J. Veldman

Clinically oriented three-step strategy for assessment of adnexal pathology

To determine the diagnostic performance of ultrasound‐based simple rules, risk of malignancy index (RMI), two logistic regression models (LR1 and LR2) and real‐time subjective assessment by experienced ultrasound examiners following the exclusion of masses likely to be judged as easy and ‘instant’ to diagnose by an ultrasound examiner, and to develop a new strategy for the assessment of adnexal pathology based on this.

Hyperreactio luteinalis in a spontaneously conceived singleton pregnancy

Hyperreactio luteinalis is a rare condition in pregnancy that is caused by high β-human chorionic gonadotropin (β-hCG) levels or abnormal sensitivity of the β-hCG receptor. It is mostly seen in patients with trophoblastic disease, multiple pregnancy or after fertility treatment. We describe our imaging findings and management of a case of hyperreactio luteinalis diagnosed in a singleton spontaneously conceived pregnancy. A 28-year-old primigravida was referred to the gynecological ultrasound department of the University Hospitals, Leuven, for the evaluation of bilateral adnexal masses at 14 weeks’ gestation. Her pregnancy had been spontaneously conceived and she had no personal or family history of ovarian, breast or colon cancer. There was no history of subfertility and the patient did not use any kind of medication. The adnexal masses were first visualized in a regional hospital when she presented to the emergency room with abdominal pain. Vaginal examination revealed large mobile bilateral masses that filled the pouch of Douglas. Transabdominal and transvaginal gray-scale and color Doppler ultrasound examination was performed using a GE Voluson E8 Expert scanner (4–8-MHz transabdominal transducer and 6–12-MHz transvaginal transducer (GE Healthcare Technologies, Milwaukee, WI, USA)). Large bilateral multilocular masses measuring 141 × 134 × 103 mm (volume, 1019 cm3) in the left ovary and 127 × 120 × 87 mm (volume, 694 cm3) in the right ovary were visualized. Both masses contained more than 10 locules with rather thick (>3 mm) septa and anechoic cyst fluid. The cyst wall was regular (Figure 1) and the color score was 3 (moderately vascularized) in both masses. The fetus was normal in size for gestational age and no structural abnormalities were visualized. There was a small quantity of free fluid in the pouch of Douglas (30 × 22 mm) but no ascites. Both ultrasound examination and an X-ray of the chest were negative for metastases and pleural effusion. Blood analysis showed no abnormalities but a raised level of serum CA-125 of 442 kU/L. Owing to the progressive growth and the size of the masses, reaching the level of the diaphragm, and the large number of locules, the masses were suspected to be mucinous borderline tumors of the intestinal type and the patient was referred for surgery. Surgery was performed at 18 weeks of gestation using a midline incision. The right mass reached the level of the liver and the left mass filled the entire paracolic area (Figure 2). There was no ascites and no macroscopic signs of metastases. A right adnexectomy was performed and, on frozen section, the intraoperative diagnosis was hyperreactio luteinalis (Figure 3). The left mass was punctured but left in situ. Postoperative recovery and the subsequent course of the pregnancy were uneventful. The patient had a spontaneous vaginal delivery of a 3800-g girl at 40 weeks. At 9 weeks’ postpartum, the patient was asymptomatic and ultrasound examination showed that the left adnexa was normal and contained a hemorrhagic corpus luteum cyst. Hyperreactio luteinalis is a rare condition that can occur at any stage of pregnancy, but is typically seen in the third trimester1. In almost all cases it is triggered by very high endogenous or exogenous β-hCG stimulation2. Therefore most publications report on the presence of hyperreactio luteinalis in a multiple or molar pregnancy, in association with choriocarcinoma and fetal hydrops, or after fertility treatment. An abnormally rapid rise in β-hCG in the first trimester or abnormal sensitivity of the hCG receptor due to a gene mutation can lead to the exceptional case of hyperreactio luteinalis in a spontaneous singleton pregnancy3. Burger described the first case of hyperreactio luteinalis not associated with trophoblastic disease, since when a few cases have been reported in spontaneous singleton pregnancies4–6. Depending on the size of the masses either patients are asymptomatic or they present with pain due to intraabdominal pressure, torsion or intracystic hemorrhage. Virilization due to hyperandrogenism can occur in as many as 25% of affected patients7,8. Symptoms of

OC08.01: Differentiation of uterine pathology by transvaginal elastography: preliminary results

Objectives: Fetoscopic SLP improves outcome in TTTS by promoting resolution of cardiovascular (CV) manifestations. The time course and pattern of disease regression is unknown. We sought to investigate the nature of CV disease regression after SLP by analysis of individual cardiovascular elements through application of the CHOP score for TTTS. Methods: The CHOP score is a fetal echo derived system for detailed CV characterization of TTTS. Elements of the Score include 4 domains in the recipient: 1) ventricular characteristics of dilation, hypertrophy, systolic dysfunction, 2) atrioventricular valve (AV) regurgitation, 3) diastolic properties of Doppler AV inflow (double or single peak), ductus venosus, and umbilical venous flow, 4) right ventricular outflow tract obstruction (RVOTO) as assessed by pulmonary artery measuring smaller than aorta or pulmonary stenosis/atresia; and in the donor, evaluation of umbilical artery diastolic flow. In 32 twin pairs individual elements of the Score as well as myocardial performance indices (MPI) were measured at 1 day and 1 week after SLP and compared to pre-op values using paired t-test. Results: Overall score was unchanged at 1 day (pre-op 6.6 + 4.0 vs. 6.0 + 3.8, P = NS) but significantly improved by 1 week (4.2 + 4.1, P < 0.001) after SLP. At 1 day, there was no improvement in systolic or diastolic parameters and AV regurgitation worsened, however there was slight improvement in RVOTO (P < 0.05) and recipient RV and LV MPI (P = 0.02). At 1 week, improvements in ventricular dilation (P = 0.01), hypertrophy (P = 0.01) and all of the diastolic parameters were noted, with further improvement in RVOTO (P = 0.002) and recipient RV and LV MPI (P < 0.01). Systolic performance and AV regurgitation did not improve. Conclusions: Minimal improvement is seen 1 day after SLP, however diastolic CV elements, but not systolic, improve substantially at 1 week. Acute diastolic relaxation of the recipient right ventricle after SLP may improve filling and result in an increase in pulmonary artery diameter.

OC17.01: The association of patients' characteristics and bleeding pattern with uterine intracavitary pathology

Objectives: To describe the sonographic and clinical findings in a cohort of fetuses with commissural anomalies. To compare between US, MRI and autopsy findings. Methods: Retrospective review of all the cases with commissural anomalies diagnosed between January 1989–May 2010. Results: 176 cases of commissural anomalies were identified. The number of cases diagnosed rose from a mean of 1.25/year during 1989–2000 to 15.8/year during 2001–2010. The mean gestational age was 26.5 ± 4.7 weeks (range 15–38). Agenesis of the corpus callosum (ACC) was diagnosed in 47%, dysgenesis of the corpus callosum (DCC) in 46%, cavum septi pellucidi (CSP) anomalies in 5% and pericallosal lipoma in 2%. Associated anomalies were present in 122 (69%) and included anomalies of: central nervous system (104), musculoskeletal (29), genitourinary (17), cardiac (14), dysmorphic features (24), gastrointestinal (5), and miscellaneous (12). Colpocephaly was evident in 71 (40%) cases. MRI was performed in 79 (45%) cases; added new information but did not modify management in 10; and was not conclusive in 7 cases. Autopsy were performed in 65 cases out of 119 (78%) terminated pregnancies. There was a case of IUFD, 53 (30%) children were delivered but 5 died. Out of the 48 livebirths there were 13 with ACC, 22 with DCC, 4 with lipoma and 9 with CSP anomalies. Overall 27 of them are developing normally, 10 suffer from mild to moderate developmental delay, 5 form severe developmental delay and 6 have not yet been evaluated. Conclusions: Fetal commissural anomalies can be diagnosed reliably by the sonographic examination. The correlation between US, MRI and autopsy findings is high. MRI has only a marginal role in diagnosis but contributes to reassure the patients. Prognosis is highly dependent on the presence of associated anomalies.

OP26.08: Preoperative ultrasound measurements of genital hiatus are not different between patients with and without de novo recurrence after anterior vaginal repair

on examination. Latency between age at first vaginal delivery and presentation was 32.6 years (0–72.6). There was a strong association between levator avulsion and symptoms and signs of prolapse (all P < 0.001). Patients with avulsion were not shown to present earlier, regardless of symptoms. On multivariable logistic regression, the relationship between symptoms/signs of FPOP and latency was nonlinear and was treated as a binary variable (<=20, > 20 years). However, latency was not an effect modifier of the relationship between avulsion and symptoms/signs of FPOP. Conclusions: We have found no evidence for the hypothesis that levator trauma leads to earlier presentation of women with symptoms and/ or signs of prolapse.

OP26.03: Transperineal ultrasound and clinical examination for pelvic organ prolapse correlate better if both are performed in a one stop clinic

cases and persistent incontinence despite successful fistula closure. Patients were examined supine and after voiding if bladder volume was over 50 ml. Volume datasets were obtained on coughing, on maximal Valsalva and pelvic floor muscle contraction. Results: Women were seen prior to (n = 22) or after VVF repair (n = 73). Mean age was 29.5 (16–65), mean parity was 2.7 (range, 0–11). Two patients had only delivered by C/S. Only 2 patients had a significant cystocele (stage 2), 3 a uterine prolapse stage 2 and 13 a rectocele stage 2. Levator dimensions on Valsalva were obtained in 92/95 women. Mean hiatal area on Valsalva was 18.8 cm2 (range, 7.7–45.9), and only 6/92 (7%) fulfilled the criteria for ballooning (hiatal distension >=25 cm2). A levator avulsion as defined on tomographic ultrasound was diagnosed in 27 cases (28%), of which 11 were bilateral. There was a reflex contraction of the levator ani observed on coughing in all but two patients. A levator contraction on request could be obtained in all but 6 women. Conclusions: Abnormal levator function and anatomy in patients with VVF is not uncommon, but no more so than in unselected urogynecological patients in the developed world. There was no evidence of permanent denervation of the levator ani.

OP07.04: The value of fluid instillation sonography in women under 40 years of age

Results: Mean age (±SD) was 49 years ±14. Sensibility (%), specificity (%), positive and negative LR were 96, 97, 30.9 and 0.04 for endometrial polyp, respectively; 85, 97, 24.9 and 0.16 for endometrial hyperplasia, respectively; 90, 99, 280.4 and 0.09 for endometrial cancer, respectively. Conclusions: Saline contrast sonohysterography with endometrial sampling performed by using the 14Fr bioptic intrauterine catheter showed to be accurate and efficacious in the triage of patients with AUB, showing to be a diagnostic test. Failed cases and inadequate samples should undergo hysteroscopy.

OP07.02: The added value of fluid instillation sonography in women with a total endometrial thickness ⩽ 5 mm at transvaginal ultrasound

Results: Mean age (±SD) was 49 years ±14. Sensibility (%), specificity (%), positive and negative LR were 96, 97, 30.9 and 0.04 for endometrial polyp, respectively; 85, 97, 24.9 and 0.16 for endometrial hyperplasia, respectively; 90, 99, 280.4 and 0.09 for endometrial cancer, respectively. Conclusions: Saline contrast sonohysterography with endometrial sampling performed by using the 14Fr bioptic intrauterine catheter showed to be accurate and efficacious in the triage of patients with AUB, showing to be a diagnostic test. Failed cases and inadequate samples should undergo hysteroscopy.

OP07.06: The influence of Mirena® position on the bleeding pattern after Mirena® insertion?

Objectives: To compare three-dimensional ultrasound (3D US) examination of uterus to office hysteroscopy as a method of diagnosing cause of pain and/or bleeding associated with IUCD. Methods: Patients attending the outpatient Gynecology Clinic at Cairo University Hospital and complaining of pain and/or bleeding after at least 4 months of insertion of IUCD were prospectively included in this study. All patients had full history taking, general and local examination. All patients had transvaginal 3D US of the uterus, and adnexa. Endometrial uniformity, texture of myometrium, site and position of the IUCD as well as any adnexal lesions was recorded. Patients were then referred for office hysteroscopy, after control of any bleeding or infection. Results: Ninety patients were included in this prospective study. Mean age of patients was 32.6 ± 7.2, mean parity was 3.1 ± 1.3 and mean duration of IUD insertion was 30 months. Thirty-six were complaining of bleeding (40%), 30 were complaining of pelvic pain (33.3%) and 24 had both (26.6%). By 3D US; 14 IUCDs (15.5%) were found displaced; 2 laterally, 12 downward. Sensitivity, specificity, NPV, PPV and accuracy of 3D US in diagnosing displaced IUCD compared to hysteroscopy were: 96.1, 77.8, 67.5, 97.7 & 83.7. Three cases of one transverse limb missing & two embedded IUCDs were only diagnosed by hysteroscopy. One IUCD was intra-abdominal, diagnosed by ultrasound. Seventeen patients (18.8%) had abnormality of the ovaries confirmed by ultrasound; 13 functional cysts, one endometrioma, one dermoid cyst and one hydrosalpinx. Additional findings found on hysteroscopy included one endometrial hyperplasia, one IU synechiae and one missed endometrial polyp. Conclusions: Patients with abnormal bleeding and pain with IUCD may have abnormally positioned IUCD and associated ovarian pathology which can be diagnosed by 3D US. Only when ultrasound cannot depict the cause of pain and/or bleeding, may hysteroscopy be indicated.

OC10.03: Is pain during and after Mirena® insertion related to the flexion of the uterus and the final position of the Mirena®?

Objectives: Pulsed tissue Doppler is a technique to record fetal myocardial wall movements with extremely high temporal resolution. Applicable measurements of cardiac performance indexes as TD-Tei Index or mechanical atrioventricular conduction times require knowledge of the exact length of cardiac time intervals as short as 30–50 ms. This requires meticulously fine tuning of the ultrasound parameters and high performance ultrasound equipment.The effect of two different ultrasound machines used to record fetal cardiac tissue Doppler traces on the results was analysed. Methods: Fetal cardiac tissue Doppler traces where obtained on 176 patients, who attended our institute for routine ultrasound scanning for fetal abnormalities or routine assessment of fetal growth. Ultrasound equipment used was either: Philips IU22, vision 2009 (P) or General Electrics E8, BT08 (G). Td-Tei index, the corresponding z-scores, medians and variance where compared. Results: Mean TD-Tei Index was 0.597 (P) and 0.587 (G) variance of TD-Tei Index was 0.009 and 0.008 mean Z-score of TD-Tei Index was 0.167 and −0.115 variance of Z-score of TD-Tei Index was 0.984 and 0.826 mean isovolaemic contraction time was 50.54 and 51.17 variance of isovolaemic contraction time was 116.4 and 109.3 mean isovolaemic relaxation time was 48.28 and 52.12 variance of isovolaemic relaxation time was 70.68 and 93.54 Conclusions: There where only minor differences in the means for fetal cardiac time intervals and their corresponding indices. In the variance of parameters measured with the two different ultrasound systems there were also no significant differences. The used equipment in our setup did not influence the results.