Vincent Y.T. Cheung

Sonography of Lower Uterine Segment Thickness and Prediction of Uterine Rupture

BACKGROUND Sonographic evaluation of the lower uterine segment was undertaken to study the degree of thinning and, thus, to predict uterine rupture. However, the best measuring technique and recommended cutoff values remain controversial. CASE Sonographic evaluation of the lower uterine segment at 36 weeks of gestation in a 31-year-old patient with prior low transverse cesarean delivery revealed a full thickness of 3.6 mm and a myometrial layer of 1.1 mm. Nevertheless, the patient experienced a large uterine rupture during a trial of labor at term. CONCLUSION In this case, there was a discrepancy between the full thickness and the myometrial layer, which could be representative of the lower uterine segment resistance. Such a case emphasizes the need for a consensus on sonographic measuring techniques for the prediction of uterine rupture.

Sonographically Guided High-Intensity Focused Ultrasound for the Management of Uterine Fibroids

High‐intensity focused ultrasound therapy has received increasing interest in the management of solid malignancies and benign tumors. Magnetic resonance imaging has always been used to define the target for controlling and monitoring the ablation. Recently, sonographically guided high‐intensity focused ultrasound has been introduced to monitor the ablation process. This article provides an overview of the background, clinical use, and treatment outcomes of sonographically guided high‐intensity focused ultrasound in the treatment of uterine fibroids.

The value of the early pregnancy assessment clinic in the management of early pregnancy complications.

OBJECTIVE To determine the value of North York Hospitals Early Pregnancy Assessment Clinic (EPAC) in the management of early pregnancy complications and its effect on the number of emergency room (ER) visits. METHODS The EPAC was opened in August 2005 at North York General Hospital. The number of patients being assessed, the sources of referral, the reasons for referral and the treatments provided in the clinic between January 2006 and December 2007 were reviewed. The number of patients attending the ER with the diagnoses of miscarriage, early pregnancy hemorrhage, and ectopic pregnancy one year prior to the opening of the EPAC (July 2004 to June 2005, year 0), during the first subsequent year (January to December 2006, year 1) and the second subsequent year (January to December 2007, year 2) were reviewed. RESULTS Of the 1448 referrals to the EPAC during the two-year period, 38% were referred from the ER, 31% from family physicians, 24% from obstetricians, 2% from midwives, and 5% from other sources. The reasons for referral included confirmed missed miscarriage (450 patients, 31%), threatened miscarriage (471, 32.5%), complete miscarriage (182, 12.6%), ectopic pregnancy (111, 7.7%), incomplete miscarriage (59, 4.1%), hyperemesis gravidarum (23, 1.6%), and others (152, 10.5%). Through arrangements made by the clinic, 200 women underwent dilatation and curettage, and 133 were administered misoprostol to induce miscarriage. Fifty-seven patients with ectopic pregnancy received medical treatment with methotrexate, and 13 patients had surgery for ectopic pregnancy. There was no significant change in the total number of patients being assessed in the ER for early pregnancy hemorrhage, miscarriage, and ectopic pregnancy before and after the opening of the EPAC. However, there was a significant reduction in the number of repeat assessments in the ER for ectopic pregnancy, from 37% in year 0 (n = 24/65) to 24% in year 1 (n = 14/54) and 14.5% in year 2 (n = 9/62). There was also a trend towards a reduction in the number of repeat assessments in the ER for hemorrhage (year 0 = 32.4%; year 1 = 29.4%; year 2 = 27.5%), and miscarriage (year 0 = 19.5%; year 1 = 12.6%; year 2 = 16.9%). CONCLUSION The EPAC is of significant value in the management of early pregnancy complications. It is particularly useful in the follow-up of patients with ectopic pregnancy and also helps to reduce the number of patients attending the ER for follow-up of other early pregnancy complications.

Non-tubal ectopic pregnancy

doi:10.1016/j.ijgo.2011.06.021 were no changes in lipid parameters or liver function tests. Dysmenorrhea, deep dyspareunia, and pelvic pain decreased significantly after 3 months of treatment (Pb0.001), and women remained significantly pain free after 6 months of treatment (Pb0.001). The present study showed the efficacy of low-dose vaginal danazol for the treatment of recurrent pain in severe endometriosis, with subjective assessment of pain intensity by visual analog scale providing an adequate assessment of 3 pain components. Locally administered danazol is absorbed and transported directly to the tissues, with serum concentrations being lower than after oral administration [4]. Vaginal danazol is reliably effective for pain relief, with limited adverse effects. However, further studies are needed to confirm the effects of long-term use in severe endometriosis. Conflict of interest

Caesarean scar pregnancy: a 10-year experience.

To review the management and outcome of all women with caesarean scar pregnancy (CSP) at a single centre.

Local Methotrexate Injection as the First-line Treatment for Cesarean Scar Pregnancy: Review of the Literature

The objective of this study was to determine the outcome of using ultrasound-guided local methotrexate injection as the first-line treatment of cesarean scar pregnancy (CSP). A literature review was performed on all eligible reports using this modality as the first-line treatment of CSP. Relevant publications were obtained from the PubMed electronic database from inception to December 2014. Ninety-six cases from 95 women reported in 17 articles were reviewed. The success rate was 73.9% after a single local methotrexate injection. An accumulated success rate of 88.5% could be achieved after additional local or intramuscular methotrexate administration. Eleven cases (11.5%) failed methotrexate treatment and required surgical interventions. Except for women with serum human chorionic gonadotropin levels higher than 100 000 IU/L, ultrasound-guided local methotrexate injection could be considered as a first-line treatment modality for CSP.

Time to Revisit the Human Chorionic Gonadotropin Discriminatory Level in the Management of Pregnancy of Unknown Location

The purpose of this study was to review the management and outcomes of all patients with pregnancy of unknown location who had serum human chorionic gonadotropin (hCG) levels greater than 1000 mIU/mL in our institution and to determine the likelihood of a subsequent normal intrauterine pregnancy at different hCG discriminatory levels.

Ovarian Reserve After Ultrasound-Guided High-Intensity Focused Ultrasound for Uterine Fibroids: Preliminary Experience

OBJECTIVE To determine the effect on ovarian reserve of ultrasound-guided high-intensity focused ultrasound (HIFU) in the treatment of uterine fibroids. METHODS We performed a mid-study analysis of markers of ovarian reserve using data from a prospective cohort study evaluating the safety of ultrasound-guided HIFU for uterine fibroids. Blood samples obtained from 12 women with uterine fibroids less than one week before treatment were used for measurement of serum anti-Mullerian hormone (AMH), and this testing was repeated in the first, third, sixth, and 12th month after ultrasound-guided HIFU treatment. RESULTS Fourteen fibroids from 12 patients were treated using ultrasound-guided HIFU. The median baseline fibroid volume was 101.2 cm(3) (range 18.5 to 349.2 cm(3)). The median treatment time was 140.5 minutes (46 to 192 minutes), and median sonication time was 1449 seconds (range 541 to 2445 seconds). The median energy delivered was 575 521.5 joules (range 216 400 to 898 273 joules). The median AMH levels (ng/mL) before treatment and at one, three, six, and 12 months after treatment were 0.3 (range 0.01 to 1.94), 0.47 (0.01 to 1.43), 0.205 (0.01 to 1.81), 0.26 (0 to 2.37), and 0.06 (0.02 to 1.04), respectively. There was no significant difference between the AMH levels before and at any time after treatment. No patient became amenorrheic or reported symptoms suggestive of menopause after treatment. CONCLUSION Our preliminary experience suggests that ovarian reserve does not seem to be affected by ultrasound-guided HIFU in the treatment of uterine fibroids.

Two-dimensional versus three-dimensional laparoscopy: evaluation of physicians' performance and preference using a pelvic trainer

STUDY OBJECTIVE To compare the proficiency and preference of physicians in performing standard tasks in a box trainer using 2-dimensional (2D) versus 3-dimensional (3D) laparoscopy. DESIGN Prospective randomized controlled trial. DESIGN CLASSIFICATION Prospective, randomized controlled trial (Canadian Task Force classification I). SETTING Tertiary care teaching hospital. PARTICIPANTS Thirty physicians from the Department of Obstetrics and Gynecology. INTERVENTION Participants were randomly assigned to perform a set of 3 to 4 tasks in a pelvic trainer using 2D laparoscopy first and then 3D laparoscopy, and vice versa. MAIN RESULTS AND MEASUREMENTS The time taken to complete the tasks and side effects experienced were noted. Participants were asked to complete a modified Global Operative Assessment of Laparoscopic Skills (GOALS) form at the end of their tasks to evaluate their experiences and to assess their own proficiency with both visual modalities. RESULTS The time taken for peg transfer, duct cannulation, and suturing was significantly faster using 3D laparoscopy compared with 2D laparoscopy. There were no significant differences in the time taken for pattern cutting with both visual modalities. Participants experienced more dizziness using 3D laparoscopy (6.9% vs 37.9%; p = .004). The GOALS self-evaluation score was significantly higher for 3D compared with 2D laparoscopy. After the study, 11 of 29 (37.9%) participants preferred 2D, 16 of 29 (55.2%) preferred 3D, and 1 of 29 (8.3%) had no preference. CONCLUSION Although 3D laparoscopy scored higher on self-evaluation and was preferred by more participants, it only gave better objective performance in the completion of some selected tasks by participants with intermediate skill levels and was associated with more dizziness. Further studies are needed to determine the value of 3D laparoscopy, especially when used in the clinical setting.

Cesarean scar molar pregnancy

BACKGROUND: Molar pregnancy found in a cesarean scar is exceedingly rare. It can be challenging to manage and can have potentially catastrophic consequences. CASE: A 34-year-old multigravid woman presented with persistent symptoms of pregnancy after a surgical termination of pregnancy. Cesarean scar molar pregnancy was suspected on ultrasonography, and suction evacuation was performed under ultrasound guidance. This was followed by bimanual compression, oxytocin, and uterine artery embolization to reduce bleeding. CONCLUSION: A high index of suspicion is needed for early diagnosis and management of cesarean scar molar pregnancy.