Paul Shekleton

Clinical predictors for buserelin acetate treatment of uterine fibroids: a prospective study of 40 women.

Buserelin acetate, a luteinizing hormone-releasing hormone agonist, is known to be effective in the shrinkage of uterine fibroids. A prospective trial was undertaken (1) to compare the efficacy of intranasal (IN) and subcutaneous (SC) administration of buserelin acetate and (2) to assess if tumor regression correlated with fibroid size and/or patient age. Forty patients were randomly allocated to receive 6 months of either IN buserelin acetate (n = 21) or SC buserelin acetate (n = 19). Four patients did not complete the study and were excluded from statistical analysis. Fibroid regression occurred in all 36 patients. Overall regression to 66% or less of the initial fibroid volume occurred in 70% of subjects. There was no significant difference in fibroid shrinkage between the two administration routes. A significant positive correlation was found between initial fibroid size and subsequent fibroid regression, with larger tumors being more likely to shrink than smaller fibroids. No correlation was found between the patients age and the extent of fibroid regression.

Ovarian status in healthy postmenopausal women

Objective:There are currently no programs to assess ovarian health in postmenopausal women. The aim of this study was to describe the ovaries in healthy women at least 5 years after menopause by questionnaire, transvaginal ultrasonography, and blood ovarian cancer markers. Design:A total of 515 women who were asymptomatic and at the Stages of Reproductive Aging Workshop +2 stage of menopause (>5 y postmenopause) were recruited by advertisement. Clinical history was obtained by questionnaire, and biophysical assessment by a transvaginal ultrasound investigation and biochemical assessment by serum CA-125 and inhibin were performed. Abnormal findings were confirmed and then reviewed. Results:Both ovaries were identified by transvaginal ultrasonography in 71% of women. The right ovary was visualized in 86.3% of these volunteers, and the left ovary was visualized in 78%. The presence of small unilocular cysts and echogenic foci facilitated identification of the ovary in some women. Ovarian/paraovarian lesions were present in 12.6% of women. Abnormalities of the endometrium and uterus were also common, prompting surgery in 7.2% of the women. Total serum inhibin concentrations were normal for postmenopausal women, whereas serum CA-125 was elevated in two women. Conclusions:We find that the description and detection of postmenopausal ovaries by transvaginal ultrasonography allows the identification of both ovaries in most postmenopausal women. Ultrasonography-detected abnormalities of the ovary and/or the uterus/endometrium are common in women at this stage of life. The potential need for surgical intervention after the detection of such abnormalities needs to be carefully evaluated when considering transvaginal ultrasonography as a screening tool for ovarian cancer.

Fetal cardiac diagnosis and its influence on the pregnancy and newborn--a tertiary centre experience.

Objectives: To evaluate the impact of an abnormal fetal cardiac scan on the management of the pregnancy and the outcome of the newborn. Methods: We reviewed all pregnancies that were referred to the Fetal Cardiac Unit for assessment to determine if the finding of a cardiac abnormality influenced the pregnancy and fetus, timing and mode of delivery, the treatment and outcome of the newborn. Diagnoses were confirmed by echocardiography following the baby’s delivery. Results: Between January 2005 and July 2006, there were 251 detailed fetal cardiac scans carried out on at risk pregnancies or those with suspected abnormal scans in 127 fetuses. Seven of the 92 mothers with abnormal fetal cardiac scans opted for termination. Two were successfully treated during the pregnancy for hydrops fetalis arising from a tachyarrhythmia. One was induced early because of deterioration of fetal well-being and increasing cardiac size. Twenty-six infants required a prostaglandin infusion prior to surgery. Two required intensive care for associated malformations. There were 24 survivors following complex surgery, and 2 deaths. Two infants with severe tricuspid valve incompetence from a dysplastic valve died, one associated with a septicaemia and the other where surgery was delayed because of prematurity and low birth weight. There was no maternal morbidity or mortality. Conclusions: Early detection of fetal cardiac malformation allows for careful counselling of the parents, ongoing antenatal review with a planned site and timing of delivery, and anticipatory postnatal care for optimum outcomes. The importance of careful screening is emphasized to allow for referral of mothers with potentially abnormal scans to an appropriate tertiary centre for confirmation and management.

Fibroid-Associated Heavy Menstrual Bleeding: Correlation Between Clinical Features, Doppler Ultrasound Assessment of Vasculature, and Tissue Gene Expression Profiles

Despite the prevalence of uterine fibroids (Fs), few studies have investigated the links between clinical features and the cellular or molecular mechanisms that drive F growth and development. Such knowledge will ultimately help to differentiate symptomatic from asymptomatic Fs and could result in the development of more effective and individualized treatments. The aim of this study was to investigate the relationship between ultrasound appearance, blood flow, and angiogenic gene expression in F, perifibroid (PM), and distant myometrial (DM) tissues. We hypothesized that angiogenic gene expression would be increased in tissues and participants that showed increased blood flow by Doppler ultrasound. The study was performed using Doppler ultrasound to measure blood flow prior to hysterectomy, with subsequent tissue samples from the F, PM, and DM being investigated for angiogenic gene expression. Overall, PM blood flow (measured as peak systolic velocity [PSV]) was higher than F blood flow, although significant heterogeneity was seen in vascularity and blood flow between different Fs and their surrounding myometrium. We did not find any correlation between PSV and any other clinical or molecular parameter in this study. We identified 19 angiogenesis pathway-related genes with significant differences in expression between F and DM, and 2 genes, matrix metalloproteinase 9 (MMP9) and Neuropilin 2 (NRP2), that were significantly different between F and PM. These results are consistent with subtle differences between PM and DM. Understanding the differences between symptomatic versus asymptomatic Fs may eventually lead to more effective treatments that directly target the source of heavy menstrual bleeding.

The effect of image size on screen-positive rates for nuchal translucency screening

It has been shown previously that the absolute measurement of nuchal translucency (NT) thickness, one of the most effective screening tests for fetal Down syndrome, significantly decreases with increasing image size. We undertook a prospective study to assess whether this effect materially alters the NT‐derived risk estimation for fetal Down syndrome. In 350 women, NT was measured at both 100 and 200% image sizes. The median NT measurement at 200% was 8% smaller than at 100%. The screen‐positive rates at 100 and 200% image sizes were 5.1% (18/350) and 2.3% (8/350), respectively (P= 0.048). Altering the image magnification settings is likely to decrease the sensitivity of NT‐derived Down syndrome risk estimation. Further study is required to test the effect of our finding on the sensitivity of NT screening and to assess whether adjustments in gain settings mitigate the effect.

Acoustic streaming: a new technique for assessing adnexal cysts

To determine whether acoustic streaming has clinical value in the differentiation between various ovarian and adnexal cysts.

Continuous measurement of tissue pH in the human fetal scalp.

A method for continuous measurement of scalp tissue pH is described. The tissue pH probe was found to be robust and values for tissue pH were close to those for scalp blood pH. Combining the pH and fetal heart rate (FHR) electrodes in the one mechanical assembly facilitated application to the fetal scalp in early labour but the combined assembly electrode was found to have some disadvantages and manufacture of a separate tissue pH electrode is recommended. Continuous monitoring of scalp tissue pH enables closer study of the physiological basis of changes in fetal acid base status and should prove useful to the obstetrician in management of high risk pregnancies during labour.

Isolated ventriculomegaly on prenatal ultrasound: What does fetal MRI add?

Cerebral ventriculomegaly is one of the most commonly detected fetal anomalies at the midtrimester ultrasound. Current evidence suggests that magnetic resonance imaging (MRI) is indicated when the isolated ventriculomegaly (IVM) on ultrasound is severe (>15 mm), but there is less agreement when IVM is mild or moderate (10–15 mm). The current study aimed to determine the frequency and nature of additional findings on MRI in IVM and their relationship to the severity of VM and gestational age.

Prognostic factors of severe foetal megacystis.

Background:  At antenatal ultrasound, severe megacystis implies high foetal mortality rate. Traditionally, many of these foetuses undergo termination of pregnancy. We undertook a study to investigate the prognostic factor(s) for megacystis foetuses.

Ovarian status in healthy postmenopausal women: follow-up 12 months after transvaginal ultrasound

Objective: We have previously reported on the point prevalence of ovarian lesions detected by transvaginal ultrasound (TVU) in 515 asymptomatic women at least 5 years postmenopause. The aims of this study were to report, in the same women, on the repeatability of visualization of the ovaries (TVU) and the natural history of ovarian lesions seen at baseline but not treated surgically and to assess whether any women developed new ovarian abnormalities 12 months later. Methods: The study involved a cohort of 515 postmenopausal women recruited from the community, at least 5 years past their last period. They were assessed at baseline and again after 12 months with TVU and serum levels of inhibin and CA-125. Results: The right and left ovaries were seen on both occasions in 80% and 68% of women, respectively. Of the 49 women who had an ovarian lesion at baseline, did not undergo surgery at that time, and had a follow-up TVU, the lesion was unchanged 12 months later in 30 women. Four women developed a new ovarian lesion within the 12 months. None of the 14 women who underwent surgery on the basis of the ovarian appearance at baseline, or the 2 who had surgery on the basis of the ovarian appearance at follow-up, had an ovarian malignancy. Conclusions: The use of TVU in women at least 5 years after menopause is problematic because the ovaries cannot be visualized in all women and because TVU has the potential to identify many benign lesions that would otherwise remain undetected. These are important considerations in weighing up the risks and benefits of using TVU as a screening tool.