Harold Schulman

The clinical implications of Doppler ultrasound analysis of the uterine and umbilical arteries

Serial Doppler velocimetry of the umbilical and uterine arteries has revealed a relatively clear separation between normal and abnormal waveforms. Abnormal umbilical artery waveforms are defined by a systolic/diastolic ratio greater than or equal to 3 in the last 10 weeks of pregnancy. When abnormal waveforms persist, fetal growth retardation and adverse perinatal outcome are likely. Abnormal uterine artery waveforms are also recognized by a systolic/diastolic ratio averaged from both vessels of more than 2.6 after 26 weeks. In addition, the abnormal vessel will usually contain a persistent diastolic notching. Abnormal uterine vessels strongly correlate with the presence or subsequent development of preeclampsia and fetal growth retardation. Doppler velocity flow provides valuable insights into the pathophysiology of various disease states. It provides a basis for new clinical and basic research into disease mechanisms and methods for improving perinatal and maternal morbidity.

Simple Cyst in the Postmenopausal Patient: Detection and Management

The aims of our study were to determine the prevalence of simple ovarian cysts in asymptomatic postmenopausal patients and to investigate the natural history of these cysts by ultrasonographic follow‐up examinations. Three thousand five hundred and eighty‐five women participated in the volunteer pelvic cancer screening program. Entry criteria were as follows: postmenopausal, no clinical symptoms, and no previous gynecologic pathology. An anechoic, small cyst less than 5 cm in greatest diameter was classified as a simple ovarian cyst. A scoring system to determine malignant potential had been established previously. All simple cysts had a score of 2 or less and had a morphology typical of benign lesions. In the case of a positive finding, the patient would be seen at 3 to 6 month intervals. The decision for surgical intervention was made by a private gynecologist or patient or if an interval change was noted. One thousand seven hundred and sixty‐nine postmenopausal women (49.34% of all patients from the screening program) participated in this study. One hundred and sixteen simple cysts were found, with a prevalence of 6.6% in our population. Among those patients, 27 (23.28%) simple cysts resolved spontaneously, 69 (59.48%) have persisted, and 20 (17.24%) have been lost to follow‐up study. Eighteen women (26.09%) with persistent simple ovarian cyst underwent surgery. No malignant ovarian conditions were identified. In conclusion, simple ovarian cysts are more common in postmenopausal women than previously was thought. This condition is very unlikely to be malignant and can be followed conservatively.

The advantages of using triple-marker screening for chromosomal abnormalities

OBJECTIVEnOur purpose was to assess the utility of triple-marker serum screening for chromosomal abnormalities.nnnSTUDY DESIGNnOur laboratory received 10,605 samples that were between 15 and 22 weeks gestation for maternal serum screening of chromosomal abnormalities. Triple-marker maternal serum screening consisted of alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol in conjunction with maternal age. Women > or = 35 years old were first offered amniocentesis. If they refused amniocentesis, they were offered the screening test. A second-trimester risk for trisomy 21 > or = 1:270 was considered screen positive. Patients were screen positive for trisomy 18 if all three markers were low: alpha-fetoprotein < or = 0.75 multiples of the median, unconjugated estriol < or = 0.60 multiples of the median, and human chorionic gonadotropin < or = 0.55 multiples of the median.nnnRESULTSnThe initial screen-positive rate was 8.3% (880 women); amniocentesis was offered to 766 (7.2%). Twelve of 16 ascertained cases of trisomy 21 (75%), two of three cases of trisomy 18 (67%), five cases of 45,X karyotype, and one case each of 45,X/46,XX, 47,XXY, 47,XYY, 46,XX,ins(2)(q21p13p15)mat, and 69,XXX karyotypes were identified in the screen-positive patients. All four known cases of trisomy 21 in the 886 women > or = 35 years old who were screened were detected, with a 21% false-positive rate. Omitting unconjugated estriol from our screening program would have resulted in detecting nine of 16 trisomy 21 and six of 12 other chromosomal abnormalities. The false-positive rate would have remained the same.nnnCONCLUSIONnIn our sample cohort addition of unconjugated estriol to the screening program resulted in an increased detection rate of chromosomal abnormalities with no change in the false-positive rate. Considering the advancement in screening for chromosomal abnormalities, maternal age alone as an indication for amniocentesis should be reevaluated.

Vaginal birth after two or more previous cesarean sections

The recommendation from the American College of Obstetricians and Gynecologists is to allow vaginal delivery after one cesarean section. This report is an update of our experience of 57 women with two or more cesarean sections who were allowed to labor.

Computerized analysis of fetal heart rate variation in postterm pregnancy: prediction of intrapartum fetal distress and fetal acidosis.

OBJECTIVEnOur purpose was to evaluate whether computerized analysis of fetal heart rate variation may improve fetal surveillance in postterm pregnancy.nnnSTUDY DESIGNnThree hundred thirty-seven pregnant women who were delivered after 41 weeks gestation and who had 610 antenatal tests were included in this study. Fetal tests included a nonstress test with a computerized analysis of the fetal heart rate, Doppler examination of the umbilical artery, and a biophysical profile, performed every 2 to 4 days. Induction of labor was performed when the fetal heart rate variation was reduced (< 30 msec), when fetal heart rate decelerations appeared, or when the amniotic fluid index was < or = 5. The results of the fetal surveillance tests were compared with the results of the intrapartum fetal heart rate monitoring and with the metabolic status of the babies at delivery. Sensitivity and specificity of the various tests in predicting intrapartum fetal distress and acidosis at delivery were described by means of the receiver-operator characteristic curve.nnnRESULTSnTen of 12 fetuses with reduced fetal heart rate variation had a trial of labor. Nine of these 10 fetuses had fetal distress during labor. Seven of the 12 fetuses with reduced fetal heart rate variation were acidotic at delivery (umbilical artery pH < 7.2). Overall, there were 10 acidotic fetuses at delivery in the study group. Only two of them had an umbilical systolic/diastolic ratio > 95th percentile, three had an amniotic fluid index < or = 5, and five had fetal heart rate decelerations before labor. Fetuses who demonstrated an abnormal intrapartum fetal heart rate tracing or who were acidotic at delivery had a significantly higher rate of reduced fetal heart rate variation or decelerations before labor. The largest area under the receiver-operator curve curve for predicting fetal acidosis at delivery or fetal distress during labor was achieved by means of computerized analysis of fetal heart rate variation.nnnCONCLUSIONnA computerized numeric analysis of fetal heart rate variation may improve fetal surveillance in postterm pregnancy.

Endometrial and myometrial thickness and uterine blood flow in postmenopausal women: the influence of hormonal replacement therapy and age.

The aim of our study was to assess the age and hormonal influence on endometrial and myometrial thickness and uterine blood flow in postmenopausal women. One hundred and nine healthy postmenopausal women were examined by transvaginal ultrasonography and color Doppler ultrasonography. Twenty women (18.4%) were under continuous HRT for at least 1 year. In all patients, full thickness of the endometrium and half thickness of the myometrium was measured. Pulsed Doppler waveforms were used to calculate the RI for the left and right uterine arteries. Endometrium thickness in the groups without HRT did not change as the years of postmenopause progressed. This was also true for myometrial thickness. The resistance to blood flow in the uterine arteries remained the same as the postmenopause progressed, but with each 5 year analysis, the ability to see the uterine arteries decreased. The duration of the therapy did not affect the measured parameters. The thickness of the endometrium was larger in the groups with HRT in comparison with all groups without HRT (P < 0.01). Myometrial thickness and uterine blood flow are not affected and did not show any significant influence from HRT. In conclusion, continuous HRT significantly influences the thickness of the postmenopausal endometrium but not of the myometrium or the uterine artery blood flow.

Prevalence in a volunteer population of pelvic cancer detected with transvaginal ultrasound and color flow Doppler.

Our objective was to find the prevalence of non‐symptomatic endometrial and ovarian neoplasms in a volunteer population of women, aged 40 and over. We offered a free volunteer screening program to asymptomatic women for a study using transvaginal ultrasound and color flow Doppler for the detection of pelvic cancer. In the first 2 years, 2117 women were examined, 51.3% post‐menopausal. An ovarian cyst was defined as having a maximum diameter of more than 2.4 cm. Color flow was used to identify blood vessels feeding pelvic organs and adnexal enlargements. An abnormal Doppler flow velocity for the ovary was defined as a resistance index of less than 0.41. Ovarian cysts of less than 5 cm with normal Doppler indices were followed up in 6 months to 1 year. An adnexal morphology score was created to quantify the usefulness of this parameter, particularly in postmenopausal women. Indications for surgery were pre‐defined as a persistent ovarian cyst of more than 5 cm, a persistent suspicious Doppler and a total endometrial thickness of greater than 0.59 cm in postmenopausal women not taking hormones.

Uterine-umbilical velocimetry in open heart surgery

The effect of the nonpulsating cardiac pump in uterine and umbilical circulation has not been studied extensively by measuring the resistance of the uterine and umbilical circulation with velocimetry. During open heart surgery, we were able to demonstrate the effects of the nonpulsatile cardiac pump.

Central and peripheral haemodynamic changes in post‐term fetuses: correlation with oligohydramnios and abnormal fetal heart rate pattern

Objective To assess the hypothesis that the occurrence of oligohydramnios and abnormal fetal heart rate (FHR) pattern in post‐term fetuses is associated with impaired fetal cardiac function.

The characterization of flow signals from tubal and ovarian arteries using intraoperative continuous wave Doppler

Ovarian vascular Doppler is a promising screening test for early ovarian cancer detection. However, disagreements on flow indices used, flow signal shapes and ovarian vessel localization cause continuing controversy. We aimed at clarifying some of this confusion by directly measuring the adnexal arterial blood flow during laparotomy. A 10‐MHz continuous Doppler probe was used to examine adnexal vessels in 24 patients undergoing laparotomy for benign gynecological pathology. Resistance (RI) and pulsatility (PI) indices were calculated for each vessel and the shape of the flow signals was noted. The tubal arteries showed a low‐velocity flow pattern with relatively high end‐diastolic flow when compared to the ovarian artery signals obtained from the infundibulopelvic ligament.