Pekka Ylöstalo

Ultrasound screening and perinatal mortality: controlled trial of systematic one-stage screening in pregnancy

During a 19-month period, 95% of all pregnant women in the greater Helsinki area, Finland, entered a study to compare one-stage ultrasonography screening with selective screening according to antenatal hospital use, obstetric procedures, and fetal outcomes. Of 9310 women who entered the trial, 4691 were randomly allocated to ultrasound screening between the 16th and 20th gestational weeks and 4619 to follow-up only. Screened and control groups otherwise had the same antenatal care, which included ultrasonography according to usual practice. Screened women made fewer visits to the antenatal outpatient clinic than did women in the control group (2.3 vs 2.6). There were no differences in the number of labour inductions or mean birthweights in the two groups. Perinatal mortality was significantly lower in the screened than in the control group (4.6/1000 vs 9.0/1000); this 49.2% reduction was mainly due to improved early detection of major malformations which led to induced abortion. All twin pregnancies were detected before the 21st gestational week in the screening group compared with 76.3% in the control group; perinatal mortality in the small series of twins was 27.8/1000 vs 65.8/1000, respectively.

Increased Nuchal Translucency as a Marker for Fetal Chromosomal Defects

BACKGROUNDnScreening for trisomy 21 (Downs syndrome) by measuring maternal serum alpha-fetoprotein, chorionic gonadotropin, and estriol concentrations and then performing chorionic-villus sampling or amniocentesis identifies approximately 60 percent of fetuses with this disorder. We used ultrasonography to detect increased nuchal translucency and cystic hygroma, which are characteristic features of fetuses with chromosomal defects.nnnMETHODSnWe performed transvaginal ultrasonography in 10,010 unselected adolescents and women less than 40 years of age with live singleton fetuses at 10 to 15.9 weeks of gestation. Increased fetal nuchal translucency was defined as an area of translucency at least 3 mm in width, and cystic hygromas were defined as septated, fluid-filled sacs in the nuchal region. Subjects whose fetuses had these findings were offered fetal karyotyping. Information on pregnancies, deliveries, and neonates was subsequently obtained from hospital records and national birth and malformation registries.nnnRESULTSnNuchal translucency or cystic hygroma was seen in 76 fetuses (0.8 percent), of which 18 (24 percent) had an abnormal karyotype. The sensitivity for trisomies 21, 18, and 13 combined was 62 percent (13 of 21 fetuses), and the sensitivity for trisomy 21 alone was 54 percent (7 of 13 fetuses).nnnCONCLUSIONSnThe use of transvaginal ultrasonography to detect increased nuchal translucency and cystic hygroma is a sensitive test for fetal aneuploidy. It can be done earlier in pregnancy than serum screening, and it decreases the subsequent need for chorionic-villus sampling or amniocentesis.

Transvaginal sonography and hysteroscopy in postmenopausal bleeding

We compared transvaginal sonography and hysteroscopy with dilatation and curettage findings in 45 women with atypical postmenopausal bleedings. The histological diagnosis was atrophy in eight (17.8%) women. hormonal effects in 14 (31.1%), endometrial polyp in 19 (42.2%) xnd adenocarcinoma in four (8.8%). Hysteroscopy detected 16 (78.9%) of the 19 cases wirh polyps and two of the four with carcinoma. Sensitivity and specificity for endometrial pathology were 86.9% and 91.7% respectively. A polyp was directly diagnosed by transvaginal sonography in 13 (57.9%) women and an infiltrative endometrial cancer in two. Sensitivily and specificity for endometrial pathology were 73.9%) and 95.7% respectively. All but one case of endometrial pathology were found when the endometrium (both layers) was thicker than 5 mm. Thus, an endometrial thickness of ≥ 5 mm had a sensitivity of 95.7%, a specificity of 45.5% and a positive predictive value of 64.7% for endometrial pathology. This study shows that transvaginal scanning allows detection of an endometrial pathology in the vast majority of cases and it may be used as the first diagnostic step in the investigation of women with atypical postmenopausal bleeding.

Serum human chorionic gonadotropin dynamics during spontaneous resolution of ectopic pregnancy

OBJECTIVEnTo study serum hCG dynamics in patients with ectopic pregnancy (EP) selected for expectant management.nnnDESIGNnA prospective observational study.nnnSETTINGnHelsinki University Central Hospital, Helsinki, Finland.nnnSUBJECTSnOne hundred eighteen patients, who were selected for expectant management among 493 patients with EP.nnnINTERVENTIONSnPatients were examined every 1 to 3 days using transvaginal sonography and serum hCG determinations until hCG values < 10 IU/L (conversion factor to SI unit, 1 IU/L = 2.93 pmol/L) were reached. Laparoscopy was performed if the patient developed abdominal pains or intra-abdominal hemorrhage as revealed by sonography.nnnMAIN OUTCOME MEASUREnSerum hCG level.nnnRESULTSnThe median gestational age at the start of follow-up in patients with a spontaneous resolution was 44 days and in patients requiring laparoscopy was 48 days. The success rate for a spontaneous resolution was 88% when the initial hCG level was < 200 IU/L but only 25% at levels > 2,000 IU/L. In the 77 patients with a spontaneous resolution, the initial median hCG concentration was 374 IU/L (range, 20 to 10,762 IU/L) and it decreased to normal in 4 to 67 days (mean, 20 days). In the 41 patients requiring laparoscopy the median initial hCG concentration was 741 IU/L (range, 165 to 14,047 IU/L); a normal level was reached in 3 to 43 days (mean, 12 days) after operation. Follow-up period before operation was 1 to 24 days (mean, 9 days). Laparoscopy was indicated in two thirds of the patients with a serum hCG level > 64% of the initial value after 7 days of follow-up.nnnCONCLUSIONSnSpontaneous resolution of EP correlated with a low and rapidly decreasing hCG level.

Early screening for ectopic pregnancy in high-risk symptom-free women

We screened 225 symptom-free pregnant women at increased risk for ectopic pregnancy with transvaginal sonography and human chorionic gonadotropin (hCG) assays. Among 55 (24.4%), who proved to have an ectopic pregnancy, 46 (84%) cases were diagnosed at the initial screening at a median of 37 days of gestation, and the rest at repeated scans. The false-positive rate was 1.2%. Early diagnosis prevented tubal rupture, substantial haemorrhage, and the need for emergency care, allowing elective treatment. Such early surveillance reduced the risk of complications and facilitated treatment, and should be offered to at-risk women.

Preoperative sonographic evaluation of endometrial cancer

Preoperative sonography was performed in 93 patients with a histologic diagnosis of endometrial cancer. Uterine volume was enlarged (mean, 164 +/- 143.7 cm3; range, 25 to 800) but did not significantly correlate with the degree of myometrial invasion. Endometrial echoes were identified in 93.5% of the cases. A significant correlation (p less than 0.01, Newman-Keuls test) was found between endometrial echoes volume and myometrial invasion. Myometrial invasion was correctly predicted by sonography in 80% of the cases. Polypoid intraluminal growth was the most common factor affecting sonographic accuracy. Sonographic staging was accurate in 91% of the cases. Sonography appears to be an efficient, economic, and practical tool for clinical staging of endometrial cancer.

Suspected ectopic pregnancy: ultrasound findings and hCG levels assessed by an immunofluorometric assay

Summary. One hundred suspected ectopic pregnancies were assessed by ultrasound on the basis of the following criteria: (A) viable intrautcrine fetus, intrauterine pregnancy is certain; (B) intrauterine double sac or eccentric ring, intrauterine pregnancy is probable; (C) empty uterus or central ring but no adnexal mass or cul‐de‐sac fluid, ectopic pregnancy is possible; (D) empty uterus or central ring and an adnexal mass or cul‐de‐sac fluid, ectopic pregnancy is probable; (E) viable ectopic fetus, ectopic pregnancy is certain. Serum human chorionic gonadotrophin (S‐hCG) was detected by an immunofluorometric assay (sensitivity 0.2 i.u./l, cut‐off level 10 i.u./l). All the 51 patients in groups A and B had an intrauterine pregnancy. Normal gestational sacs were found also at S‐hCG levels of <3600 i.u./l, the lowest level being 894 i.u./l. Ectopic pregnancy was confirmed in 29 of the 30 women in groups D and E. In the 19 women categorized into group C serial hCG assay and repeated sonography diagnosed ectopic pregnancy in 12 and miscarriage of an intrauterine pregnancy in the other seven. Ectopic pregnancy was always found when no gestational sac was seen by sonography and the hCG level was > 1000 i.u./l.

Low-dose oral methotrexate with expectant management of ectopic pregnancy

Objective To investigate recovery times and need for laparoscopy in women with ectopic pregnancy who were treated for 5 days 2.5 mg/day of oral methotrexate or placebo. Methods Sixty women with ectopic pregnancy among patients of an outpatient clinic specializing in early pregnancy disorders were selected for medical treatment in a double-blind, placebo-controlled study. The diagnosis was made by transvaginal sonography and serum hCG determinations, either at admission or after repeated examinations. Women were recruited for the study if they had mild symptoms: the hCG increase was less than 50% within 2 days, the diameter of the ectopic pregnancy was less than 40 mm, there were no signs of intra-abdominal bleeding by transvaginal sonography, and there were no secondary reasons for laparoscopy. Either 2.5 mg of methotrexate or placebo was given orally for 5 days. Serum hCG was determined after 2 days, and hCG, red blood cell count, white blood cell count, platelet count, and serum glutamic-oxaloacetic transaminase were measured; transvaginal sonography was performed after 5 and 12 days. Expectant management was continued individually with check-ups at 1–3-week intervals. Laparoscopy was performed if the patient developed abdominal pain or intra-abdominal hemorrhage, as seen by transvaginal sonography. Statistical analysis was by paired or unpaired t test, Mann-Whitney U test, regression analysis, and repeated measures analysis of variance. Results Seventy-seven percent of the patients recovered without the need for laparoscopy in both groups, and there were no significant differences in recovery times or the need for laparoscopy between groups. Conclusion Oral methotrexate, 2.5 mg for 5 days, does not appear to be more effective than placebo in the treatment of ectopic pregnancy in women eligible for expectant management.

Fetal anomalies in a controlled one-stage ultrasound screening trial. A report from the Helsinki Ultrasound Trial.

The aim of the study was to compare whether systematic strictly timed screening of all pregnancies would improve the detection of major fetal anomalies. All pregnant women (95%) from a certain area were randomly allocated for one ultrasound screening examination between the 16th and 20th weeks of gestation. Otherwise the screening (N = 4691) and control groups (N = 4619) received the same antenatal care. Screening included a systematic search for fetal anomalies. In the screening group, 40% of major fetal anomalies were detected in the screening, and 11 abortions were induced because the malformation was either lethal or severely handicapping. In the control group, 77.0% of participants had ultrasound examination any time during pregnancy. By ultrasound 13 (27%) major fetal anomalies were detected, only two of these before the 21st week of gestation. Screening detected most of the anomalies of the central nervous system and genitourinary system and cases with multiple anomalies, but was less satisfactory in detecting the anomalies of the heart and gastrointestinal tract. The perinatal mortality rate was 4.2 per 1000 in the screening group and 8.4 per 1000 in the control group (p = 0.013). The detection of major fetal anomalies in ultrasound screening can reduce perinatal mortality. A systematic search for fetal anomalies should be included in the ultrasound screening of all pregnancies.

Diagnosis of placenta previa by transvaginal sonographic screening at 12–16 weeks in a nonselected population

Objective: To evaluate the clinical significance of placenta previa at 12–16 weeks gestation found by transvaginal sonographic screening. Methods: An unselected population of 6428 pregnant women was scanned by transvaginal sonography during 1993–1994 to assess the gestational age and to diagnose major fetal anomalies. The location of the placenta was also recorded systematically. If the edge of the placenta extended over the internal cervical os, this distance was measured with electronic calipers. Results: In 156 of 6428 patients (2.4%), the placental edge extended 15 mm or more over the internal cervical os at 12–16 weeks gestation. Eight of these patients had placenta previa at delivery. Using this criterion at screening, two cases of placenta previa at delivery were missed. The frequency of placenta previa at delivery in this nonselected population was ten of 6428 (0.16%). Conclusions: The likelihood of placenta previa at delivery is 5.1% (95% confidence interval 2.2, 9.9) if the placenta extends at least 15 mm over the internal cervical os at 12–16 weeks gestation.