OHS developed and those in whom it did not. It is concluded that the development of OHS is a frequent but acceptable result of ovulation induction.

Lack of sensitivity of endometrial thickness in predicting the presence of an ectopic pregnancy.

The purpose of this study was to evaluate whether endometrial thickness measurements can be used to differentiate between patients with ectopic pregnancy and spontaneous abortion. Of 676 patients with clinical suspicion of ectopic pregnancy, no intrauterine pregnancy was seen in 128. Of these, 42 (33%) had ectopic pregnancy, 52 (40%) had spontaneous abortion, and 34 (27%) had intrauterine pregnancy. No significant difference was found in endometrial thickness between women with ectopic pregnancy (mean, 9.0 mm; range, 2 to 20 mm) and those with spontaneous abortion (mean, 8.4 mm; range, 2 to 18 mm). A thin endometrium seen on transvaginal sonography cannot be used to exclude the diagnosis of ectopic pregnancy.

Salivary gland enlargement and elevated serum amylase in bulimia nervosa

BACKGROUND Clinical reports have described salivary gland enlargement in bulimia nervosa, particularly in patients with elevated serum amylase concentration. The goal of the current study was to provide a controlled comparison of salivary gland size in patients with bulimia nervosa and healthy volunteers. METHODS Subjects included 17 women with bulimia nervosa and 21 healthy female control subjects. Dimensions of the parotid and submandibular salivary glands were estimated by ultrasonography. Blood samples for amylase measurement were obtained after overnight fast. RESULTS Parotid gland size was enlarged 36% in patients with bulimia nervosa in comparison to control subjects (p < .01). For the patient group, salivary gland size was significantly correlated with frequency of bulimic symptoms and with serum amylase concentration. CONCLUSIONS These results provide new quantitative data demonstrating increased salivary gland size in bulimia nervosa. Further studies are needed to evaluate factors responsible for salivary gland enlargement and hyperamylasemia in this disorder.

Echocardiographic diagnosis of left ventricular thrombi

Left ventricular thrombi have not been commonly recognized by M-mode or by cross-sectional echocardiographic techniques despite their frequency at postmortem examination in patients dying of cardiovascular disease. We discuss two patients, with left ventricular throbmi recognized echocardiographically and confirmed by pathologic and/or angiographic evaluation, whose M-mode and cross-sectional echocardiographic abnormalities add to the variable spectrum of appearance of left ventricularl thrombi. The sensitivity and specificity of echocardiographic techniques in the diagnosis of intracardiac thrombi are discussed.

Technical factors influencing sonographic visualization of fetal echogenic intracardiac foci.

A fetal echogenic intracardiac focus (EIF) is most commonly a normal variant in a normal fetus, but owing to reports of an increased risk of aneuploidy with EIFs, the finding causes concern when noted on routine obstetric sonograms. This study was undertaken to determine which factors influence the sonographic visualization of fetal EIFs.

Management of a cervical heterotopic pregnancy presenting with first-trimester bleeding: case report and review of the literature

OBJECTIVE To report a rare case of a cervical heterotopic pregnancy resulting from intrauterine insemination (IUI) that presented with first-trimester bleeding. DESIGN Case report and literature review. SETTING Large university-affiliated infertility practice. PATIENT(S) A 40-year-old gravida 2 para 1 Asian woman at 7-3/7 weeks gestational age following clomiphene citrate/IUI for the treatment of secondary infertility presented with heavy vaginal bleeding for several days. INTERVENTION(S) Transvaginal ultrasound on admission revealed a single live intrauterine pregnancy and a cervical gestational sac containing a nonviable embryo. The patient continued to have vaginal bleeding and 2 days later underwent removal of the cervical ectopic pregnancy tissue with ring forceps, as well as an ultrasound-guided intracervical Foley balloon and cerclage placement. The bleeding subsided, and 48 hours later the Foley and cerclage were removed. MAIN OUTCOME MEASURE(S) Pregnancy outcome. RESULT(S) The remainder of the pregnancy was uncomplicated and the patient had a full-term cesarean delivery for footling breech of a healthy male infant. CONCLUSION(S) Cervical heterotopic pregnancy is a very rare event that almost universally results from infertility treatment. We present a case where we were able to remove the cervical ectopic and tamponade the bleeding, thus preserving the intrauterine pregnancy for this subfertile couple, and we review the existing literature.