Rasha A. Kamel

Three-Dimensional Sonohysterography Compared With Vaginoscopic Hysteroscopy for Evaluation of the Uterine Cavity in Patients With Recurrent Implantation Failure in In Vitro Fertilization Cycles

STUDY OBJECTIVE To estimate the degree of agreement between 3-dimensional sonohysterography (3D-SHG) and vaginoscopic hysteroscopy (VH) in detection of uterine cavity abnormalities in patients with recurrent implantation failure in in vitro fertilization cycles. DESIGN Comparative observational cross-sectional study (Canadian Task Force classification II-1). SETTING Private assisted-conception unit. PATIENTS One hundred forty-three patients with a history of at least 2 previous implantation failures despite transfer of good quality embryos in assisted-conception cycles. INTERVENTIONS 3D-SHG was followed by VH. The Cohen κ for interrater agreement was calculated for the level of agreement between the 2 diagnostic procedures. Procedure time in seconds was recorded for both procedures. Patients were asked to rate their degree of discomfort or pain during both procedures using a visual analog scale. MEASUREMENTS AND MAIN RESULTS There was a substantial degree of concordance between 3D-SHG and VH (κ = 0.77; 95% confidence interval, 0.6-0.84). The median procedure time for 3D-SHG was 296 seconds (range, 231-327 seconds), and for VH was 315 seconds (range, 232-361 seconds), and the difference was statistically significant (p =.02). The visual analog scale pain scores also showed that 3D-SHG, with a median pain score of 2.1 (range, 1-3) was better tolerated than VH, with a median pain score of 2.9 (range, 2-4) (p < .001). CONCLUSION Our results show that there is a substantial degree of concordance between 3D-SHG and VH in diagnosing uterine cavity anomalies. We also found that 3D-SHG took significantly less time and induced less patient discomfort than did VH. We recommend that 3D-SHG should be the method of first choice for outpatient evaluation of the uterine cavity.

Quinagolide compared with cabergoline in the prevention of ovarian hyperstimulation syndrome: a randomized trial

Objective The aim of the present study was to compare quinagolide with cabergoline in the prevention of ovarian hyperstimulation syndrome (OHSS) in at-risk patients undergoing in-vitro fertilization (IVF) treatments and to compare the pregnancy rate, the tolerability and the complication rate of the two drugs. Study design A randomized controlled trial. Patients and methods A total of 112 patients undergoing IVF/intracytoplasmic sperm injection long luteal GnRH agonist procedure considered at risk of OHSS were randomized into two groups. Group I patients received quinagolide 75 µg and group II patients received cabergoline 0.5 mg for 8 days starting from the day of human chorionic gonadotrophin injection. Results The total number of patients who developed OHSS in our study was similar in the two groups, with nine (16.1%) patients in the quinagolide group compared with 11 (19.6%) in the cabergoline group (P=0.81). However, the majority of these patients developed only mild OHSS comprising 55.6% in the quinagolide group and 63.6% in the cabergoline group. There was no statistical difference between the two groups regarding the incidence of early OHSS (P=0.77) or late OHSS (P=1.0). Severe/critical grades of OHSS occurred in only 3.6% of the cases in the quinagolide group and 1.8% of the cases in the cabergoline group, whereas the incidence of moderate OHSS was 3.6 and 5.4% in the quinagolide and the cabergoline groups, respectively. Quinagolide was responsible for significantly more nausea (P=0.03) and vomiting (P=0.009) than cabergoline, but there was no statistically significant difference between the two groups regarding other side effects. Conclusion Quinagolide seems to be just as effective as cabergoline in the prevention of OHSS in at-risk patients undergoing IVF treatments.

How reliable is fetal occiput and spine position assessment prior to induction of labor

To assess the reliability of fetal occiput and spine position determination in nulliparous women prior to induction of labor (IOL), and to evaluate identification of fetal occiput and spine positions prior to IOL in the prediction of labor outcome.

Levator ani muscle co-activation at term is associated with a longer second stage of labor in nulliparous women: Levator ani muscle co-activation and second stage of labor

To assess the effect of levator ani muscle (LAM) coactivation at term on outcome of labor in nulliparous women.

OP17.07: Intermethod agreement between mid-sagittal and parasagittal measurements of the angle of progression in labour: Short oral presentation abstracts

Methods: In this prospective observational study, we included women in active first stage of labour for whom we obtained static and dynamic measurements (at uterine contraction and maternal bearing down) of AOP using 2D ultrasound, then vaginal examination was performed and degree of cervical dilatation recorded (US images stored, AOP measurement was done by second operator blind to examination and obstetricians conducting delivery were blinded to US). AOP were compared between women with Caesarean delivery (CD) and those with vaginal delivery. Receiver–operating characteristics (ROC) curves were constructed to assess the accuracy in the prediction of CD. Further classification was done to compare performance of AOP measured with cervical dilatation ≤5cm & >5cm, both static and dynamic. Results: 119 women were included in the study. 90 (76%) delivered vaginally while 29 had CD (24%). Women undergoing CD had significantly narrower AOP at rest (93 vs 104,P=0.001) and under maternal pushing (102 vs 118,P<0.0001). AUC for AOP prediction of CD was 69% (95%CI, 58-80%)(P=0.002) and 74% (95%CI, 64-84%) (P<0.001), for static and dynamic assessment, respectively. Comparing ROC curves for dynamic versus static assessment, the difference was not statistically significant p = 0.2. AUC for AOP measured at cervical dilatation ≤5cm was 72% (95%CI,57-86%)(P=0.005) and 64% (95%CI,48-80%)(P=0.1) for cervical dilatation>5cm. While in dynamic assessment, AUC for prediction of CD; for AOP measured at cervical dilatation ≤5cm was 78% (95%CI,66-90%)(P<0.001) and 64% (95%CI,46-81%) (P=0.1) at cervical dilatation>5cm. Comparing ROC curves for early versus late assessment, the difference was not significantly significant p = 0.2 both in static and dynamic measurements. Conclusions: Performance AOP in predicting CD, measured in first stage of labour static or dynamic, is not dependant on degree of cervical dilatation.

Contraction of the levator ani muscle during Valsalva maneuver (co-activation) is associated with a longer active second stage of labor in nulliparous women undergoing induction of labor

Background: The Valsalva maneuver is normally accompanied by relaxation of the levator ani muscle, which stretches around the presenting part, but in some women the maneuver is accompanied by levator ani muscle contraction, which is referred to as levator ani muscle coactivation. The effect of such coactivation on labor outcome in women undergoing induction of labor has not been previously assessed. Objective: The aim of the study was to assess the effect of levator ani muscle coactivation on labor outcome, in particular on the duration of the second and active second stage of labor, in nulliparous women undergoing induction of labor. Study Design: Transperineal ultrasound was used to measure the anteroposterior diameter of the levator hiatus, both at rest and at maximum Valsalva maneuver, in a group of nulliparous women undergoing induction of labor in 2 tertiary‐level university hospitals. The correlation between anteroposterior diameter of the levator hiatus values and levator ani muscle coactivation with the mode of delivery and various labor durations was assessed. Results: In total, 138 women were included in the analysis. Larger anteroposterior diameter of the levator hiatus at Valsalva was associated with a shorter second stage (r = ‐0.230, P = .021) and active second stage (r = ‐0.338, P = .001) of labor. Women with levator ani muscle coactivation had a significantly longer active second stage duration (60 ± 56 vs 28 ± 16 minutes, P < .001). Cox regression analysis, adjusted for maternal age and epidural analgesia, demonstrated an independent significant correlation between levator ani muscle coactivation and a longer active second stage of labor (hazard ratio, 2.085; 95% confidence interval, 1.158–3.752; P = .014). There was no significant difference between women who underwent operative delivery (n = 46) when compared with the spontaneous vaginal delivery group (n = 92) as regards anteroposterior diameter of the levator hiatus at rest and at Valsalva maneuver, nor in the prevalence of levator ani muscle coactivation (10/46 vs 15/92; P = .49). Conclusion: Levator ani coactivation is associated with a longer active second stage of labor.

Does maternal dexamethasone improve autoimmune-associated congenital heart block?

Objective The aim of this study was to detect cases of autoimmune-related congenital heart block (CHB) by measuring the fetal PR interval and to determine whether treatment of affected cases with maternal oral dexamethasone will result in resumption of normal sinus rhythm (NSR). Study design This was a prospective observational study. Patients and methods A total of 96 pregnant patients known to have an autoimmune disease with documented positive anti-SSA/Ro and/or anti-SSB/La antibodies at 20–22 weeks of gestation were recruited. Of these, 67 (69.7%) patients had systemic lupus erythematosus (SLE), whereas 29 patients (30.2%) had Sjögren’s syndrome (SS). All recruited patients had a Doppler study of the fetal heart to measure the mechanical PR interval. Patients with any degree of CHB who were not on steroid therapy before were started on daily oral dexamethasone. Patients with prolonged fetal PR interval, originally taking prednisone, were converted to an equivalent dose of dexamethasone. All recruited patients underwent a follow-up scan at 32–34 weeks. Results Twenty-two patients with SLE and seven patients with SS had CHB of varying degrees. More patients with SLE had a previous child with CHB (22.4%) than patients with SS (10.3%), but the difference was not statistically significant (P=0.16). Patients with a previous history of an affected child with CHB represented 15% of the study population (15/67 patients with SLE and 3/29 patients with SS). Of these 18 patients, 15 (83.3%) had a fetus with prolonged PR interval in the present study. Of the treated patients, four fetuses had second-degree CHB and two fetuses had complete CHB and none of these fetuses reverted to NSR, whereas three of these fetuses developed hydrops and died before the follow-up scan at 32–34 weeks. However, 55% (11/20) of fetuses with first-degree CHB were found to revert to NSR at 32–34 weeks. Conclusion Fetuses of patients with positive anti-SSA and/or anti-SSB antibodies are at a risk of CHB, especially if they have previous affected siblings. Measurement of the PR interval seems to be an appropriate method for detection of this condition. Prompt treatment of first-degree CHB with maternal oral dexamethasone may help revert some fetuses to NSR.

Assessment of fetal cardiac function using the modified myocardial performance index in third-trimester fetuses of diabetic mothers

Objective To determine whether the fetal cardiac function is impaired in fetuses of diabetic mothers in the third trimester using the Doppler-based modified myocardial performance index (Mod-MPI) compared with gestational age-matched controls. Study design A cross-sectional observational study. Patients and methods The study included 45 diabetic pregnant women in the third trimester and 52 gestational age-matched controls. Measurement of glycosylated hemoglobin level (HbA1c) was performed to validate the quality of metabolic control. Selected patients underwent a fetal echocardiographic examination to determine the Mod-MPI. The isovolumetric contraction time (ICT) was measured from the closure of the mitral valve to the opening of the aortic valve (AV), the ejection time (ET) from the opening to the closure of the AV, and the isovolumetric relaxation time (IRT) from the closure of the AV to the opening of the mitral valve. The Mod-MPI was calculated as (ICT+IRT)/ET. Results A total of 28 patients in the diabetic group had well-controlled diabetes, whereas the remaining 17 patients with a serum HbA1c more than 7% had poorly controlled diabetes. The IRT was significantly shorter in the control group than both the well-controlled diabetics (P<0.01) and the poorly controlled diabetics (P<0.001). The overall Mod-MPI was statistically significantly lower in the control group than the study group as a whole (P<0.001) as well as in the poorly controlled diabetics (P<0.001), but although it was lower than in the well-controlled diabetics, the difference did not reach statistical significance (P=0.053). Conclusion Fetuses of diabetic mothers show evidence of third trimesteric diastolic myocardial dysfunction as shown by a higher Mod-MPI than age-matched controls that appears more marked in fetuses of mothers with poorly controlled diabetes.

Comparison between transfrontal and axial three-dimensional ultrasound acquisition in the visualization of midline structures of the fetal brain

Objective To compare the visualization of the midline structures of the fetal brain as well as visualization of the fastigium of the fourth ventricle and the primary and secondary vermian fissures obtained by three-dimensional (3D) multiplanar reconstruction of volumes acquired from the axial plane with transfrontal 3D acquisition. Study design A prospective observational study. Patients and methods A total of 127 patients with a normal fetal anomaly scan between 18 and 24 weeks participated in this study. Fetal brain volumes for the multiplanar evaluation were obtained with the transcerebellar plane as the initial plane of acquisition, with the incident ultrasound beam making an angle of about 45° with the cerebral midline. For the transfrontal acquisition, the plane of the midsagittal fetal facial profile was obtained with the ultrasound beam aligned with the frontal suture so as to utilize the metopic suture as an acoustic window. Results The acquisition of the fetal brain in the axial plane was successful in 122 cases (96.1%), whereas the transfrontal acquisition was successful in 106 cases (83.4%), with a statistically significant difference between the two methods (P=0.002). Visualization of the median plane of the fetal brain by 3D multiplanar reconstruction was adequate in 99 out of the 122 (81.1%) volumes, whereas 94 out of the 106 (88.7%) transfrontal acquisitions resulted in adequate midline images; the difference between the two acquisition methods was not statistically significant (P=0.12). There was no statistically significant difference between the two acquisition methods in the visualization of the fastigium of the fourth ventricle or the primary and secondary vermian fissures, which were adequately visualized in 58/122 (47.5%) of the 3D multiplanar reconstructed images and in 62/106 (60.8%) of the transfrontally acquired volumes (P=0.09). Conclusion Images of the midsagittal plane of the fetal brain obtained by 3D multiplanar reconstruction of volumes acquired from axial plane are easier to acquire than the 3D transfrontal approach and result in comparable image quality, with adequate visualization of the cerebral midline as well as the main landmarks of the cerebellar vermis.

OP30.03: Classification of submucous myomas using 3D multislice saline infusion sonohysterography and its correlation with hysteroscopy

OP30.01 Interobserver agreement on reporting uterine intracavity lesions at gel infusion sonography (GIS) T. Van den Bosch1, J. Luts2, T. Bourne3,1, T. Bignardi4, G. Condous4, E. Epstein5, F. Leone6, A. Testa7, L. I. Valentin8, S. Van Huffel2, D. Van Schoubroeck1, D. Timmerman1 1Obstetrics & Gynecology, University Hospitals K.U. Leuven, Leuven, Belgium; 2Electrical Engineering, ESAT-SCD, K.U. Leuven, Leuven, Belgium; 3Obstetrics and Gynaecology, Imperial College London, Hammersmith Campus, London, United Kingdom; 4Acute Gynaecology, Early Pregnancy Advanced Endosurgery Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Sydney, NSW, Australia; 5Obstetrics & Gynecology, Lund University Hospital, Lund, Sweden; 6Obstetrics & Gynecology, Clinical Science Institute L. Sacco, University of Milan, Milan, Italy; 7Obstetrics & Gynecology, Universitá del Sacro Cuore, Rome, Italy; 8Obstetrics & Gynecology, Malmö University Hospital, Lund University, Malmö, Sweden