Lachlan de Crespigny

Preovulatory follicular size: a comparison of ultrasound and laparoscopic measurements.

Ovarian follicles in the immediate preovulatory period were measured with real-time or static ultrasound. Thirty-nine follicles were examined in thirty-six patients. In 29 spontaneous cycles the mean follicular diameter was 21.1 mm (range 17 to 25 mm) and the mean volume was 5.1 ml. In seven stimulated cycles the mean diameter was 18.4 mm and the mean volume was 3.5 ml. Laparoscopic needle aspiration of the follicular contents was performed within 12 hours of ultrasound examination in every case. Follicular dimensions based on the volume of aspirated fluid correlated well with the ultrasound measurements (r = 0.847; P < 0.001), which suggests that ultrasound is a useful technique for examining preovulatory follicular development.

The ‘simple’ ovarian cyst: aspirate or operate?

Summary. One hundred ultrasound‐guided ovarian cyst punctures were performed in 88 patients. To minimize the risk of unexpected malignancy, only persistent or painful cysts <10 cm in diameter were aspirated, cysts with solid areas or multiple locules were excluded. Cytological diagnosis was not possible in 72 of the 100 fluids; of the others 20 contained cells suggestive of follicular or luteal cysts, four samples suggested endometriosis and four benign tumours of epithelial origin. Oestradiol levels were high in 54 cystic fluids, and a combination of oestradiol estimation and cytology facilitated the identification of a follicular origin. Most such patients would normally have undergone surgery, but this was eventually required in only 10 of 60 in whom the cyst fluid was clear or slightly blood‐stained and in 16 of the 28 with heavily blood‐stained fluid. Ultrasound‐guided ovarian cyst puncture would appear to be a valid alternative to surgery for carefully selected benign ovarian cysts especially when the cyst is considered not to contain blood.

Ultrasound Control of Clomiphene/Human Chorionic Gonadotropin Stimulated Cycles for Oocyte Recovery and in Vitro Fertilization

Three pregnancies have been achieved through in vitro fertilization (IVF) following clomiphene/human chorionic gonadotropin (hCG) stimulation monitored only with ultrasound. When the results of 120 stimulated cycles were compared with those from 213 spontaneous cycles during a one-year period, the clomiphene-ultrasound-hCG method led to a significantly higher laparoscopy rate as well as significantly better yields of mature oocytes and embryos for intrauterine transfer. The luteal phase was normal in the stimulated group. This ultrasound-monitored technique was simpler to manage and less costly and appears to be the current method of choice for obtaining oocytes for IVF.

Demonstration of ectopic pregnancy by transvaginal ultrasound

Summary. Transvaginal ultrasound was used in the assessment of 148 patients clinically suspected of having an ectopic pregnancy. Transvaginal ultrasound allowed earlier demonstration of an intrauterine pregnancy without confusion with a pseudosac. Of the 36 patients with an ectopic pregnancy, this was strongly suspected in 29 (81%). A live extrauterine fetus was seen in 8 (22%), ectopic trophoblast or a gestation‐sac‐like structure in 19 (53%), and a pelvic haematoma in 2 (6%). Transvaginal ultrasound is advocated as the technique of choice in patients suspected of having an ectopic pregnancy.

Ultrasound in an in Vitro Fertilization Program

Ultrasound examinations of the preovulatory follicle were performed on 39 patients in 58 consecutive spontaneous cycles in which ovum aspiration for in vitro fertilization was planned. Examinations during the follicular phase helped to indicate when patients should be admitted for intensive monitoring of urinary luteinizing hormone (LH) levels and as a means of lateralizing the side of follicular development in those patients in whom one ovary was known to be inaccessible to laparoscopic aspiration. The technique was also of value in determining whether ovulation had occurred in those patients in whom the anticipated midcycle LH surge was not detected and as a routine measure prior to laparoscopy to ensure the continuing presence of the follicle.

Vault Haematoma after Vaginal Hysterectomy: An Invariable Sequel?

Summary: Fifty consecutive patients undergoing vaginal hysterectomy were studied prospectively by ultrasound to determine the incidence of vault haematoma and the relationship between its size and the development of postoperative pyrexia; 49 patients (98%) had a vault haematoma and 35 (70%) were febrile postoperatively. Large vault haematomas (mean diameter > 5 cm) were invariably associated with significant febrile morbidity, whilst 1 in 3 patients with a small haematoma was afebrile. Colporrhaphy did not influence the likelihood of haematoma formation.

Early diagnosis of pregnancy failure with transvaginal ultrasound

Vaginal ultrasound was used to assess a consecutive series of 353 patients to determine the minimum mean gestation sac diameter at which a failed pregnancy could be diagnosed. Fetal heart movements could be demonstrated in all pregnancies with living fetuses when the mean sac diameter exceeded 1.2 cm. Vaginal ultrasound is superior to both static and transabdominal real-time ultrasound in the diagnosis of early pregnancy failure.

Ultrasound‐Guided Puncture for Gynaecological and Pelvic Lesions

Summary: A series of 34 patients who underwent a total of 37 ultrasound‐guided cyst punctures and fine needle biopsies for diagnosis and treatment of pelvic lesions are reported. In all but 1 patient the lesion visualized was entered and cytological diagnosis was achieved, although 1 patient required a second attempt under general anaethesia. Seven cysts were endometriotic; these and all the remaining cysts were benign and only 4 patients developed a recurrence of the cyst following puncture. No patient in whom the ultrasound appearance suggested a benign cyst was found to have an ovarian malignancy. Three patients with malignant lesions had a total of 4 punctures or biopsies and a final patient had a fine needle biopsy of an ovary to exclude malignancy.

Ectopic Pregnancy — Potentials for Diagnosis Using Ultrasound and Urine and Serum Pregnancy Tests

Summary: The ultrasound findings from 260 patients with a clinical suspicion of ectopic pregnancy have been analysed and correlated with the results of urine pregnancy tests and tests of serum LH and/or HCG levels. Most importantly in a practical clinical context, it was found that a negative serum test virtually excludes an ectopic pregnancy, and an empty uterus with an adnexal mass and/or the presence of free fluid together with a positive urine test gives a very high probability of an ectopic pregnancy. The absolute diagnosis of an ectopic pregnancy by the demonstration of a living fetus outside the uterus is an uncommon finding (8%). Conversely, an empty uterus alone on ultrasound examination in the absence of other ultrasound findings in those patients with a positive serum test is not a reliable guide to the presence of an ectopic pregnancy unless there is an irrefutable conception date at least 5 weeks previously. It is recommended that pathology laboratories and ultrasound departments establish absolute levels of HCG above which an intrauterine pregnancy should always be visible within the uterus. Given appropriate attention to the clinical condition of the patient, the combined use of diagnostic ultrasound, simple urine pregnancy tests and serum assays of beta HCG levels goes a long way to discriminating between those patients with and those without an ectopic pregnancy.

Prevention of Infection in Obstetrical and Gynaecological Ultrasound Practice

The observations of Semmelweis on prevention of puerperal fever are now deeply entrenched into medical practice and doctors should appreciate the importance of practicing good infection control procedures, in particular, that of routinely washing their hands before and afer direct patient contact, after contact with patients’ blood or other body secretions and after removal of gloves. The AIDS epidemic has refocussed medical attention on the importance of appropriate aseptic techniques and universal blood and body fluid precautions. The risk of cross-infection associated with medical procedures have become a highly emotive public health issue in Australia since the report that 4 women became HIVpositive following simple surgical procedures in a doctor’s office, and in the USA where it was documented that transmission of HIV from a healthcare worker to a patient occurred in a dental practice in Florida (1,2). In this environment, it is surprising to see in the literature the dearth of attention to prevention of cross-infection associated with ultrasound examinations and ultrasound-guided procedures. In addition, it seems surprising that, in ultrasound practice, many operators neither practise rigorous cleaning of transducers between patients nor wash their hands prior to and following an examination, and, furthermore, operators commonly have a minimalist approach to aseptic technique for interventional procedures.