Leeber Cohen

Isolated choroid plexus cyst(s): An indication for amniocentesis

OBJECTIVE Our purpose was to prospectively evaluate the risk of chromosomal abnormalities associated with isolated choroid plexus cyst(s) in gravid women undergoing second-trimester ultrasonographic examination. STUDY DESIGN During a 24-month period 9100 pregnant women underwent midtrimester ultrasonographic evaluation. Women with a fetal diagnosis of choroid plexus cyst(s) were offered amniocentesis and a repeat examination in 4 to 6 weeks. RESULTS A diagnosis of choroid plexus cyst(s) was made in 102 fetuses (1.1%). In four of these fetuses multiple congenital anomalies were noted. Three of the four fetuses had a chromosomal abnormality, two trisomy 18 and one unbalanced translocation, t(3;13). In the remaining 98 fetuses the choroid plexus cysts were isolated findings, that is, there were no other ultrasonographically detected anomalies. Seventy-five of these 98 fetuses underwent amniocentesis. An abnormal karyotype was identified in four fetuses: three had Down syndrome (two trisomy 21 and one unbalanced translocation, t[14;21]), and one trisomy 18. The offspring of the 23 patients in which amniocentesis was declined were phenotypically normal. CONCLUSIONS In our prospective study the risk of chromosomal abnormality with isolated choroid plexus cyst(s) was 1:25, a risk that exceeds the 1:200 risk of pregnancy loss after amniocentesis and the 1:126 and 1:260 risk for aneuploidy and Down syndrome, respectively, in a 35-year-old pregnant women during the midtrimester. These findings indicate that amniocentesis should be offered to pregnant women in the presence of isolated fetal choroid plexus cyst(s).

Reliability and validity of three-dimensional fetal brain volumes.

To determine the intraobserver and interobserver variability in calculating three‐dimensional fetal brain volumes and to examine the relationship between these volumes and biparietal diameter and head circumference measurements and estimated gestational age.

Role of vaginal sonography and hysterosonography in the endoscopic treatment of uterine myomas

OBJECTIVE To summarize the advantages and disadvantages of the various imaging techniques used to evaluate uterine leiomyomas preoperatively and to propose a classification system for intramural and subserosal leiomyomas that may better serve the endoscopist in surgical treatment. DESIGN A MEDLINE search of the available literature was performed. CONCLUSION(S) Selective use of the various imaging techniques is required based on the clinical situation. Classification systems that describe the degree of myometrial involvement are needed for appropriate case selection and counseling by the endoscopist.

Ultrasound evaluation of the endometrium after medical termination of pregnancy

OBJECTIVE: To determine ultrasound parameters associated with the need for clinical intervention after mifepristone and misoprostol termination of pregnancy. METHODS: Charts of patients undergoing medical termination according to a standard protocol in a 13-month period were reviewed. Endometrial thickness and the presence of gestational sac, fluid interface, or complex echoes on postprocedure ultrasonogram were recorded. Repeat doses of medication, surgical intervention, and complications were noted. Success was defined as an abortion completed after a single course of medical therapy. RESULTS: Postprocedure ultrasonograms were available for 525 of 684 patients. Endometrial thickness was measurable in 437 cases. The observed mean endometrial thickness was 4.10 ± 1.80 mm (range 0.67–13.4 mm). Endometrial thickness was inversely proportional to the number of days after initiation of therapy when ultrasonography was performed (r = –0.22; P < .001). The endometrium was thicker in the women who had failed than in those who had a successful medical abortion (6.15 ± 1.95 mm [range 3.35–10.0 mm] versus 4.01 ± 1.75 mm [range 0.67–13.4 mm], respectively; P < .001), but the wide overlap in endometrial thicknesses nullified the clinical usefulness of this difference. CONCLUSION: Endometrial thickness after administration of a single dose of mifepristone and misoprostol for medical termination should not dictate clinical intervention. The decision to treat should be based on the presence of a persistent gestational sac or compelling clinical signs and symptoms. LEVEL OF EVIDENCE: II-3

Investigation of the uterine cavity and fallopian tubes using three‐dimensional saline sonohysterosalpingography

Objective: to compare three‐dimensional saline sonohysterosalpingography (SHSG) to X‐ray hysterosalpingography (HSG) for the evaluation of the uterine cavity and fallopian tubes. Patient population: Fifteen infertile women on whom X‐ray HSG had been performed within 1 year prior to this study. Method: Fifteen infertile women underwent three‐dimensional power Doppler examination of the uterus and fallopian tubes with three‐dimensional SHSG during the follicular phase. Distension was achieved using sterile saline injected through a 5 French HSG catheter. Peritoneal accumulation of free fluid surrounding the ovary and tube was required for a diagnosis of a patent tube. Fluid accumulation in the cul‐de‐sac without visualization of the tubes was considered consistent with at least one tube being patent. Results: three‐dimensional saline SHSG was completed in 14 patients. One patient had cervical stenosis and the procedure could not be performed. No significant intrauterine pathology was identified by either X‐ray HSG or sonography. Three‐dimensional saline SHSG made false positive diagnoses of tubal occlusion in four out of seven fallopian tubes (57%). The sensitivity and specificity for detecting tubal occlusion was 75 and 83%, respectively, with a positive predictive value of 40% and negative predictive value of 95%. Detection of fallopian tube architecture was not possible with three‐dimensional saline SHSG in any patient. Simultaneous use of three‐dimensional Doppler did not clearly identify the flow of saline through the fallopian tubes. Conclusions: transvaginal three‐dimensional saline SHSG provides good visualization of the uterine cavity and myometrial walls in three orthogonal planes. However, it does not diagnose tubal occlusion or depict architecture of the fallopian tube as accurately as X‐ray HSG. Although we were able to visualize the distal fallopian tube and fimbria with real‐time imaging, we were not able to satisfactorily image the proximal tube with three‐dimensional power Doppler. This technique may be reserved as an initial screening test to evaluate the uterine cavity and test patency. Patients at high risk for tubal disease by history or with suspected tubal occlusion on three‐dimensional saline SHSG should be evaluated by either X‐ray HSG or laparoscopy with chromopertubation. Further improvements of three‐dimensional technology and contrast materials will, it is hoped, make this method comparable to X‐ray HSG.

Postoperative outcomes after robotic versus abdominal myomectomy.

Operative time was significantly longer with robotic myomectomy; however, patients experienced shortened lengths of hospital stay and less time before returning to work.

Should uterine tandem applicators ever be placed without ultrasound guidance? No: a brief report and review of the literature.

Background: Brachytherapy is an integral component of the curative treatment of locally advanced cervical cancer. Optimal applicator placement is associated with improvements in local control and treatment-related toxicity. Uterine perforation by the tandem is common and often undetected by orthogonal radiographs. The role of ultrasound in guiding tandem placement remains controversial. Methods: A 55-year-old woman with International Federation of Gynecology and Obstetrics stage IIB cervix cancer underwent placement of a Fletcher-Suit-Delcos tandem and ovoids applicator. Postoperative computed tomography was used for treatment planning. Results: The applicator appeared to be appropriately placed on clinical exam and orthogonal radiographs. Postoperative computed tomography revealed the tandem had perforated the anterior uterine wall. In a second procedure, the tandem was placed correctly under intraoperative ultrasonography. Conclusions: A review of the literature finds a relatively high rate of uterine perforation of the uterus that is undetected by orthogonal radiographs or clinical examination. Multiple reports support the use of real-time ultrasound for patients with especially challenging anatomy. As this report illustrates, uterine perforation is possible in any patient. Therefore, routine real-time ultrasonography should be considered for all uterine tandem insertions.

Congenital malformations of the uterus: The role of ultrasound

Congenital uterine anomalies in women often do not cause any symptoms, except when there is an obstruction of the uterine outflow tract, which occurs infrequently. Patients with congenital uterine anomalies often go undetected or are only discovered incidentally during an evaluation for something else. Consequently, it is difficult to determine the prevalence of congenital uterine anomalies in the general population, and it appears more frequently in certain populations, namely in those with recurrent pregnancy loss or infertility. This paper will review the pathogenesis of congenital uterine anomalies and the standard classification for these anomalies. We will focus on ultrasound and other diagnostic modalities (hysterosalpingogram, laparoscopy with hysteroscopy, and magnetic resonance imaging). We will compare the accuracy and differences between these diagnostic techniques. With the development of three-dimensional ultrasound, the diagnosis of congenital uterine anomalies can be made accurately, effectively, and with less invasiveness than with other procedures. We will briefly review the treatments and pregnancy outcomes in these different anomalies.

Transabdominal three-dimensional volume imaging of the fetal brain at 18–24 weeks’ gestation

Objective: This study was undertaken to determine the quality of the visualization of fetal neuroanatomical structures at 18–24 weeks gestation using three‐dimensional transabdominal ultrasound. Methods: A retrospective study of 40 stored fetal head volumes obtained from 1 November 1999 to 30 June 2000 was undertaken as part of an institutional review board‐approved study. The quality of stored images for three axial planes, the midline sagital plane and three coronal planes was graded using a three tier system (optimal, suboptimal and poor). Results: Optimal visualization for the seven anatomic planes under study ranged from 38% to 55%. Conclusion: Three‐dimensional trans abdominal volume studies of the fetal brain show promise for the diagnosis of structural anomalies of the developing brain. However, technological improvements in the quality of resolution will be required for this technique to be incorporated into routine clinical practice.

Ultrasound and ovarian cancer.

From the published studies it would appear that ultrasound is a very sensitive tool for identifying advanced stage ovarian cancer. The identification of Stage I ovarian cancer with ultrasound screening is more problematic since only 25 to 50% of ovarian cancers are identified in low-risk and high-risk respectively using this technique. Due to the low annual prevalence of ovarian cancer routine screening of premenopausal women or low-risk women after the menopause is unlikely to be cost-effective. The subject of biologic markers to screen for ovarian cancer is addressed elsewhere in this book. It is clear that a primary screening test less expensive than ultrasound is needed. The multicenter National Cancer Institute screening program is designed to evaluate possible new markers. At this time ovarian cancer screening should be done in high-risk groups under careful investigational scrutiny. Patients who are high-risk should be carefully advised of the limitations of diagnostic ultrasound in identifying early stage disease. Transvaginal ultrasound in expert hands is sensitive but not ideally specific for discriminating benign from malignant disease. The judicious use of color Doppler evaluation may help discriminate with greater specificity.