Megumi Ishibashi

Antenatal three-dimensional sonographic diagnosis of persistent cloaca

We present a case of fetal persistent cloaca diagnosed by two- (2D) and three-dimensional (3D) sonography and the HDlive rendering mode. 2D sonography revealed a bicornate uterus with hydrometra, bilateral hydrosalpinx, a single umbilical artery, and ascites. 3D sonography and the HDlive rendering mode clearly showed these intra-abdominal structures. To the best of our knowledge, this is the first report of persistent cloaca employing antenatal 3D sonography and the HDlive rendering mode.

Flexible magnifying endoscopy with narrow band imaging for the diagnosis of uterine cervical tumors: A cooperative study among gastrointestinal endoscopists and gynecologists to explore a novel microvascular classification system

Narrow band imaging with magnifying endoscopy (NBI-ME), which is useful for the assessment of micro-vessels, has excellent diagnostic potential for early gastrointestinal epithelial neoplasia. Conventional diagnostic tools for uterine cervical epithelial tumors are still unsatisfactory. An accurate diagnostic tool for uterine cervical epithelial tumors is required to preserve the reproductive ability of young women with uterine cervical tumors. Flexible NBI-ME was performed in patients with cervical squamous cell lesions that required further examinations based on their Pap smear results (cytology ≥ low-grade squamous intraepithelial lesion) at Kagawa University Hospital between April 2014 and April 2015. NBI-ME results concordant with the punch biopsy sites were compared with the histological results. A retrospective review of the NBI-ME images identified abnormal NBI-ME results regarding micro-vascular patterns. All images were categorized as having abnormal features. NBI-ME revealed the following vascular pattern differences of different stage tumors: Dot-like vessels without irregular arrangements and high density in cervical intraepithelial neoplasia (CIN) CIN1-CIN2; dot-like vessels with irregular arrangements and high density in CIN3-carcinoma in situ; crawling vessels in minimum invasive cancer; and willow branch vessels and new tumor vessels in invasive cancer. NBI-ME may be an effective diagnostic tool for uterine cervical epithelial tumors, which may lead to the establishment of a novel classification system.

Antenatal three-dimensional sonographic features of placental shelf

The sonographic appearance of tissue contiguous with the edge of the placenta that protrudes into the amniotic cavity is called a placental shelf, and this shelf is considered to represent a circumvallate placenta [1, 2]. A circumvallate placenta in the third trimester may cause placental abruption, preterm delivery, fetal growth restriction, and perinatal death [3]. However, Shen et al. [2] reported that an early second-trimester placental shelf appears to be a common, benign, and transient sonographic finding, and never persists to the third trimester. We describe a case of an early second-trimester placental shelf diagnosed by conventional two-dimensional (2D) and three-dimensional (3D) ultrasound, but a partially circumvallate placenta was confirmed after delivery in the present case. A 35-year-old woman, gravida 4, para 3, was referred to our ultrasonography clinic because of suspected amniotic band syndrome at 18 weeks and 2 days of gestation. Conventional 2D ultrasound (Voluson E-8, General Electric Medical Systems, Kretztechnik, Zipf, Austria; curvilineararray transabdominal transducer, 2–5 MHz) revealed typical findings of a placental shelf (Fig. 1). 3D ultrasound (Voluson E-8, General Electric Medical Systems, Kretztechnik, Zipf, Austria; curvilinear-array transabdominal transducer, 2–5 MHz) clearly depicted its features, i.e., a smooth, round, and thick free edge with a triangular shape (Fig. 2). The placental shelf was not attached to any fetal parts, and there was no fetal abnormality. The shelf could not be detected 3 weeks later. A healthy male infant weighing 2,604 g was delivered by elective cesarean section at 37 weeks and 4 days of gestation, with Apgar scores of 8 and 9 at 1 and 5 min, respectively. The placental weight was 480 g, and the macroscopic findings revealed a partially circumvallate placenta (Fig. 3). There have been some reports of antenatal detection of a placental shelf using conventional 2D ultrasound [1, 2]. However, visualization of the continuity and extension of the placental shelf was not easily accomplished with conventional 2D ultrasound. There has been only one reported case of a placental shelf diagnosed by prenatal 3D ultrasound [2]. As shown in the present and previous reports, more detailed information on the placental shelf was obtained by means of 3D ultrasound. In particular, the special relationship between the placental shelf and fetus visualized by 3D surface-rendered display was more readily discernible as compared with conventional 2D ultrasound. 3D ultrasound has the potential to supplement conventional 2D ultrasound in diagnosing a placental shelf. Moreover, 3D sonographic images provide entirely new visual experiences for examiners and couples owing to the near-photographic depiction of the placental shelf and fetal conditions in utero. Shen et al. [2] detected 17 placental shelves (11.2%) in 152 consecutive anomaly scans performed between 13 and 16 weeks of gestation. In their study group, early secondtrimester placental shelves rarely persisted to mid-gestation, and never to the third trimester. All placentas with early second-trimester placental shelves were normal, and there were no placenta-related perinatal problems [2]. In T. Hata (&) T. Fujiwara M. Ishibashi E. Kuwamura C. Tenkumo Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp

EP15.25: HDliveFlow silhouette mode for the diagnosis of uterine enhanced myometrial vascularity/arteriovenous malformations: Electronic Poster Abstracts

after fibroids was provided only by sutures (control group, CG). In all patients’ ultrasound examination has been done 1, 3, 6 and 12 months after myomectomy to assess the healing of the myomectomy wound. Results: In CG, in the ultrasound examination, an avascular hypoechogenic area, less than 3 cm in diameter, was observed. In SG, 1 month after myomectomy an avascular hyperechogenic area (AHA) corresponding to the absorbent material was observed in the place of enucleation of the fibroid. Median (Me) AHA volume (calculated from 3 dimensions) 1 month after surgery was 30% of the volume of enucleated fibroids. Me AHA volume 3 and 6 months after myomectomy was respectively 12,5% and 3,7%. 12 months after surgery, in all patients, AHA was not observed (an ultrasound image similar to CG). Conclusions: We conclude that uterus image after myomectomy of large fibroids with intraoperative application of absorptive materials with fibrinogen is similar to that after classic myomectomy, after 12 months of observation.

HDlive Flow silhouette mode for the diagnosis of uterine enhanced myometrial vascularity/arteriovenous malformations

AbstractWe present our initial experience of using the HDlive Flow silhouette mode to construct images of two cases of uterine enhanced myometrial vascularity/arteriovenous malformations (EMV/AVMs). In the first case, the HDlive Flow silhouette mode clearly depicted a fused vascular tumor with irregular contour in the posterior myometrium. In the second case, a large hypervascular mass occupying the entire fundal lesion of the uterus was clearly identified using the HDlive Flow silhouette mode. Moreover, spatial relationships among the hypervascular mass, intrauterine blood collection, and dilated, spiral-shaped right uterine artery enabled the clear localization of the mass. The HDlive Flow silhouette mode provides a novel, unique sonographic image of uterine EMV/AVMs, and might facilitate their diagnosis and localization in the myometrium.

OP27.11: HDlive, HDliveFlow and HDliveFlow silhouette mode for the diagnosis of gestational trophoblastic disease

Objectives: To evaluate the utility of a routine screening for abnormal invasive placentation (AIP) in women with previous Caesarean sections (CS) according to the placental insertion site. Methods: Retrospective analysis of AIP and maternal outcomes of women evaluated between January 2014 and 2016 with a scoring system based on 5 sonographic criteria (i.e. placental lacunae, loss of the hypoechoic retro-placental space, bladder wall abnormalities, abnormal vascularisation at myometrial-bladder interface and placental thinning) which identified 2 risk classes (high: ≥2 criteria, low: ≤1 criteria). AIP was determined following surgery and/or pathological analysis. Results: We enrolled 135 women, 97 women (71.9%) with history of ≥2 CS without placenta previa (PP) (CS group) and 38 women (28.1%) with PP (9/38 with a previous CS and 29/38 with no CS) (PP group). According to our score, 122 women (90.4%) were at low risk, 13 (9.6%) at high risk. AIP was confirmed in 14/135 (10.4%) cases. Hysterectomy was performed in 9 cases with confirmed AIP. All AIP cases were in the PP group (14/14, 100%). Women with PP had higher risk of AIP than those with multiple CS without PP (37.8% vs 0%, p<0.0001). Our score diagnosed 10/14 confirmed AIP with 71% of sensitivity (IC95%:48;94) and 98% of specificity (IC95%:96;100), PPV of 77% (IC95%:54;100) and NPV of 97%(IC95%:94;100). Placental lacunae alone had a sensitivity and a specificity of 86% and 93%. Logistic and multiple regression analyses, corrected for maternal age and BMI, gestational age and fetal weight at time of delivery, need of radiology assistance, suggested that only placental lacunae were significantly associated with AIP (CR 28.05; 95% CI 2.91 to 270.58; p < 0.01) and blood loss during CS (CR 0.553; r = 0.588; p < 0.001). Conclusions: Our data suggest that AIP prevalence is not increased in women with multiple previous CS without PP; only women with PP need a routine screening for AIP. Placenta lacunae are the most associated criterion for AIP and blood loss during CS.