Elysia Moschos

Ultrasound and Assessment of Ovarian Cancer Risk

OBJECTIVE The purpose of this article is to review the ultrasound characteristics of ovarian and adnexal masses and to discuss the prediction of the likelihood of ovarian cancer based on these characteristics and clinical parameters. CONCLUSION Ultrasound characteristics can be used to diagnose the classic-appearing nonneoplastic entities, benign neoplasms and malignancies. In cases in which the appearance of an ovarian mass is not classic, assignment of relative risk of malignancy using a multiparametric model is appropriate and beneficial for patient management.

Saline-infusion sonography endometrial sampling compared with endometrial biopsy in diagnosing endometrial pathology

OBJECTIVE: To evaluate prospectively whether saline-infusion sonography endometrial sampling will improve diagnosis of benign and malignant endometrial disease compared with blind endometrial biopsy in perimenopausal and postmenopausal women with abnormal uterine bleeding. METHODS: After initial assessments and endometrial biopsies, women aged 40 or older with abnormal uterine bleeding were referred for transvaginal ultrasonography. Patients with abnormal endometrial evaluations were offered sonohysterography and invited to enter the saline-infusion sonography endometrial sampling study. Saline-infusion sonography endometrial sampling was performed at the end of sonohysterography using an endometrial sampling curette at the sight of the endometrial abnormality or at a representative site in the endometrial cavity if the cavity was normal. Histopathologic diagnoses of blind endometrial biopsy and saline-infusion sonography endometrial sampling were compared with final outcomes. Kappa values for the two sampling techniques were calculated for diagnostic accuracy. RESULTS: A total of 88 saline-infusion sonography endometrial samples were obtained; final outcomes were attained in 80 cases. When comparing saline-infusion sonography endometrial sampling with final outcomes, saline-infusion sonography endometrial sampling provided a diagnosis 89% of the time (95% confidence interval [CI] 82–95%) compared with endometrial biopsy at 52% (95% CI 42–62%). Forty-five patients with endometrial biopsies had final outcomes. When comparing endometrial biopsy with final outcomes, endometrial biopsy underestimated the incidence of pathology, especially when focal lesions and malignancy were present. This difference was statistically significant (P<.005). CONCLUSION: Saline-infusion sonography endometrial sampling is superior to endometrial biopsy in diagnosing endometrial pathology in perimenopausal and postmenopausal women with abnormal uterine bleeding. LEVEL OF EVIDENCE: II

Does the Type of Intrauterine Device Affect Conspicuity on 2D and 3D Ultrasound

OBJECTIVE The objective of our study was to assess the conspicuity and position evaluation of intrauterine devices (IUDs) on 2D ultrasound and 3D ultrasound in nongravid patients. MATERIALS AND METHODS Review of the ultrasound database for the period from July 2008 through June 2009 was performed for identification of patients with IUDs, of the type and position of the IUD, and of the patients presenting symptoms. The conspicuity of the IUD on 2D sagittal and transverse planes and 3D coronal views was scored according to a 7-point scale. Data analysis was performed using the Student t test and the Pearson chi-square test. RESULTS Of the 269 patients with IUDs who had undergone ultrasound during the study period, 180 patients had a copper IUD; 59, a levonorgestrel-releasing device; and three, a Lippes loop. Twenty-seven IUDs were excluded because they were not seen on ultrasound (n = 15) or the type of IUD was not identifiable (n = 12). Of the 239 IUDs identified, the conspicuity score for copper IUDs (mean score, 5.3 [SD, 1.4]) differed significantly from that for levonorgestrel-releasing IUDs (mean, 3.1 [1.0]) on 2D ultrasound (p < 0.001). The difference in the conspicuity score for copper IUDs (mean, 6.6 [0.95]) versus that for levonorgestrel-releasing devices (mean, 6.2 [0.92]) on 3D ultrasound was marginally significant (p = 0.05). One hundred seventy-six IUDs (74%) were properly positioned within the endometrial cavity and 60 (25%) were malpositioned; proper positioning of three IUDs (1%) could not be confirmed. The indications for sonographic evaluation were pain (111/239, 46%), missing strings (91/239, 38%), and bleeding (34/239, 14%). Of the patients who presented with bleeding, the IUD was malpositioned in 13 (38%). CONCLUSION The levonorgestrel-releasing IUD is significantly less conspicuous than the copper IUD on 2D imaging. Three-dimensional ultrasound enhances the conspicuity of both types of IUD.

Intrauterine devices in early pregnancy: Findings on ultrasound and clinical outcomes

OBJECTIVE The objective of this study was to describe ultrasound findings, clinical symptoms, and outcomes of first-trimester pregnancies with intrauterine devices (IUDs). STUDY DESIGN This was a retrospective review of 42 women with history of IUD placement and positive serum human chorionic gonadotropin in the first trimester. RESULTS There were 31 intrauterine pregnancies (IUPs), 3 ectopic pregnancies, and 8 pregnancies of unknown location. Of 36 IUDs visualized, 15 were normally positioned and 21 malpositioned. Of 31 IUPs, 8 IUDs were within the endometrium, 17 were malpositioned, and 6 were not seen. Indications included bleeding (14 of 31), pain (12 of 31), and missing strings (5 of 31); 11 had no symptoms. Of 26 IUPs with known pregnancy outcomes, 20 were term deliveries and 6 had failed pregnancies of 20 weeks or less. CONCLUSION More than half of IUDs identified in the first trimester were malpositioned. IUP was 3 times as likely with a malpositioned or missing IUD. Three quarters of the IUPs with known outcomes had term deliveries. Symptoms were not predictive of IUD malposition.

Sonographic Findings of Morbidly Adherent Placenta in the First Trimester

The purpose of this study was to evaluate the association between first‐trimester sonographic findings and morbidly adherent placenta at delivery.

Endometrial thickness predicts intrauterine pregnancy in patients with pregnancy of unknown location

To determine whether endometrial thickness and other parameters are useful predictors of normal intrauterine pregnancy (IUP) in the setting of vaginal bleeding and sonographic diagnosis of pregnancy of unknown location (PUL).

First‐trimester diagnosis of cesarean scar ectopic pregnancy

Once considered extremely rare, implantation of a pregnancy within the scar of a previous cesarean section is becoming more common. In fact, its incidence is now higher than that of cervical ectopic pregnancies. We identified 5 cases of ectopic pregnancy implanted in a prior cesarean section scar at our institution since 2004. We outline the criteria for the first‐trimester sonographic diagnosis of cesarean scar ectopic pregnancy, including a new sign of lower uterine segment ballooning, which has previously not been reported. Clinicians must have a heightened awareness of this serious and potentially fatal pregnancy complication.

Placenta accreta and vaginal bleeding according to gestational age at delivery.

OBJECTIVE: To evaluate the incidence of vaginal bleeding in women with placenta accreta according to gestational age at delivery. METHODS: This is a retrospective cohort study of women with prior cesarean delivery and persistent placenta previa delivered at our institution between December 1997 and December 2011. Diagnosis of invasion was based on hysterectomy performed for an abnormally adherent placenta with histologic confirmation. Suspicion for invasion was based on the impression of the attending physician at the time of ultrasonography. Records were reviewed to identify indication for delivery and estimated blood loss. Statistical analyses were performed using Students t test, &khgr;2 test, and Mantel-Haenszel and Jonckheere-Terpstra tests for trend. RESULTS: Of 216 women with prior cesarean delivery and persistent previa, 65 (30%) required cesarean hysterectomy and had histologic confirmation of invasion. Urgent delivery for bleeding was performed in 20% of these pregnancies (13/65). Delivery for bleeding decreased significantly with advancing gestation (P=.001). In our series, 71% with accreta were delivered at 36 weeks of gestation or greater with delivery for bleeding in five (11%), and estimated blood loss was not increased in these pregnancies. Of 79 women with ultrasonographic suspicion for accreta, the incidence of vaginal bleeding prompting urgent delivery also decreased with advancing gestation (P<.001). CONCLUSION: Likelihood of vaginal bleeding necessitating delivery declined with advancing gestation in pregnancies with placenta accreta as did blood loss. Most were delivered at 36 weeks of gestation or greater, nearly 90% in the absence of bleeding complications. Thus, although preterm delivery is an important consideration when placenta accreta is suspected, our findings support individualizing delivery planning. LEVEL OF EVIDENCE: II

Biometric sonographic findings of abnormally adherent trophoblastic implantations on cesarean delivery scars

The purpose of this study was to review first‐trimester transvaginal sonograms of patients with cervicoisthmic implantations and prior cesarean deliveries to determine whether sonographic biometric measurements can distinguish between abnormally adherent trophoblastic implantations and normally implanted pregnancies.

Comparison of saline infusion sonography (SIS) versus SIS-guided endometrial sampling in the diagnosis of endometrial pathology

To compare saline infusion sonography (SIS) to tissue obtained from SIS‐guided endometrial sampling (SISES) to determine sensitivity and specificity for benign and malignant conditions of the endometrium.