Z. Appelman

The onion skin sign: a specific sonographic marker of appendiceal mucocele.

Objective. To evaluate the association of the onion skin sign as a sonographic marker for appendiceal mucocele. Methods. The sonographic onion skin sign was considered specific for the preoperative diagnosis of appendiceal mucocele. Therefore, detection of this sign in a mass located in the right lower abdomen, unrelated to the female reproductive organs, indicated surgical intervention with a presumptive diagnosis of appendiceal mucocele. From 1998 through 2001, female patients who were found to have atypical cysts containing this sign underwent surgery. The cases were closely followed, and intraoperative findings and final histologic diagnoses were recorded. Results. Appendiceal mucocele was the final diagnosis in all 7 patients in whom the onion skin sign was observed. One additional patient had an appendiceal mucocele with a sonographic picture of a clear tubular cystic structure. Conclusions. A sonographically layered cystic mass in the right lower quadrant of the abdomen in the presence of a normal ovary strongly suggests the diagnosis of appendiceal mucocele. Recognition of the sonographic onion skin sign in a cystic mass in the right lower quadrant may facilitate the accurate preoperative diagnosis of appendiceal mucocele.

Aspiration of Simple Pelvic Cysts during Pregnancy

Traditional management of persistent ovarian cysts in pregnancy is explorative laparotomy at 16–20 weeks of gestation and resection of the tumor. Scheduling surgery to this time of pregnancy is accepted in order to prevent abortions that are common whenever surgery is done in the first trimester, without delaying treatment of ovarian tumors which harbor a malignant potential. In the following article we report of 10 cases where simple ovarian cysts diagnosed during pregnancy were successfully treated by sonographically guided cyst aspiration. This new approach is justified with no fear of missing a malignant ovarian tumor due to strict ultrasonic characteristics of benign cysts that include unilocular simple appearing cyst with no solid echogenic parts, septations or papillary structures. For 5 of the 10 women undergoing aspiration, this constituted the definitive treatment, while the remaining 5 were later operated. We conclude that aspiration of simple cysts during pregnancy is safe, may save surgical intervention and in some cases this will be the definitive treatment.

Intractable postpartum bleeding due to placenta accreta : local vasopressin may save the uterus

A 41 year old woman presented with painless vaginal bleeding at term (39 completed weeks) of her first pregnancy; her antenatal course was unremarkable. A cardiotocography revealed a normal fetal heart rate pattern with irregular contractions. An ultrasonographic examination revealed a central placenta praevia, and therefore we proceeded with a caesarean section. A healthy male infant weighing 3030 g was born. The placenta completely covered the internal os, and no plane of cleavage could be found at the posterior attachment of the placenta. On attempting to remove the placenta, severe bleeding occurred, and several obstetric and pharmacological manoeuvers were undertaken immediately, including intravenous oxytocin (20 mIU/min), intramyometrial methylergometrine (total dose 0-4 mg), intramyometrial 15-methyl prostaglandin F,, (total dose 0.75 mg), and administration of blood, blood components and electrolytes. Altogether the patient received seven units of packed cells. Digital removal of placental tissue, direct uterine massage, intrauterine packing, sutures of placental bed, bilateral ligation of uterine arteries and finally bilateral ligation of hypogastric arteries were performed. Despite these measures, bleeding continued although to a lesser extent. At this stage we infiltrated vasopressin (1 mL [= 5 IU] diluted with 19 mL NaCl 0.9%) six to seven infiltrates of 1 mL subendometrially at the site of placenta accreta. Almost immediately the bleeding ceased and did not reoccur. The post-operative period was uneventful.

Severe hemolytic disease of the newborn due to anti-c.

Two cases of severe hemolytic disease of the newborn due to c‐isoimmunization are presented. Both women were multiparous, had previous blood transfusion and high maternal tites of anti‐c (1:1024 and 1:4036, respectively).

Sonographic evaluation of the uterus in postmenopausal women receiving tamoxifen: characterization of mid-uterine abnormalities

BACKGROUND Tamoxifen is known to exert agonist estrogenic effects on the uterus. Its use in postmenopausal women has also been associated with various endometrial and uterine abnormalities that can be detected by endovaginal sonography. OBJECTIVE To study postmenopausal patients receiving tamoxifen who were referred for evaluation following the detection of abnormal uterine findings by endovaginal sonography. METHODS Fifty-two women treated with tamoxifen for breast cancer who were found to have an abnormal uterine sonogram constituted the study population. Uterine sonograms were reviewed and clinical and sonographic data were correlated with the results of the histologic examinations. RESULTS Forty-five women demonstrated a thickened mid-uterine structure. Of these, in thirty-nine patients (87%) either no tissue of scant fragments of normal endometrium were obtained on curettage, and six women (13%) had endometrial hyperplasia. Seven women had fluid loculation lined by thin endometrium. Their subsequent histologic examination was normal. The sonograms of the women who demonstrated an appearance of a thickened endometrium but no neoplasia, characteristically demonstrated hyperechogenic cystic area with no midline echo. CONCLUSIONS Among 52 postmenopausal patients receiving tamoxifen presented with an abnormal uterine sonogram, 39 (75%) women were found to have a thick mid-uterine structure resembling a thickened endometrium without histologic evidence of neoplasia. This phenomenon can be characterized by typical sonographic features, and may be differentiated from other uterine abnormalities.

The influence of midtrimester termination of pregnancy on subsequent fertility: four to five years follow-up

A four to five years follow-up upon subsequent fertility was performed on 46 women who underwent a midtrimester termination of pregnancy. Thirty out of 31 (96.8%) women who wanted to conceive became pregnant. Of those, term delivery rate was 73.3%. Only one woman who desired to conceive could not become pregnant. Her infertility workup revealed bilateral occlusion of tubes. We conclude that termination of pregnancy in midtrimester possibly has little, if any, impact upon subsequent fertility.

Preoperative sonography in detecting small benign cystic teratomas

Identification of small ovarian benign cystic teratomas (dermoid cysts) is difficult and sometimes impossible by clinical findings alone. They may be missed even on direct inspection during laparotomy or laparoscopy. There are several typical ovarian sonographic signs which are known to occur frequently in women with benign ovarian cystic teratomas. High‐resolution sonography can identify the cysts based on their typical sonographic signs. Since these very small dermoid cysts are sometimes undetected by the naked eye during the operation, ultrasonography with particular attention to the signs is very important. We present three case reports that illustrate the problem and stress the contribution of preoperative sonography in the diagnosis and treatment of such cases.

Familial Barrett's adenocarcinoma.

TO THE EDITOR: An 81-yr-old man of Jewish Ashkenazi descent was referred for esophagectomy due to a 15 mm adenomatous polyp with high-grade dysplasia (HGD) within Barretts epithelium (BE). On endoscopic ultrasound (EUS) a T1, N0 polypoid tumor was identified and the patient was offered endoscopic mucosal resection (EMR). The polypoid lesion was removed by EMR, but a small remnant of the lesion was left with HGD and a focus of adenocarcinoma. As the patient refused esophagectomy, photodynamic therapy (PDT) was applied but adenocarcinoma foci persisted. Following a second PDT BE disappeared completely. A year later normal esophageal squamous epithelium without dysplasia was found on endoscopy.

Mucin stratification in pseudomyxoma peritonei: a pathognomonic ultrasonographic sign.

Pseudomyxoma peritonei (PMP) is a condition characterized by multifocal epithelial peritoneal implants, producing gelatinous ascites made up of copious amounts of mucin, with a primary origin in either the appendix or the ovary. Morbidity results primarily from progressive accumulation of mucin, causing obstruction of the abdominal viscera1. We present a case of PMP showing pathognomonic features on preoperative ultrasound examination, with specific stratification resulting from its viscous gelatinous content as described previously by our group2. A 72-year-old woman presented to the Gynecology Department of Kaplan Medical Center with abdominal pain and ascites. The previous year she had undergone routine abdominal/pelvic ultrasonography because of a family history of ovarian cysts. The examination revealed two hypoechogenic irregular masses in the pelvis (35 and 25 mm in diameter) and a normal left ovary; the right ovary was not visualized. Tumor markers were normal. Follow-up ultrasound examination 5 months later

Aspiration of ectopic pregnancy under guidance of vaginal ultrasonography.

This case report describes the treatment of tubal pregnancy by aspiration of the gestational sac content and injection of methotrexate by transvaginal sonographic guidance. The confirmation of the embryo aspiration as indicated by disappearance of the embryo with its heart beat and the resulting 46,XY karyotype, raises the question whether methotrexate injection is necessary.