Wellington de Paula Martins

Aterosclerose carotídea avaliada pelo eco-Doppler: associação com fatores de risco e doenças arteriais sistêmicas

Background: A high prevalence of carotid atherosclerosis in the population and its frequent association with several risk factors contribute to high morbidity and mortality rates. Objective: To investigate frequency and association of extracranial carotid atherosclerosis with age, sex, hypertension, ischemic coronary disease, smoking, type 2 diabetes mellitus, obesity, peripheral arterial disease, stroke, carotid occlusion, intima-media thickness and kinking. Methods: The carotid and bilateral extracranial arteries of 367 individuals (132 males and 235 females), with a mean of 63 years of age (35-91 years) were evaluated via anamnesis, clinical semiology and ultrasonography. The possible association between carotid atherosclerosis, represented by unspecific atheromatous plaques with stenosis > 10% or discrete and diffuse atheromatosis with stenosis < 10% and the risk factors listed above was statistically analyzed by the odds ratio with a confidence interval of 95%. Results: The frequency of carotid atherosclerosis and intima-media thickness was, respectively, 52 and 30.2%. There was an association between atherosclerosis types and age (≥ 64 years), stroke, obesity and smoking. When only carotid stenosis ≥ 60% was considered, there was an association with age (≥ 64 years), carotid occlusion and coronary disease. Intima-media thickness was associated with age (≥ 64 years), kinking, carotid occlusion, hypertension and ankle-brachial index < 0.9. Conclusion: Carotid atherosclerosis is highly prevalent in the population (52%) and is associated with age, obesity, stroke, coronary disease, and smoking.

EP27.11: Normal/arcuate vs septate uterus: interobserver reliability/agreement of currently used measurements

withdrawn EP27.11 Normal/arcuate vs septate uterus: interobserver reliability/agreement of currently used measurements A. Ludwin2,9, W.P. Martins5,4, C.O. Nastri4,5, I. Ludwin2,9, M.A. Coelho Neto4, V. Leitão4, M. Acién10, J. Alcazar8, B.R. Benacerraf3, G. Condous1, R.L. De Wilde17, M.H. Emanuel6, W.E. Gibbons11, S. Guerriero7, W.W. Hurd12, D. Levine13, S. Lindheim14, A. Pellicer15, F. Petraglia15, E. Saridogan16 1Obstetrics and Gynecology, Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia; 2Department of Gynecology and Oncology, Chair of Gynecology and Obstetrics of Jagiellonian University, Krakow, Poland; 3Harvard Medical School, Brookline, MA, USA; 4Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil; 5Reproductive Medicine, SEMEAR fertilidade, Ribeirao Preto, São Paulo, Brazil; 6Obstetrics and Gynecology, Spaarne Hospital, Hoofddorp, Netherlands; 7Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; 8Obstetrics and Gynecology, University of Navarra, Pamplona, Spain; 9Ludwin and Ludwin Gynecology, Krakow, Poland; 10San Juan University Hospital/Miguel Hernández University, Alicante, Spain; 11Baylor College of Medicine, Houston, TX, USA; 12Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology, Duke University Medical Centre, Durham, NC, USA; 13Beth Israel Deaconess Medical Centre, Boston, MA, USA; 14Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA; 15Instituto Valenciano de Infertilidad, Krakow, Spain; 16University College London Hospital, London, United Kingdom; 17Carl-von-Ossietzky-University Oldenburg, Oldenburg, Germany Objectives: To evaluate the inter-observer reliability/agreement of currently used measurements to distinguish between normal/arcuate and septate uterus. Methods: We included 100 women evaluated between Jun-2016 and Jul-2016 with suspected uterine anomaly, using a single 3D data-set of each uterus. Two observers using the same initial data-set, independently manipulated the uterus to obtain the coronal plane and performed the following measurements blinded to each other results: indentation depth, indentation angle, and uterine fundal wall thickness; the latter was used to calculated the indentation to wall thickness (I:WT) ratio. Inter-observer reliability and agreement of indentation depth, angle and I: WT ratio were assessed by concordance correlation coefficient (CCC) and limits of agreement (LoA). Results: The inter-rater reliability of indentation depth (CCC=0.99, 95%CI=0.98-0.99) was significantly better than both indentation angle (CCC=0.96, 95%CI=0.94-0.97) and I:WT ratio (CCC=0.92, 95%CI=0.90-0.94). The LoA were: indentation depth = -1.7mm to +2.1mm; indentation angle = -17◦ to +16◦; and I:WT ratio = -75% to + 96%. Conclusions: Among the three measurements frequently used to distinguish between normal/arcuate and septate uterus, the indentation depth was the most reliable; differences up to ± 2mm are expected if the measurement is repeated by another observer. EP27.12 Abstract withdrawn EP28: BLEEDING, ENDOMETRIAL AND MYOMETRIAL PATHOLOGY EP28.01 Uterine artery pseudoaneurysm with coexisting artrovenous malformation F. Buonomo1, R. Federico1, R. De Leo2, M. Mirandola1, T. Stampalija1, G. Ricci1 1Institute of Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy; 2Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy A 33-year old woman with a massive uterine bleeding occurred after a LPS treated uterine rupture due to a miomectomy scar pregnancy. US revealed an anechoic intramiometrial lesion surrounded by multiple tubular anechoic lesions distributed in the myometrium. 2D US and Colour Doppler sonography revealed a central arterial-like turbulent, low impedance blood flow inside the lesion. The hypothesis was of a uterine artery pseudoaneusysm and coexisting AV malformation. A 3DTVUS was performed to evaluate the exact position of the lesion and its angioarchitecture. The HD-flow 3D reconstruction of the resulting image revealed a large right pseudoaneurysm vascularised by an ecstatic vessel originated by the right uterine artery. Right artery embolisation was performed. 3D HD flow Doppler evaluation four days later showed persistent blood flow deriving from a collateral left uterine artery vessel. The patient was led to left uterine artery embolisation as well. 3D reconstruction of colour/Power Doppler sonographic images can enable us to understand the spatial relationship of vessels in areas where complex structures are present. 3D-US can provide additional information useful to clinicians such as identification of the vascular connections including its feeding and draining vessel. The present case emphasises the importance of ultrasound investigation, in the management of vascular pathologies, initially with 2D grey and subsequently with Colour Doppler and 3D, both in terms of diagnostic approach of vascular defects as well as of follow up in order to assess the persistence of a turbulent flow after invasive procedures such as artery embolisation. Supporting information can be found in the online version of this abstract

P26.10: Normal/arcuate vs septate uterus: agreement among experts' subjective impression evaluating the coronal plane of the uterus on 3D ultrasound

using HDlive. The four images for each uterus were combined in a single image, and the 100 combined images (one for each uterus) were anonymised and submitted to 15 experts (5 clinicians, 5 surgeons and 5 sonologists). These experts were asked to judge the image quality of each imaging technique using an 11-point numeric scale (0-10), providing only one vote for each imaging technique. Results were summarised as median and interquartile range (IQR), and comparison across groups performed with Friedman test. Results: Considering the opinion of all fifteen experts, only MP was considered as providing significantly worse imaging quality: MP=7(6-9), VCI=8(8-10), Omniview=8(8-9), and HDlive=9(8-10); p=0.002. Considering only the five clinicians the results were: MP=7(5-9.5), VCI=8(7.5-9.5), Omniview=8(7.5-9.5), and HDlive=8(8-9.5; p=0.39). Considering only the five surgeons, the results were: MP=7(5-9.5), VCI=8(7.5-9.5), Omniview=8(7.5-9.5), and HDlive=8(8-9.5). Considering only the five sonologists, the results were: MP=7(6-8.5), VCI=8(7.5-10), Omniview=9(8.5-9.5), and HDlive=10(9-10). Conclusions: Experts showed a preference for rendered imaging techniques when assessing the coronal plane of the uterus.

P26.09: Image quality of the coronal plane of the uterus by 3D ultrasound: comparison of four techniques based on the opinion of several experts

female offspring of PCOS women already show higher androgen levels compared to the female offspring of non-PCOS women. Methods: Androgen levels were determined in maternal serum and umbilical cord blood from PCOS and non-PCOS women and the respective offspring at the Medical University of Graz, Austria, between 2012 and 2015. Results: A total of 79 PCOS and 354 non-PCOS women were recruited. The main results are shown in table 1. Conclusions: The comparison revealed that androgen levels in female offspring of PCOS and non-PCOS women do not differ although maternal hormone levels differ significantly.

EP27.02: Ultra-high magnification (IMSI) vs standard sperm selection (ICSI) for assisted reproduction

The development of Mullerian duct anomalies can be explained by two theories: the classical unidirectional caudal to cranial fusion theory and the alternative bidirectional theory suggesting that fusion proceeds simultaneously in both caudal and cranial directions. In the literature case reports inconsistent with the traditional unidirectional theory can be found. We present an uncommon case which supports the alternative theory. A 38-year-old nulligravida presented in our centre for assisted reproductive treatment because of infertility. Considering her personal history, she underwent laparoscopy with hysteroscopy in 2002 where uterus didelphys was suspected and longitudinal vaginal septum was resected. However, another laparoscopy in 2014 revealed the uterus of a normal shape. We decided to perform hysterosalpingo-foam sonography (HyFoSy) with contrast ExEmFoam®. After acquiring a 3D volume of the uterus, two catheters were placed into both external cervical canals and ExEmFoam® was continuously administered first into the left cervical canal and subsequently into the right one. The progress through uterine cavities and tubes was observed in real-time with ultrasound. Finally, a 3D volume of the uterus with contrast foam was acquired. Frontal views of the uterine cavity from 3D volume were rendered. We observed both tubes patent. As for the uterus, we found normal uterine fundus without indentation with symmetrical corns. The cavity was separated with wide septum starting from the fundus and going downwards between the cervices with the lower half of the septum relatively thin. Interestingly, the distinctive oval communication of size 5.5 x 7 mm between both uterine cavities was observed at the level of an upper and middle third of the septum. The final diagnosis of complete septate uterus with double cervix and communication between both cavities is inconsistent with the traditional embryonic theory and suggests the bidirectional theory is more probable.

P26.06: Evaluating tubal patency using three different ultrasound techniques: interobserver reliability, agreement and diagnostic accuracy

Results: 15 studies were included encompassing 3,795 women; 1,246 in the subgroup ‘mild male infertility’ and 1,188 in ‘normal semen quality’. Clinical pregnancy was reported by all studies, and there is no evidence of a difference between single and double IUI (figure 1). We could not identify a particular subgroup that could benefit from the intervention. Evidence for live birth, ectopic pregnancy, and miscarriage was too imprecise because they were reported by too few studies. Conclusions: Currently, there is no evidence to support the use of double IUI in clinical practice. It requires a second appointment and insemination, thus making the treatment more complex and expensive, without a clear evidence of a benefit. Nevertheless, evidence is still of low quality and our confidence in the effect estimate is limited: the true effect may be substantially different from the hereby demonstrated.

EP27.04: Normal/arcuate vs septate uterus: agreement between currently recommended cut-off values for measurements and experts' opinion

EP27.04 Normal/arcuate vs septate uterus: agreement between currently recommended cut-off values for measurements and experts’ opinion A. Ludwin2,9, W.P. Martins5,4, C.O. Nastri4,5, I. Ludwin2,9, M.A. Coelho Neto4, V. Leitão4, M. Acién8, J. Alcazar8, B.R. Benacerraf3, G. Condous1, R.L. De Wilde10, M.H. Emanuel6, W.E. Gibbons11, S. Guerriero7, W.W. Hurd12, D. Levine13, S. Lindheim14, A. Pellicer15, F. Petraglia16, E. Saridogan17 1Obstetrics and Gynecology, Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia; 2Department of Gynecology and Oncology, Chair of Gynecology and Obstetrics of Jagiellonian University, Krakow, Poland; 3Harvard Medical School, Brookline, MA, USA; 4Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil; 5Reproductive Medicine, SEMEAR Fertilidade, Ribeirao Preto, São Paulo, Brazil; 6Obstetrics and Gynecology, Spaarne Hospital, Hoofddorp, Netherlands; 7Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; 8Obstetrics and Gynecology, University of Navarra, Pamplona, Spain; 9Ludwin and Ludwin Gynecology, Krakow, Poland; 10Carl-von-Ossietzky-University Oldenburg, Oldenburg, Germany; 11Baylor College of Medicine, Huston, TX, USA; 12Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology, Duke University Medical Centre, Durham, NC, USA; 13Beth Israel Deaconess Medical Centre, Boston, MA, USA; 14Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA; 15Instituto Valenciano de Infertilidad, Valencia, Spain; 16University of Florence, Florence, Italy; 17University College London Hospital, London, United Kingdom

Lower limb venous diameters and haemodynamics during pregnancy and postpartum period in healthy primigravidae

Objective Analyse venous haemodynamics in healthy primigravidae during pregnancy and in the postpartum. Methods Cohort with primigravidae evaluated in the three trimesters of pregnancy and postpartum. Duplex evaluated venous diameters and reflux; air plethysmography evaluated venous filling index, ejection fraction, residual volume fraction and outflow fraction in both limbs. Results During pregnancy, diameters increased in bilateral common femoral and right infravalvar great saphenous, but returned to first trimester values after delivery. Reflux developed in one woman (5%) in the second trimester and in two more women (15%) in the third trimester. No reflux was detected in postpartum. Bilateral venous filling index was higher during pregnancy. Bilateral ejection fraction and residual volume fraction did not change. Bilateral outflow fraction increased progressively. The right limb outflow fraction in left lateral decubitus was similar. All changes returned to first trimester values after delivery. Conclusions Healthy primigravidae presented changes in lower limbs’ veins during pregnancy: diameters in bilateral common femoral and infravalvar great saphenous veins increased; new reflux was developed in 15% of women, but there was no venous hypertension. Calf muscular pump function did not change. All changes returned to first trimester values after delivery.