Myoma vs. contraction in pregnancy: differentiation with color Doppler imaging

Age-related changes in thickness of anterior lower uterine segment in normal singleton pregnancy during 20-35 weeks' gestation

PURPOSE

To observe age-related changes in the anterior lower uterine segment (LUS) thickness in normal pregnancy from 20 to 35 weeks' gestation.

METHODS

Subjects were 235 uncomplicated singleton cases that underwent single ultrasound examination at 4-week intervals during 20-35 weeks' gestation. Sagittal LUS sections were evaluated with transvaginal ultrasonography. Anterior LUS thickness (Th) was measured every centimeter from the lowest bladder point (Th0cm) to 4 cm from that point (Th4cm). Th values were standardized by dividing by the Th0cm value. Intragroup comparisons of standardized Th values and intergroup comparisons of actual Th values were made according to gestational age. Statistical analyses were performed with the Kruskal-Wallis and Tukey honest standard deviation tests; significance was set at p < 0.05.

RESULTS

In the 20-23-, 24-27- and 32-35-week groups, standardized Th decreased from Th0cm to Th2cm; in the 28-31-week group standardized Th decreased from Th0cm to Th3cm. Median Th3cm values decreased from 5.0 mm at 20-23 weeks to 3.0 mm at 28-31 weeks, but remained unchanged thereafter.

CONCLUSIONS

The anterior LUS gradually thinned from Th0cm to Th3cm at 20-35 weeks' gestation. Th3cm became increasingly thin between 20-23 and 28-31 weeks' gestation.

Three-dimensional power Doppler in the evaluation of painful leiomyomas and focal uterine thickening in pregnancy

OBJECTIVE

To determine the usefulness of 3-dimensional (3D) power Doppler ultrasound in distinguishing painful leiomyomas from focal myometrial contractions or nonpainful leiomyomas in pregnancy.

METHODS

A 2D section of the area of interest in the uterine wall was first obtained in 29 patients to determine whether the pain originated from a myoma or a uterine contraction. Then, volume acquisition was activated and Doppler indices (vascularization index, flow index, and vascularization-flow index) were calculated for thickened and normal uterine wall.

RESULTS

Of 15 patients found to have uterine myomas, 11 had multiple tumors and 4 had single tumors. In the remaining 14 patients the painful uterine thickening proved to be a focal contraction. Painful segments of uterine thickening were associated with lower Doppler indices. Painful myomas were found to have significantly lower indices than normal uterine wall (P=0.008, 0.03, and 0.01 for VI, FI, and VFI, respectively, vs. 0.001, 0.003, and 0.01). However, the differences in indices between nonpainful myomas and uterine wall on the one hand, and nonpainful myomas and focal uterine contractions on the other, were not statistically significant.

CONCLUSION

Three-dimensional power Doppler ultrasound may be a sensitive and reliable tool for distinguishing painful uterine myomas from focal myometrial contractions and nonpainful myomas.

Fibroids in Pregnancy???Common but Poorly Understood

Uterine fibroids are the most common benign tumors in women, occurring in approximately 20% to 30% of women of reproductive age. They are therefore common in pregnancy. The true incidence of fibroids during pregnancy is, however, unknown, but reported rates vary from as low as 0.1% of all pregnancies to higher rates of 12.5%. It seems that pregnancy has little or no effect on the overall size of fibroids despite the occurrence of red degeneration in early pregnancy. Fibroids, however, affect pregnancy and delivery in several ways, with abdominal pain, miscarriage, malpresentation, and difficult delivery being the most frequent complications. The size, location, and number of fibroids and their relation to the placenta are critical factors. Ultrasound scanning plays a central role in diagnosing and monitoring fibroids during pregnancy and in determining the relative position of the fibroids to the placenta. It is equally useful for detecting heterogeneous echo patterns associated with the appearance of pain in pregnancy. Color flow Doppler scanning differentiates fibroids from myometrial thickening, which may be mistaken for fibroids. Few treatment options are available during pregnancy, but in carefully selected patients, myomectomy has been performed successfully without jeopardizing pregnancy outcome. A successful pregnancy and delivery is common with appropriate surveillance and supportive management.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader should be able to summarize the influence of pregnancy on fibroids, to explain the influence of fibroids on pregnancy, and to outline the management of fibroids during pregnancy.

Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography

PURPOSE

Our objective was to evaluate the differences between leiomyoma and adenomyosis by color Doppler sonography with new criteria.

METHODS

A total of 78 patients with symptomatic uterine nodularities who were sonographically suspected to have leiomyoma or adenomyosis without other coexisting pathologic conditions was enrolled in the study. All patients underwent transvaginal color Doppler sonography (7.0-MHz vaginal probe) or transabdominal color Doppler sonography (5.0 MHz) during the early follicular phase. The morphology, tumor vascular pattern, and blood flow impedance of the uterine tumors were measured. All of the patients underwent surgery and the pathologic reports were used as references.

RESULTS

The mean age was not statistically significant in patients with adenomyosis versus leiomyoma (P > 0.05). The morphologic criteria for adenomyosis and leiomyoma by sonography detected 79% of adenomyosis and 84% of leiomyoma. Adenomyosis had 87% randomly scattered vessels or intratumoral signals and 88% of leiomyomas showed peripheral scattered vessels or outer feeding vessels. Eighty-two percent of adenomyosis had a pulsitility index (PI) of arteries within or around uterine tumors > 1.17 and 84% of leiomyomas had a PI < or = 1.17. The reliability test of tumor vascular pattern and blood flow impedance were better than that of using morphological criteria alone.

CONCLUSIONS

With the aid of color Doppler sonography, tumor vascular pattern and blood flow impedance of the arteries within or around uterine tumors could more accurately diagnose adenomyosis and leiomyoma in addition to the morphologic criteria on transvaginal sonography.

Clinical presentation of uterine fibroids

It is often accepted that fibroids cause a variety of female reproductive problems, such as menorrhagia, pain, infertility, pregnancy loss and pregnancy complications. Understandably, therefore, many 'successful' medical or surgical interventions have been proposed. However, while fibroids are certainly commonly associated with these conditions, it remains unclear whether this is coincidental, because of the high prevalence of fibroids, or causal. In particular, this chapter explores the roles of fibroids in menorrhagia, discussing possible pathophysiological mechanisms and the utility of medical and surgical management. Similarly, the relationship between fibroids and infertility is examined, concluding that fibroids are not causative in the vast majority of cases and thereby questioning the effectiveness of myomectomy as a treatment for infertility. The use of hormone replacement therapy in post-menopausal women with existing fibroids is also discussed, concluding that this is generally safe and appropriate. In pregnancy, it is a commonly held tenet that uterine fibroids enlarge and that they are associated with various adverse outcomes such as miscarriage, placental abruption, fetal growth retardation and Caesarean section. This chapter evaluates the available evidence for this and concludes that, as with infertility, the role of fibroids has been exaggerated. Nonetheless, pregnancy management options are discussed.