Lauren M. Mack

Incidental Finding of Decidualized Vesical Endometriosis in an Asymptomatic Obstetrical Patient

A 38-year-old woman, gravida 4, para 2012, presented for routine obstetric anatomic sonography at a gestational age of 20 weeks 1 day. The patient had 2 previous full-term vaginal deliveries and a gynecologic history notable for left salpingo-oophorectomy because of a mature cystic teratoma. A detailed second-trimester anatomic survey was performed according to American Institute of Ultrasound in Medicine guidelines.1 The fetus appeared normal, and there was no suspicion of placenta previa. However, the sonographic findings included a projection into the maternal bladder, first seen on transabdominal sagittal images of the maternal cervix (Figure 1A). This area was reevaluated several times during the course of the transabdominal evaluation and did not appear to change or settle throughout the 20-minute examination. Transvaginal sonography was then performed to better interrogate this suspicious mass. It appeared heterogeneous in echo texture, measuring 2.0 × 2.5 × 1.2 cm, involved the bladder wall, and projected into the bladder cavity. A 3-dimensional rendering was done to look at the polypoid extensions of the mass (Figure 1B). Vascularity was noted when interrogated with color Doppler imaging (Figure 1, C and D). At the time of the sonographic examination the patient reported no history of dysuria, hematuria, or changes in urinary frequency. The differential diagnosis included a benign bladder wall polyp or, less likely, malignancy. The patient remained asymptomatic and was seen 2 weeks later for a cystoscopy. At this time, the patient disclosed that her father had a history of both prostate and bladder cancer. On cystoscopy, the mass was 3.0 cm in size with avascular lobular bumps; it appeared to be pushing the urothelium anteriorly. It was located at the posterior wall of the bladder a few centimeters from the trigone, to the left of the midline. The mass did not have the normal erythematous vascular tissue, as seen in endometriomas, and was thought to be either a leiomyoma of the uterus or bladder; however, malignancy could not be ruled out because biopsy was not performed . Secondary to possible trauma from the cystoscopy, the patient started to have gross hematuria with a clot and intermittent urinary frequency. She underwent a second cystocopic examination 4 weeks later. The size of the main lesion was unchanged; however, the two edematous areas now had a more cauliflower-like appearance. An uncomplicated excisional biopsy was performed after informed consent approval because of the risk of preterm labor, and multiple frozen sections were sent for pathologic examination. The pathologic report confirmed two separate sections containing decidualized tissue with calcification and rare attenuated epithelial cells, consistent with endometriosis. No malignancy was identified. The patient recovered from the biopsy and underwent serial sonographic examinations to ensure no regrowth of the mass. Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. Vesical endometriosis is rare and occurs in 1% of women with pelvic endometriosis. There are a few reported cases of vesical endometriosis in pregnancy.2–4 Symptoms of vesical endometriosis, which are not specific and may be attributed to recurrent cystitis, include catamenial frequency, urgency, pain at micturition, and vesical tenesmus.5 In symptomatic premenopausal patients, given negative urine culture results, vesical endometriosis should be strongly considered.6 On sonography, vesical endometriosis can appear polypoid or as localized bladder wall thickening. The endometrial tissue may protrude through the hyperechoic layers of submucosa and serosa, simulating bladder cancer; however, it is usually still covered by a rim of serosa and submucosa. There can also be moderate blood flow noted, which can increase during pregnancy.2 The sonographic appearance of vesical endometriosis can make it difficult to distinguish from other conditions in the pregnant patient because of decidualization. Decidualization involves hypertrophy of the endometrial stromal cells, leading to thickening of the normal endometrium induced mainly by progesterone to accommodate pregnancy. Formation of ectopic decidua (deciduosis) is well documented, especially in the ovaries, and can occur in endometriosis tissue or in the normal subceolomic mesothelium. The rapid growth and increased vascularization of ovarian endometriosis with decidualization may mimic malignancy.7 Similarly, rapid growth and increased vascularization can lead to differential diagnostic challenges in vesical endometriosis. The differential diagnosis of a bladder mass in pregnancy includes a benign bladder polyp, bladder leiomyoma, bladder cancer, and placenta percreta. Bladder cancers typically originate from the transient epithelium and occur on the floor of the bladder. Bladder cancer grows in a papillary and multicentric fashion, similar to the appearance of the mass in our patient. A previous review of cases comparing the sonographic appearance of vesical endometriosis and bladder cancer differentiated them on the basis of the thin hyperechoic bladder wall that typically covers the endometrial tissue in endometriosis (Figure 1C).2 In contrast, the

Automated Fractional Limb Volume Measurements Improve the Precision of Birth Weight Predictions in Late Third‐Trimester Fetuses

Fetal soft tissue can be assessed by using fractional limb volume as a proxy for in utero nutritional status. We investigated automated fractional limb volume for rapid estimate fetal weight assessment.

A Novel Semiautomated Fractional Limb Volume Tool for Rapid and Reproducible Fetal Soft Tissue Assessment

The purpose of this study was to document the reproducibility and efficiency of a semiautomated image analysis tool that rapidly provides fetal fractional limb volume measurements. Fifty pregnant women underwent 3‐dimensional sonographic examinations for fractional arm and thigh volumes at a mean menstrual age of 31.3 weeks. Manual and semiautomated fractional limb volume measurements were calculated, with the semiautomated measurements calculated by novel software (5D Limb Vol; Samsung Medison, Seoul, Korea). The software applies an image transformation method based on the major axis length, minor axis length, and limb center coordinates. A transformed image is used to perform a global optimization technique for determination of an optimal limb soft tissue boundary. Bland‐Altman analysis defined bias with 95% limits of agreement (LOA) between methods, and timing differences between manual versus automated methods were compared by a paired t test. Bland‐Altman analysis indicated an acceptable bias with 95% LOA between the manual and semiautomated methods: mean arm volume ± SD, 1.7% ± 4.6% (95% LOA, −7.3% to 10.7%); and mean thigh volume, 0.0% ± 3.8% (95% LOA, −7.5% to 7.5%). The computer‐assisted software completed measurements about 5 times faster compared to manual tracings. In conclusion, semiautomated fractional limb volume measurements are significantly faster to calculate when compared to a manual procedure. These results are reproducible and are likely to reduce operator dependency. The addition of computer‐assisted fractional limb volume to standard biometry may improve the precision of estimated fetal weight by adding a soft tissue component to the weight estimation process.

Are First Trimester Nuchal Septations Independent Risk Factors for Chromosomal Anomalies

There is conflicting information regarding the role of nuchal septations during first‐trimester genetic screening. This study was designed to determine whether nuchal septations are risk factors for chromosomal anomalies, independent of increased nuchal translucency (NT), in the first trimester of pregnancy.

Significance and Outcomes of Fetal Growth Restriction Below the 5th Percentile Compared to the 5th to 10th Percentiles on Midgestation Growth Ultrasonography: Outcomes of Severe Fetal Growth Restriction

To determine whether there are differences in neonatal and pregnancy outcomes in pregnancies complicated by severe fetal growth restriction, defined as estimated fetal weight below the 5th percentile, compared with estimated fetal weight in the 5th to 10th percentiles at midgestation.

Does a Novel Pelvic Floor Dilator During Active Labor Reduce Pelvic Floor Injury? [19L]

INTRODUCTION: Study purpose is to examine safety and feasibility of a novel pelvic floor dilator used during active labor to reduce pelvic floor injury. METHODS: Pilot study evaluating performance of novel semi-automated pelvic floor dilator (Materna Medical, San Francisco). Inclusion criteria were healthy primiparas, singletons, cephalic presentation and planned epidural. At 36 weeks gestation and 12 weeks postpartum, pelvic examination was done by urogynecologist blinded to patients course. During active labor, device was inserted in vaginal introitus to achieve preset pelvic floor dilation of 8 cm over 30–60 minute. Primary outcome was rate of lacerations, superficial skin bleeding, skin abrasion or need for surgical repair. Secondary outcomes were pelvic floor disruption diagnosed clinically, mode of delivery, and perineal lacerations (rate and degree). RESULTS: The device was used in 21 patients; 18 delivered vaginally and 3 by cesarean. Of those who delivered vaginally, 8 patients achieved 8 cm pelvic floor dilation and 8 achieved 7 cm. There were no lacerations, superficial skin bleeding, skin abrasions or surgical repair due to device. Of the 16 patients with device in place for at least 20 minutes, 12 had 1st/2nd degree lacerations and 2 had 3rd degree lacerations. All patients with 3rd degree lacerations had operative vaginal delivery. No pelvic floor abnormalities were identified on baseline pelvic examination. No occult disruptions of pelvic floor were diagnosed clinically at 12-week postpartum. CONCLUSION: The novel pelvic floor dilator appears to safely dilate the vaginal canal to 8 cm during active labor and no occult pelvic floor disruptions were identified.