Non-surgical management of live ectopic pregnancy with ultrasound-guided local injection: a case series

OBJECTIVES

To describe a series of consecutive cases of live ectopic pregnancies managed with ultrasound-guided local injection of methotrexate (MTX) or potassium chloride (KCl).

METHODS

Eighteen consecutive women with live and unruptured, tubal, cornual or cervical ectopic pregnancies referred to our unit for evaluation and management underwent risk-benefit counseling. Under transvaginal ultrasound guidance, puncture and injection of the ectopic pregnancy was performed using an automated puncture device. Either MTX or KCl was injected, producing immediate cessation of fetal cardiac activity.

RESULTS

Of the 18 ectopic pregnancies, 10 were cervical, four were tubal and four were cornual. The mean initial beta-hCG level was 33 412 IU and the mean gestational age was 6 + 6 weeks. Ten ectopic gestational sacs were injected with KCl and eight were injected with MTX. There was no difference in time to resolution of the ectopic pregnancies between those injected with KCl and those with MTX.

CONCLUSIONS

Unruptured live ectopic pregnancies of many types can be successfully managed without surgical intervention through local injection of KCl or MTX.

Simple ultrasound evaluation of the anal sphincter in female patients using a transvaginal transducer

OBJECTIVE

Fecal incontinence affects 0.2% of women aged 15-64 years and about 1.3% of women over 64 years. Most cases are related to instrumental deliveries affecting the anal sphincter complex. We propose a simple technique using the generally available transvaginal transducer to evaluate the anal sphincter complex.

METHODS

Ninety-two patients underwent ultrasound examination. Group I consisted of 53 nulliparous patients. In Group II there were six patients with normal spontaneous vaginal deliveries without episiotomies. In Group III there were 14 patients with vaginal deliveries and one to three episiotomies but no lacerations. In Group IV there were nine postpartum patients with recently repaired (48 h to 3 weeks) third- and fourth-degree lacerations. All women in Groups I-IV were asymptomatic. Group V consisted of 10 patients symptomatic for fecal incontinence. We used a vaginal probe (5-9-MHz) with the footprint placed in the fourchette pointing towards the anus in a transverse and then in a median (sagittal) plane. If seen, the combined internal and external anal sphincter thickness at the 12 o'clock location was measured. We visualized normal star-shaped mucosal folds on the transverse section and described the sonographic anatomy in both planes.

RESULTS

The mean sphincter thickness measured at 12 o'clock in Group I was 2.3 (range, 1.0-4.7) mm, in Group II it was 2.9 (range, 2.4-3.4) mm, and in Group III it was 2.3 (range, 1.0-3.7) mm. The differences between these three groups were not significant. Patients from Group IV showed thinning or discontinuous sphincter anatomy at the 12 o'clock position. All symptomatic patients from Group V showed abnormal sphincter anatomy, and the normal star-like appearance of the anal mucosa on the transverse section was deformed, radiating from the point of the sphincter damage. Four of the 10 patients in this group underwent surgical repair. In these patients the sonographic findings were confirmed.

CONCLUSIONS

The images obtained using this imaging modality show the sphincter muscle anatomy as well as the possible pathology. Due to its simplicity the technique can be applied in any place where a vaginal transducer is available.

Pattern and process in Amazon tree turnover, 1976-2001

Previous work has shown that tree turnover, tree biomass and large liana densities have increased in mature tropical forest plots in the late twentieth century. These results point to a concerted shift in forest ecological processes that may already be having significant impacts on terrestrial carbon stocks, fluxes and biodiversity. However, the findings have proved controversial, partly because a rather limited number of permanent plots have been monitored for rather short periods. The aim of this paper is to characterize regional-scale patterns of 'tree turnover' (the rate with which trees die and recruit into a population) by using improved datasets now available for Amazonia that span the past 25 years. Specifically, we assess whether concerted changes in turnover are occurring, and if so whether they are general throughout the Amazon or restricted to one region or environmental zone. In addition, we ask whether they are driven by changes in recruitment, mortality or both. We find that: (i) trees 10 cm or more in diameter recruit and die twice as fast on the richer soils of southern and western Amazonia than on the poorer soils of eastern and central Amazonia; (ii) turnover rates have increased throughout Amazonia over the past two decades; (iii) mortality and recruitment rates have both increased significantly in every region and environmental zone, with the exception of mortality in eastern Amazonia; (iv) recruitment rates have consistently exceeded mortality rates; (v) absolute increases in recruitment and mortality rates are greatest in western Amazonian sites; and (vi) mortality appears to be lagging recruitment at regional scales. These spatial patterns and temporal trends are not caused by obvious artefacts in the data or the analyses. The trends cannot be directly driven by a mortality driver (such as increased drought or fragmentation-related death) because the biomass in these forests has simultaneously increased. Our findings therefore indicate that long-acting and widespread environmental changes are stimulating the growth and productivity of Amazon forests.

First-trimester diagnosis of sacrococcygeal teratoma: the role of three-dimensional ultrasound

A fetus was suspected of having a sacrococcygeal teratoma (SCT) on routine nuchal translucency evaluation by sonography at 12+3 weeks. The patient was referred for three-dimensional (3D) sonography to further delineate the extent of the mass. In this case, real-time scanning of the mass in 3D mode assisted the diagnosis of the mass and patient counseling. We present what we believe to be the first case of SCT imaged in the first trimester using 3D ultrasound.

Transrectal scanning: an alternative when transvaginal scanning is not feasible

OBJECTIVE

In scanning the female pelvis the clear images of transvaginal sonography (TVS) result from placing the transducer close to the region of interest. The advantages of TVS over transabdominal sonography (TAS) and transperineal sonography are well documented. Transrectal scanning is proposed mostly for ultrasound guidance in draining a pelvic abscess. Our aim was to investigate the applicability of transrectal scanning (TRS) for cases in which TVS is impossible.

METHODS

Forty-two patients with an absolute or a relative contraindication to TVS were scanned transabdominally and transrectally. The TRS was performed using a transvaginal probe, which was lubricated and slowly advanced into the rectum. The technique used was similar to that of TVS. Images were compared for resolution and quality.

RESULTS

All scans were completed without significant patient discomfort or complaints. TRS was clearly superior to TAS in 31 cases. In nine cases TAS furnished some clinical information but TRS yielded better images. Only in one such case was TAS similar in quality to TRS. In four obese patients TAS did not reveal sufficient pelvic anatomy to generate a clinical diagnosis, whereas TRS revealed two sets of normal ovaries and two patients with ovarian cysts. In the two cases with vaginal agenesis TRS revealed the diagnosis of Rokitansky-Küster syndrome. In three of the four patients with ruptured membranes the cervix could be measured precisely.

CONCLUSION

Transrectal scanning should be used liberally after proper patient selection and counseling. The images obtained are superior to TAS and comparable to those obtained by TVS.

Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the "niche" in the scar

OBJECTIVE

To apply an existing diagnostic imaging test (saline infusion sonohysterography) to characterize the "filling defect" of a previous cervical cesarean delivery scar in the nonpregnant uterus.

METHODS

Forty-four patients with histories of cesarean delivery who underwent saline infusion sonohysterography for a variety of gynecologic indications were included. During the procedure, the area below the bladder recess was examined using transvaginal sonography. A filling defect or "niche" was defined as a triangular anechoic structure at the presumed site of a previous cesarean delivery scar. The depth of the niche was measured. Uterine size, the presence of fibroids and polyps, and the number of previous cesarean deliveries were noted.

RESULTS

All patients had a niche indenting the anterior uterine-cervical wall. The mean +/- SD depth of the niche was 6.17 +/- 3.6 mm. There was no correlation between the number of cesarean deliveries and the depth of the niche. Thirty-six percent of our patients had fibroids, and 18% had endometrial polyps.

CONCLUSION

Saline infusion sonohysterography was able to detect filling defects in women who previously had cesarean deliveries. We hope that by focusing our attention on the transvaginal sonographic appearance of the detectable uterine scar (niche) with or without the use of saline infusion sonohysterography in the nonpregnant uterus, it will train our eyes to look for the scar in the pregnant uterus. In addition, our study patients had a high prevalence of abnormal uterine bleeding. The role of the cesarean delivery scar in women with unscheduled bleeding needs to be further evaluated.

Three-dimensional transvaginal neurosonography of the fetal brain: 'navigating' in the volume scan

OBJECTIVES

Fetal neuroscan by ultrasound has gained in importance over recent years. Two-dimensional (2D) transvaginal sonography was an important step in understanding the constantly changing and developing fetal brain. The objective of this article is to describe the use of three-dimensional ultrasound of the fetal brain enhanced by the transvaginal transfontanelle scanning technique.

METHODS

Thirty-four pregnant patients were referred to us because of a history of brain anomaly or suspected brain pathology. The fetuses were scanned transvaginally. Two-dimensional as well as three-dimensional (3D) images were generated. The volumes obtained by the 3D-ultrasound machine were displayed in the three conventional orthogonal planes (coronal, sagittal and axial).

RESULTS

Of the 34 fetuses 10 had normal brain anatomy and 24 had brain pathology. In all 34 cases the 2D images as well as the 3D volumes were of diagnostic quality and all three planes could be obtained. The axial sections could only be obtained by the 3D re-construction of the volume scans. The 2D images produced were acquired from a common point originating from the foot print of the transvaginal probe at the fetal anterior fontanelle or the sagittal suture, the sections 'radiate' from this point. Therefore, these sections are not parallel sections, but are oblique to each other. In contrast, the 3D volume could be examined using the classical parallel sections in all three orthogonal planes. The posterior fossa could be seen better if the footprint of the probe was placed over the posterior fontanelle or on the sagittal suture. The marker dot enabled a precise creation of anatomy and pathology. In the 'angio mode' it was possible to follow the anterior cerebral and pericallosal artery.

CONCLUSIONS

The 3D-ultrasound technology using the transvaginal approach is effective and practical to perform during fetal neuroscan. The ability to 'navigate' in the volume and the 'marker dot' enables exact location of normal structures and evaluation fetal brain pathology. The volume can be reviewed over and over again, can be mailed to an expert, could be shown to consultants (pediatric neurology and neurosurgeons) and used for teaching.

Three-dimensional ultrasound evaluation of the fetal brain: the three horn view

OBJECTIVE

To describe an easy technique for obtaining one of the most important views of the fetal brain and image. The entire lateral ventricle including the anterior, posterior and inferior horns is demonstrated on one image. We propose to call this view, obtained in an oblique plane 'the three horn view'.

METHODS

Depending upon the scanning technique employed there are two ways to obtain the three horn view: (1) by two-dimensional (2D) transvaginal transfontanelle sonography obtained by using the left and right Oblique-1 sections, and (2) by three-dimensional (3D) imaging of the fetal brain, is obtained by acquiring a volume scan of the brain orienting the fetal head in the three main orthogonal planes and by rotating or tilting the midcoronal section to the left and right.

RESULTS

To illustrate the technique of obtaining the three horn view four normal fetal brains were scanned. Two scans utilized the 2D transvaginal transfontanelle approach and two scans utilized the 3D scanning technique. The same technique was then applied to six fetuses with various brain malformations with inflicted changes in the shape of the proposed three horn view.

CONCLUSION

The three horn view, depicting the anterior, posterior, and inferior horns on the same image, was easy to obtain using both the 2D and the 3D ultrasound techniques. It provided diagnostic and clinically useful information much like neonatal transfontanelle ultrasound imaging after which it was emulated.

Second- and third-trimester ultrasound evaluation of chorionicity and amnionicity in twin pregnancy. A simple algorithm

OBJECTIVE

To develop a simple and systematic algorithm to determine chorionicity and amnionicity in the second and third trimester by ultrasound.

STUDY DESIGN

The algorithm was constructed based upon years of experience in examining multifetal pregnancies and by adopting the different sonographic signs suggested in the literature.

RESULTS

The following parameters were used to construct the algorithm: sexing of the fetuses, placental location, and origin, thickness and number of layers of the membranes.

CONCLUSION

The flow chart developed is simple to use and embodies all possible sonographic parameters to help determine chorionicity and amnionicity in the second and third trimester.

Amniocentesis after multifetal pregnancy reduction: is it safe?

OBJECTIVE

This report reviews the obstetric outcomes of women with multifetal pregnancy reductions who subsequently underwent elective amniocentesis.

STUDY DESIGN

Five hundred eight patients underwent multifetal pregnancy reduction at our institution. Among these, 91 patients underwent subsequent elective amniocentesis. The obstetric outcomes of all 508 patients were followed up. By means of logistic regression we evaluated several variables to determine any association with loss rate: (1) the finishing number of fetuses, (2) the number of fetuses undergoing reduction (starting number of fetuses minus the finishing number of fetuses), (3) the gestational age at reduction, (4) the maternal age at reduction, and (5) the procedure protocol. We observed that the finishing number of fetuses, the number of fetuses removed, and the procedure protocol were significantly associated with pregnancy loss rate. Women who underwent subsequent amniocentesis were compared with those who did not undergo amniocentesis. By means of multivariate conditional likelihood analysis we stratified the two groups according to the previously mentioned significant variables to compare the pregnancy loss rates.

RESULTS

Among patients who subsequently underwent elective amniocentesis the total uncorrected pregnancy loss rate was 9.0% and the early premature delivery rate was 4.5%. The number of fetuses removed, the finishing number of fetuses, and the procedure protocol were statistically significantly associated with the loss rate. The adjusted odds ratio relating amniocentesis to the pregnancy loss rate was 0.7 (95% confidence interval, 0.31.5; P =.3.)

CONCLUSIONS

The uncorrected rates of pregnancy loss and of early premature delivery among patients with multifetal pregnancy reduction who underwent subsequent amniocentesis were comparable to those of patients with multifetal pregnancy reduction who did not undergo amniocentesis.

Color flow-directed Doppler studies of ovarian masses. Computer analysis

OBJECTIVE

To determine if analyzing the entire color Doppler image (CDI) pulse wave of an ovarian mass can improve the ability to predict its histopathology.

STUDY DESIGN

The CDI of 42 histopathologically diagnosed adnexal masses were retrospectively analyzed. Using an image analysis software program, the following parameters were calculated: area under the curve, compactness, Feret diameter, perimeter, shape factor and width of the waveform. Using an automated curve-fitting software program, the up and down slopes were processed separately for the optimal equation and coefficient for each slope. Two computerized neural networks were created, both consisting of an input layer, one hidden layer and an output layer of three neurons: benign, borderline and malignant. The first network contained two input neurons: pulsatility index (PI) and resistance index (RI). The second network contained 10 input neurons consistent with the shape and slope parameters calculated. The coefficient of determination (R2) was determined for each network.

RESULTS

The neural network utilizing RI and PI failed to train (1,397 runs, 67,056 facts, R2 = 0.59, 0.12 and 0.43 for benign, borderline and malignant masses, respectively). The network using the 10 calculated parameters achieved an R2 of 0.96 after 685 runs and 27 facts.

CONCLUSION

Analyzing the CDI studies of ovarian masses, using the entire pulse wave, improved the ability to differentiate between their benign, borderline and malignant histopathology.

Transvaginal sonographic markers of tubal inflammatory disease

OBJECTIVES

Since the introduction of transvaginal sonography (TVS), clear pictures of the female reproductive tract have been obtained. These images enable the accurate description of Fallopian tube pathology. However, the current literature on the ultrasound diagnosis of pelvic inflammatory disease (PID) is confusing and contradictory. The goal of our study was to identify sonographic markers of inflammatory disease of the pelvis and to place these in a clinical context.

PATIENTS AND METHODS

Seventy-seven patients were scanned by TVS. They were divided into two groups, according to their clinical picture, the first group with acute PID and the second with a history of chronic PID or no history at all. The sonographic markers studied were shape, wall structure and wall thickness of the Fallopian tube. Ovarian involvement and the presence of pelvic fluid were also evaluated.

RESULTS

The best marker of tubal inflammatory disease, either acute or chronic, was the presence of an incomplete septum of the tubal wall, which was present in 92% of the total cases. A thick wall and the 'cogwheel' sign were sensitive markers of acute disease, whereas a thin wall and 'beads-on-a-string' sign were indicators of chronic disease. Palpable findings and surgical history were not discriminatory, but were present in three-quarters and one-third of the study population, respectively. Three false-positive cases are presented: an ovarian cystadenoma, an appendiceal mucocele and one case with periovarian fluid accumulation.

CONCLUSIONS

The tubo-ovarian complex and the tubo-ovarian abscess should be considered separate entities that differ in their clinical implications. TVS allows one to distinguish between them. Distinguishing characteristics of acute and chronic salpingitis are presented.

Sonographic assessment of chorionicity and amnionicity in twin pregnancies: how, when and why?

During the first trimester, chorionicity can be assessed as early as five weeks post-conception, but a reliable detection of amnionicity cannot be performed before the 8th week when the amnion can be clearly imaged. The late second and third trimesters twin pregnancies are a true challenge to the imaging specialist because the detection of chorionicity and amnionicity has to rely upon sonographic clues, such as placenta location, fetal gender, membrane origin, thickness, and layer. Sonographic methods used to determine chorionicity and amnionicity in twins can be extrapolated to any multifetal pregnancy, regardless of the number of fetuses present.

Transvaginal gray-scale imaging of ureteral jets in the evaluation of ureteral patency

We have previously reported on the value of transvaginal color Doppler evaluation of the ureteral jets to confirm ureteral patency. In this study, we attempt to validate the simple and widely available gray-scale ultrasound technique to perform the same task. Fifty consecutive patients without a history of urinary complaints were recruited. The presence or absence of the right and left ureteral jets was registered using gray-scale imaging, comparing the technique to color Doppler as the 'gold standard'. The time to the detection of the first jet as well as the total scanning time were documented for each side. The jets were seen with equal frequency on both the right and the left sides (34 observations each). In 24 patients, both jets were visualized. The median time to detection of the first jet was 47 s (range 34-79 s) for the right jet and 53 s (36-84 s) for the left jet (p = 0.42). The median total scanning time was 176 s (139-259 s). Gray-scale imaging was associated with a sensitivity of 68% and a positive predictive value of 100%. Although color Doppler results may be more attractive because of their impressive color-coded appearance, the major disadvantage of this technique is that it requires sophisticated and costly equipment. Transvaginal gray-scale imaging is a reliable and useful test for the detection of ureteral jets in the bladder. It can be used as a first-line diagnostic tool, particularly in settings where color Doppler is not available. Its benefits include safety, low cost, convenience and simplicity. With a positive predictive value of 100%, this test may be used in the postoperative patient, especially when ureteral patency is in question.

Monochorionic quadramniotic quadruplets: sonographic workup

OBJECTIVE

We raise the issue of scanning multifetal pregnancies of higher order as early as possible. A rare case of monochorionic/quadramniotic pregnancy seeking multifetal pregnancy reduction and its clinical management is presented.

METHODS

Transabdominal scanning at 16 weeks was performed correctly diagnosing the monochorionic quadruplet pregnancy.

RESULTS

Suspecting vascular connections between the placentae, the fetal reduction was declined. The patient was delivered at 31 weeks. The 4 female neonates survived with slight ventilatory assistance.

CONCLUSION

Multifetal pregnancies in general, but those of higher order in particular, have to be scanned as early as 8-10 weeks to correctly and easily assign their chorionicity and amnionicity. The case of a monochorionic/quadramniotic pregnancy and its clinical course are presented.

Ovarian steroid cell tumors: sonographic characteristics

The goal of the gynecologist is to detect ovarian tumors in their earliest stages. Small virilizing tumors, which barely affect the size of the ovaries, are such lesions. Since the introduction of transvaginal sonography it is technically possible to detect small intraovarian neoplasms. Three cases of virilizing steroid cell tumors in postmenopausal women with ovarian volumes just exceeding the normal sizes for age are presented. High-frequency transvaginal ultrasound and color Doppler studies to measure flow parameters were used. These small tumors had different echogenicity from the surrounding ovarian tissue and two had low impedance-to-flow values. Gray-scale transvaginal sonography combined with color Doppler studies can make the diagnosis of small steroid cell tumors easier and, at times, better than other, more costly imaging modalities.

Development of fetal gyri, sulci and fissures: a transvaginal sonographic study

We aimed to determine the feasibility of imaging specific sulci, gyri and fissures using transvaginal sonography and to correlate their first sonographic recognition with gestational age. Retrospectively, 262 fetal brain scans were analyzed from a total of 337 scans. Scans were selected if any of the following structures were seen: in the coronal plane the lateral, callosal and cingulate sulcus and gyrus; in the median plane the parieto-occipital and calcarine fissures, and the cingulate gyrus and sulcus; and, in an oblique section, the lateral sulcus. The gestational age at which the fissures, sulci and gyri were first imaged was recorded and subsequently compared with similar anatomical studies from the literature. It was possible to identify all the targeted structures. The gestational ages at which the structures were first imaged were: the callosal sulcus, from 14 weeks; the lateral sulcus, from 18 weeks; the parieto-occipital sulcus and calcarine fissure, from 18 weeks; and the cingulate gyrus, from 26 weeks. We concluded that the developmental maturation of the normal fetal brain follows a predictable timetable, and that this maturation can be grossly followed with sonography. The sonographic recognition of the fissures, gyri and sulci lagged behind the observations by anatomical studies. The greatest discrepancy was the first appearance of the cingulate gyrus which, in the anatomical studies, could be seen by 18 postmenstrual weeks and, in our study, was seen after 26 postmenstrual weeks. The one exception was the callosal sulcus, which was first seen at 14 postmenstrual weeks in both the sonographic and anatomical studies. In conclusion, the recognition of specific structures of the cortical map is possible. Sonography may be used to image the developing cortical surface.

Transvaginal color Doppler sonography of the ureteral jets: a method to detect ureteral patency

OBJECTIVE

To evaluate the feasibility of the detection of ureteral jets into the bladder in obstetric-gynecologic patients using transvaginal color Doppler ultrasound.

METHODS

Fifty-two women were recruited and categorized into four groups: 1) 20 normal nonsurgical, 2) 17 post-cesarean delivery, 3) 12 post-total abdominal hysterectomy, and 4) three with only one functional kidney or ureter. In the first three groups, transvaginal color Doppler sonography was used to evaluate the time to detection of the first jet and the number of jets in 5 minutes bilaterally. In the last group, the presence or absence of the jet was documented only on the functional side. Statistical analysis was performed using Student t test and analysis of variance followed by Tukey honestly significant difference.

RESULTS

Urine jets could be detected bilaterally in all women except for those with only one functional kidney (accuracy 100%). Time to detection of the first jet did not differ significantly in the nonsurgical, cesarean, or hysterectomy patients on either the right side (P = .07) or the left side (P = .43). The total number of jets was similar in the nonsurgical and cesarean patients, but was significantly lower in the hysterectomy group (right side P = .006; left side P = .004). In the women with one functional kidney, the normal side was identified in all cases.

CONCLUSION

Transvaginal color Doppler sonography is a simple, accurate technique that can be used to evaluate ureteral jets into the bladder in women. The length of time to detection of the first jet is not affected by the postoperative status. Fewer jets should be expected in women who have undergone hysterectomies. This method should be used when ureteral integrity is in question, especially after surgery.