Sherif M.M. Negm

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.

OP19.08: Effect of prophylactic progesterone on incidence of preterm labour in spontaneous twin pregnancy, randomized controlled study

L. E. Romine1, M. Hwang5, N. Trivedi2, J. Wan4, Y. LaCoursiere2, P. Do4, K. Benirschke3, D. Schrimmer2, D. H. Pretorius1 1Radiology, University of California, San Diego, CA, USA; 2Reproductive Medicine, University of California, San Diego, CA, USA; 3Pathology, University of California, San Diego, CA, USA; 4School of Medicine, University of California, San Diego, CA, USA; 5School of Medicine, Vanderbilt University, Nashville, TN, USA

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.

Prophylactic progesterone and preterm labor in low-risk twin pregnancies

Objectives The aim of the study was to study the role of vaginal progesterone versus placebo in preventing preterm birth in twin pregnancies with a normal cervical length in the second trimester and its neonatal outcome. Study design The study was designed as a randomized controlled trial. Patients and methods A total of 100 women with twin pregnancies were enrolled and randomized to receive daily either 200 mg vaginal progesterone or placebo for 10 weeks from 24–34 weeks of gestation. They all underwent detailed first and second trimester anomaly scans and cervical length assessment. Patients with anomalies, monochorionic twins, medical disorders, or a cervical length less than 25 mm were excluded. Results Patients’ demographic details, age, weight, parity, and previous risk factors were not statistically different between the two groups. The mean cervical length was 34 mm in the progesterone group and 36 mm in the placebo group. Mean gestational age at delivery was 35.7 weeks with a mean birth weight of 2160 g in the progesterone group, which was not significantly different from the placebo group with a mean gestational age of 35.6 weeks and a mean birth weight of 2210 g. Fetal complications or neonatal ICU admissions were not different in the two groups. Conclusion Although vaginal progesterone reduces preterm birth and neonatal complications in singletons with a short cervix, its role in twin pregnancies with a normal cervical length is unclear and needs a larger study to prove its merit.

The use of human epididymis protein 4 for differentiation between benign and malignant ovarian neoplasm

Objective To assess and compare the sensitivity, specificity, and predictive values of human epididymis factor 4 (HE4) and CA125 (cancer antigen 125 or carbohydrate antigen 125) in the evaluation of ovarian masses (whether benign, endometriomas, or malignant). Patients and methods This was a prospective study carried out in Kasr Al Aini University Hospitals that included 30 patients who presented with adnexal masses and were treated surgically. Patients were divided into three groups: patients with benign ovarian masses, those with ovarian endometriomas, and those with malignant ovarian masses. Assessment of history, examination, and laboratory workup including HE4 and CA125 were carried out for all patients, in addition to abdominal and vaginal ultrasounds, surgical treatment, or staging. Results An receiver-operator characteristic curve with area under the curve in benign versus malignant ovarian lesions showed a 100% sensitivity and a 96% specificity for CA125 at a cut-off value of 40, whereas it showed a 100% sensitivity and a 67% specificity for HE4 at a cut-off value of 42.7. Conclusion In our study population, measurement of HE4 did not provide further benefit over measurement of CA125 in patients with ovarian masses (whether benign ovarian cysts, endometriomas, or malignant ovarian diseases). As the sample size of our study is small, further studies are needed to confirm or confute this result.

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