Newton G. Osborne

Congenital Müllerian anomalies: diagnostic accuracy of three-dimensional ultrasound

OBJECTIVE To determine whether it is possible to identify and diagnose accurately Müllerian anomalies with three-dimensional (3-D) ultrasound (US). DESIGN Controlled blinded clinical study. SETTING Normal human volunteers undergoing infertility evaluation in a university hospital. PATIENTS Forty-two patients who underwent laparoscopy and hysterosalpingography as part of their work up for infertility and were found to have either a normal uterus (30 patients) or a Müllerian abnormality (12 patients) consented to be evaluated with 3-D US by sonographers who were unaware of their infertility history or of their laparoscopy and hysterosalpingography diagnoses. INTERVENTIONS Transvaginal 3-D US evaluation over a 10- to 15-minute duration. MAIN OUTCOME MEASURES Three-dimensional imaging was successful in all cases. RESULTS Sonographers identified a Müllerian anomaly in all cases and came up with the correct classification in 11 of 12 cases. All patients with a normal uterus were identified correctly. CONCLUSIONS In all patients with Müllerian anomalies, 3-D US examination of the endometrial cavity correlated with hysterosalpingography. In 91.6% of patients, 3-D US correlated with the external uterine configuration observed by laparoscopy. This technique may be used reliably in an office setting to diagnose and classify Müllerian anomalies.

Use of three-dimensional ultrasonography for the study of normal and pathologic morphology of the human embryo and fetus: preliminary report.

Our objective was to determine whether three‐dimensional ultrasonography offers advantages over two‐dimensional sonography for the evaluation of normal and pathologic morphology of human embryos and fetuses at various stages of pregnancy. Our studies suggest that small fetal and embryonic malformations are better defined with 3D sonography. Our experience indicates that 3D sonography allows more detailed visualization of fetal internal structures. We believe that with technical improvements 3D sonography will permit a more complete evaluation of fetuses earlier in gestation than is possible with current 2D sonographic instruments.

Vaginitis in sexually active women: Relationship to nine sexually transmitted organisms

Women seen for symptoms suggestive of vulvovaginitis were studied for the detection of Mycoplasma hominis. Ureaplasma urealyticum, yeast, Neisseria gonorrhoeae, Chlamydia trachomatis, Gardnerella vaginalis, herpes simplex virus, group B beta-hemolytic streptococci, aerobes, anaerobes, and Trichomonas vaginalis. Asymptomatic women who reported to be sexually active and agreed to undergo comprehensive genital cultures were used as controls. There was a significant association of vulvovaginitis with the recovery of sexually transmitted organisms. However, all organisms were also recovered from asymptomatic patients. A total of 468 sexually transmitted organisms were recovered from 253 symptomatic patients (1.85 organisms per patient), while 125 were recovered from 130 asymptomatic patients (0.96 organisms per patient). The difference in prevalence between symptomatic and asymptomatic women for Chlamydia trachomatis, group B streptococcus, and the mycoplasmas was not statistically significant. Factors that predispose patients to the manifestations of symptoms are not clearly understood.

Control of intrauterine device insertion with three-dimensional ultrasound: is it the future?

A comparative study was designed to determine whether three‐dimensional transvaginal sonography (3D‐TVS) offered advantages over two‐dimensional transvaginal sonography (2D‐TVS) for the identification and location of IUDs in 66 asymptomatic women. Hysteroscopy was performed in cases in which there was a discrepancy between the information obtained by both methods (n = 14). In eight cases (12.2%) the IUD was misidentified with 2D‐TVS. In six cases (9.1%) it was not possible to identify the device model with 2D‐TVS. In two cases (3.0%) 2D‐TVS failed to identify the position of the device. In contrast, all IUDs were identified and located accurately with 3D‐TVS.

Fetal megacystis: differential diagnosis.

The purpose of our retrospective observational series was to determine whether the sonographic characteristics of fetal megacystic bladders can be used to reliably establish the most likely diagnosis in fetuses with this condition. The sonographic records of pregnant patients referred to our institutions over a 10‐year period who were found on initial 2‐dimensional sonography to be carrying fetuses with megacystis were examined for evidence of a keyhole sign, bladder thickness, amniotic fluid index, and fetal sex. When available, 3‐/4‐dimensional sonography, Doppler angiography, tomographic ultrasound imaging, virtual organ computer‐aided analysis, and automatic volume calculation were used as part of the detailed fetal anatomic survey. Twenty fetuses with megacystis were identified. Seventeen were male; 2 were female; and 1 had ambiguous genitalia. All male fetuses with megacystis originally had a diagnosis of prune belly syndrome. The diagnosis for 10 male fetuses with a keyhole sign was changed to megacystis secondary to posterior urethral valves. The fetus with ambiguous genitalia had prune belly syndrome. One of the female fetuses had a diagnosis of urethral atresia, and the diagnosis for the other female fetus was megacystis‐microcolon‐intestinal hypoperistalsis syndrome. In conclusion, in fetuses with megacystic bladders, it is possible to distinguish between cases with prune belly syndrome, posterior urethral valves, urethral atresia, and megacystis‐microcolon‐intestinal hypoperistalsis syndrome by a detailed anatomic survey using 2‐ and 3‐/4‐dimensioinal sonographic techniques.

Ultrasound markers of fetal infection part 1: viral infections.

Diagnosis of fetal infection has depended on identification of pathogens by means of microbiological cultures, immunologic techniques, and special molecular biology techniques that can identify organisms known or suspected of being associated with adverse outcomes of pregnancy. Rubella, cytomegalovirus (CMV), herpes simplex virus (HSV), and human immunodeficiency virus (HIV), for example, are capable of gaining access to the amniotic cavity and producing fetal infection, even when amniotic membranes are intact. Intrauterine invasion by viruses can be associated with maternal symptoms of infection or can be completely silent. In many instances extensive fetal compromise with irreversible structural damage or fetal death will have occurred by the time infection is confirmed by culture or other histopathological methods. The evidence of fetal infection may be as subtle as nascent intrauterine growth restriction (IUGR), mildly inappropriate calcification of fetal organs, placenta, cord, and membranes, and failure to adequately develop fetal fat reserves. The evidence of infection may be as dramatic as obvious fetal malformation, severe central nervous system structural damage, or fetal death. Sonography is capable of detecting most of the grave alterations and some of the subtle effects that are typical of fetal infection.

Normal uterine arterial blood flow in postmenopausal women assessed by transvaginal color Doppler sonography: the effect of hormone replacement therapy.

We used transvaginal color Doppler sonography to study the effect of hormone replacement on the uterine arterial blood flow for 203 postmenopausal women. The regimens studied involved estrogen replacement alone, continuous combined estrogen and progestogen, and estrogen followed sequentially by combined estrogen‐progestogen. The mean pulsatility index fell to 65% +/‐ 9% and the mean resistive index fell to 87% +/‐ 4% of baseline during the first month of therapy (P < 0.0001). The addition of a progestogen did not alter the effect of estrogen alone (P > 0.5). Our findings suggest that the increase in vascular flow occurs even in women who begin therapy long after menopause.

Transvaginal color Doppler assessment of endometrial status in normal postmenopausal women: the effect of hormone replacement therapy.

We used transvaginal color Doppler sonography to study the effects of hormone replacement therapy on the endometrial structure and vascular flow of 345 normal postmenopausal women. We studied women taking estrogen replacement alone, continuous combined estrogen and progestogen, and estrogen followed sequentially by estrogen‐progestogen combination. Endometrial measurements prior to the initiation of hormone replacement therapy were used as baseline values. An increase in endometrial thickness was seen soon after initiation of hormone replacement therapy (P < 0.0001). Hyperplasia or adenocarcinoma was found only when endometrial thickness was greater then 9 mm. No correlation was found between hormone replacement therapy and the occurrence of endometrial hyperplasia or adenocarcinoma.

First-trimester neck abnormalities: three-dimensional evaluation.

In order to study the first trimester ultrasonographic differences between nuchal translucency and hygroma colli, we rescanned 25 fetuses (13 with nuchal translucency and 12 with hygroma colli) using transvaginal and three‐dimensional ultrasonography, after obtaining a fetal karyotype report. Our objective was to test the premise that the different physiopathologic mechanisms of both processes would be reflected in detectable sonographic differences. Our retrospective analysis showed that the most striking ultrasonographic difference was the presence of bullae as well as greater irregularity, extent, and amplitude of the membrane in cases of hygroma colli. Fetuses with simple nuchal translucency had a more homogeneous linear membrane. Although detailed analysis was impossible in 30% of cases, we found three‐dimensional ultrasonography to be a useful technique for establishing the differences between these two entities.

Normal uterine arterial blood flow in postmenopausal women assessed by transvaginal color Doppler ultrasonography.

We used transvaginal color Doppler sonography to study uterine artery blood flow velocity waveforms in 345 normal postmenopausal women who had never been on hormone replacement therapy. Our objective was to establish the standard baseline flow values for normal postmenopausal women. The mean pulsatility index was 3.38 +/‐ 1.04 and the mean resistive index was 0.93 +/‐ 0.09. There was a positive correlation between arterial blood flow impedance and number of years since menopause. We believe that these levels may become important screening parameters for the detection of endometrial carcinoma in postmenopausal women.