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Meyer JA, Silverstein J, Timor-Tritsch IE, Antoine C. The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries. J Perinat Med 2024; 52:150-157. [PMID: 38081042 DOI: 10.1515/jpm-2023-0211] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/26/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVES To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). METHODS Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. RESULTS A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. CONCLUSIONS While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.
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Affiliation(s)
- Jessica A Meyer
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jenna Silverstein
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ilan E Timor-Tritsch
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Maternal Resources, Hoboken, NJ, USA
| | - Clarel Antoine
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
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Meyer JA, Silverstein J, Timor-Tritsch IE, Antoine C. Reply to: "Optimal closure of the uterus during cesarean section: beyond the two layers" commenting on "The Effect of Uterine Closure Technique on Cesarean Scar Niche Development After Multiple Cesarean Deliveries". J Perinat Med 2024; 0:jpm-2024-0010. [PMID: 38282351 DOI: 10.1515/jpm-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/30/2024]
Affiliation(s)
- Jessica A Meyer
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jenna Silverstein
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ilan E Timor-Tritsch
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Maternal Resources, Hoboken, NJ, USA
| | - Clarel Antoine
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
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Timor-Tritsch IE, Kaelin Agten A, Monteagudo A, Calỉ G, D'Antonio F. The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy. Best Pract Res Clin Obstet Gynaecol 2023; 91:102409. [PMID: 37716338 DOI: 10.1016/j.bpobgyn.2023.102409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/02/2023] [Accepted: 08/17/2023] [Indexed: 09/18/2023]
Abstract
Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.
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Affiliation(s)
| | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom
| | - Ana Monteagudo
- Icahn School of Medicine. Carnegie Maternal Fetal Associates New York, USA
| | - Giuseppe Calỉ
- Maternal Fetal Medicine Unit AO Villa Sofia-Cervello, Italy
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Timor-Tritsch IE, Monteagudo A, Calì G, Kaelin Agten A, Palacios-Jaraquemada JM, D'Antonio F. Hidden in plain sight: role of residual myometrial thickness to predict outcome of Cesarean scar pregnancy. Ultrasound Obstet Gynecol 2023; 62:624-632. [PMID: 37266902 DOI: 10.1002/uog.26246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/03/2023]
Affiliation(s)
- I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Hackensack Meridian School of Medicine and Maternal Resources, Hackensack, NJ, USA
| | - A Monteagudo
- Icahn School of Medicine, Carnegie Maternal-Fetal Associates, NY, USA
| | - G Calì
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit, Azienda Ospedaliera Villa Sofia-Cervello, Palermo, Italy
- Maternal-Fetal Unit, Candela Clinic, Palermo, Italy
| | - A Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
| | | | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
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5
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Bartels HC, Brennan DJ, Timor-Tritsch IE, Agten AK. Global variation and outcomes of expectant management of CSP. Best Pract Res Clin Obstet Gynaecol 2023; 89:102353. [PMID: 37329645 DOI: 10.1016/j.bpobgyn.2023.102353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 06/19/2023]
Abstract
The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.
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Affiliation(s)
- Helena C Bartels
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland.
| | | | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom.
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Bornstein E, Chervenak FA, Kulla P, Delaney K, Timor-Tritsch IE. Prenatal diagnosis and characterization of extra-axial, supratentorial pial arteriovenous malformation using high-resolution transvaginal neurosonography. Ultrasound Obstet Gynecol 2023; 61:421-424. [PMID: 36056756 DOI: 10.1002/uog.26058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/01/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Affiliation(s)
- E Bornstein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine, NY, USA
| | - F A Chervenak
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine, NY, USA
| | - P Kulla
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine, NY, USA
| | - K Delaney
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine, NY, USA
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Prayer D, Malinger G, De Catte L, De Keersmaecker B, Gonçalves LF, Kasprian G, Laifer-Narin S, Lee W, Millischer AE, Platt L, Prayer F, Pugash D, Salomon LJ, Sanz Cortes M, Stuhr F, Timor-Tritsch IE, Tutschek B, Twickler D, Raine-Fenning N. ISUOG Practice Guidelines (updated): performance of fetal magnetic resonance imaging. Ultrasound Obstet Gynecol 2023; 61:278-287. [PMID: 36722431 PMCID: PMC10107509 DOI: 10.1002/uog.26129] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 05/03/2023]
Affiliation(s)
- D Prayer
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - G Malinger
- Division of Ultrasound in Obstetrics & Gynecology, Lis Maternity Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L De Catte
- Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - B De Keersmaecker
- Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - L F Gonçalves
- Fetal Imaging, William Beaumont Hospital, Royal Oak and Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - G Kasprian
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - S Laifer-Narin
- Division of Ultrasound and Fetal MRI, Columbia University Medical Center - New York Presbyterian Hospital, New York, NY, USA
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA
| | - A-E Millischer
- Radiodiagnostics Department, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - L Platt
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, Los Angeles, CA, USA
| | - F Prayer
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - D Pugash
- Department of Radiology, University of British Columbia, Vancouver, Canada; Department of Obstetrics and Gynecology, BC Women's Hospital, Vancouver, Canada
| | - L J Salomon
- Department of Obstetrics, Hôpital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Université Paris Descartes, Paris, France
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA
| | - F Stuhr
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - I E Timor-Tritsch
- Division of Obstetrical & Gynecological Ultrasound, NYU Grossmann School of Medicine, New York, NY, USA
| | - B Tutschek
- Department of Obstetrics & Gynecology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Prenatal Zurich, Zürich, Switzerland
| | - D Twickler
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - N Raine-Fenning
- Department of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK; Nurture Fertility, The Fertility Partnership, Nottingham, UK
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Antoine C, Timor-Tritsch IE, Agoha C, Alexander J. A new era in teaching: how advanced optical recording technology could change the postcesarean delivery complication conundrum. Am J Obstet Gynecol MFM 2022; 4:100744. [PMID: 36113718 DOI: 10.1016/j.ajogmf.2022.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/19/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The last 4 decades have seen increased complications after cesarean deliveries. Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation. OBJECTIVE This study aimed to evaluate the VITOM high-definition optical recording system as a tool to highlight cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and research potential. STUDY DESIGN Contemporaneous cesarean delivery techniques offer no resolution to long-term postcesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective cesarean deliveries. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in 3 designated operating rooms reached 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. The maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 0/7 to 41 6/7 weeks of gestation. Selected photographs of crucial cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants. RESULTS The VITOM was used for 104 cesarean deliveries. Setup time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of cesarean delivery techniques. CONCLUSION The VITOM exoscope provided superb image quality, enabling a clear vision of the anatomic structures of the cesarean operation. It is a promising additional research tool to capture important details of the employed surgical techniques and provides a possible insight into long-term postcesarean sequelae.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha).
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
| | - Chikadibia Agoha
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
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Hughes-Hogan L, Popiolek D, Duncan K, Timor-Tritsch IE. Granulosa-Cell Tumor Diagnosed in the Third Decade of Life in a Patient with Ollier's Disease: A Rare But Clinically Important Correlation. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Logan Hughes-Hogan
- New York University–Langone Health, New York City, New York, USA
- Department of Obstetrics and Gynecology, and Grossman School of Medicine, New York University, New York, New York, USA
| | - Dorota Popiolek
- Department of Pathology, Grossman School of Medicine, New York University, New York, New York, USA
| | - Karen Duncan
- New York University–Langone Health, New York City, New York, USA
- Department of Obstetrics and Gynecology, and Grossman School of Medicine, New York University, New York, New York, USA
| | - Ilan E Timor-Tritsch
- New York University–Langone Health, New York City, New York, USA
- Department of Obstetrics and Gynecology, and Grossman School of Medicine, New York University, New York, New York, USA
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Antoine C, Meyer JA, Silverstein JS, Alexander J, Oh C, Timor-Tritsch IE. The Impact of Uterine Incision Closure Techniques on Post-cesarean Delivery Niche Formation and Size: Sonohysterographic Examination of Nonpregnant Women. J Ultrasound Med 2022; 41:1763-1771. [PMID: 34726789 DOI: 10.1002/jum.15859] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/24/2021] [Accepted: 09/19/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs). METHODS Saline infusion sonohysterogram (SIS) was performed in women after one prior CD, documenting the presence or absence of a postoperative niche and measuring its depth, width, length, and residual myometrial thickness. Women were grouped by HCT: Technique A (endometrium-free) and Technique B (routine non-endometrium-free). The primary outcome was the prevalence of a clinically significant niche, defined as a depth of >2 mm. HCT groups were compared using χ2 , T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05). RESULTS Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P = 0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P = .018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P = .005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P = .008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P = .04). The average niche depth was 5.7 ± 2.9 mm following Technique B with single-layer. CONCLUSION Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jessica A Meyer
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jenna S Silverstein
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Cheongeun Oh
- Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
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Guzmán López JA, Gutiérrez Sánchez LÁ, Pinilla-Monsalve GD, Timor-Tritsch IE. Placenta accreta spectrum disorders in the first trimester: a systematic review. J OBSTET GYNAECOL 2022; 42:1703-1710. [PMID: 35724241 DOI: 10.1080/01443615.2022.2071151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Placenta accreta spectrum (PAS) disorders involve an abnormality in the implantation of the placenta, being rarely diagnosed in the first trimester. To conduct a systematic review of the risk factors, clinical and imaging features, and outcomes of histopathologically confirmed cases of PAS disorders in the first trimester of pregnancy. Different databases including PubMed, MEDLINE Complete, Scopus, Web of Science, EMBASE, SciELO, LILACS, and Ovid were reviewed up to November 2018. 55 patients with a definitive histopathological diagnosis were reported. About 18 had a history of prior curettage and 47 of previous caesarean deliveries (CD). About 74.54% presented with miscarriage and ultrasound signs of caesarean scar pregnancy (CSP) were reported in 22.49%. Temporal sequence of diagnostic studies could be determined in 52 women, and, among these, PAS disorders were defined through imaging techniques in 11 (21.15%) while surgical findings unveiled them in 15 (28.84%). Nonetheless, in half of the cases, the diagnosis was concluded only on histopathological samples. PAS disorders in the first trimester of pregnancy are rarely diagnosed through imaging techniques and lead to hysterectomy in most cases. Ultrasound training to detect PAS disorders in women with risk factors is crucial for early diagnosis and prevention of adverse outcomes.
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Affiliation(s)
| | - Luz Ángela Gutiérrez Sánchez
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit, Universidad Industrial de Santander, Bucaramanga, Colombia
| | | | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Obstetrics and Gynecological Ultrasound, New York University School of Medicine, New York City, NY, USA
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Timor-Tritsch IE, Goldstein SR. Reply. Ultrasound Obstet Gynecol 2022; 59:832-833. [PMID: 35642910 DOI: 10.1002/uog.24922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- I E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University, Grossmann School of Medicine New York, NY, USA
| | - S R Goldstein
- Department of Obstetrics and Gynecology, New York University, Grossmann School of Medicine New York, NY, USA
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13
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Timor-Tritsch IE, Monteagudo A, Popiolek DA, Duncan KM, Goldstein SR. Reaffirming microcystic ultrasound appearance of borderline ovarian tumors using three-dimensional 'silhouette' rendering. Ultrasound Obstet Gynecol 2022; 59:700-704. [PMID: 35195307 DOI: 10.1002/uog.24883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/04/2022] [Accepted: 02/14/2022] [Indexed: 06/14/2023]
Affiliation(s)
- I E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - A Monteagudo
- Icahn School of Medicine, Carnegie Imaging for Women, New York, NY, USA
| | - D A Popiolek
- Department of Pathology, New York University School of Medicine, New York, NY, USA
| | - K M Duncan
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - S R Goldstein
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
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Di Mascio D, Buca D, Rizzo G, Khalil A, Timor-Tritsch IE, Odibo A, Mappa I, Flacco ME, Giancotti A, Liberati M, D'Antonio F. Methodological quality of fetal brain structure charts for screening examination and targeted neurosonography: a systematic review. Fetal Diagn Ther 2022; 49:145-158. [DOI: 10.1159/000521421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
Introduction: The methodological quality of fetal brain charts has not been critically appraised yet.
Material and methods: MEDLINE, EMBASE, CINAHL and the Web of Science databases were searched electronically up to December 31, 2020. The primary outcome was to evaluate the methodology of the studies assessing the growth of fetal brain structures throughout gestation. A list of 28 methodological quality criteria divided into three domains according to “study design”, “statistical and reporting methods”, and “specific relevant neurosonography aspects” was developed in order to assess the methodological appropriateness of the included studies. The overall quality score was defined as the sum of low risk of bias marks, with the range of possible scores being 0–28. This quality assessment was applied to each individual study reporting reference ranges for fetal brain structures.
Results: Sixty studies were included in the systematic review. The overall mean quality score of the studies included in this review was 51.3%. When focusing on each of the assessed domains, the mean quality score was 53.7% for “study design”, 54.2% for “statistical and reporting methods” and 38.6% for “specific relevant neurosonography aspects”. The sample size calculation, the correlation with a postnatal imaging evaluation and the whole fetal brain assessment were the items at the highest risk of bias for each domain assessed, respectively. The subgroup analysis according to different anatomical location showed the lowest quality score for ventricular and periventricular structures and the highest for cortical structures.
Conclusions: Most previously published studies reporting fetal brain charts suffers from poor methodology and are at high risk of biases, mostly when focusing on neurosonography issues. Further prospective longitudinal studies aiming at constructing specific growth charts for fetal brain structures should follow rigorous methodology to minimize the risk of biases, guarantee higher levels of reproducibility and improve the standard of care.
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D'Antonio F, Timor-Tritsch IE, Khalil A, Calì G. New classification of placenta accreta spectrum disorders should include presence of Cesarean scar pregnancy. Ultrasound Obstet Gynecol 2022; 59:563. [PMID: 35363411 DOI: 10.1002/uog.24880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - G Calì
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy
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D'Antonio F, Calì G, Palacios-Jaraquemada J, Khalil A, Timor-Tritsch IE. Cesarean scar pregnancy is associated with abnormal implantation but not macroscopic myometrial invasion in early first trimester of pregnancy. Ultrasound Obstet Gynecol 2022; 59:550-551. [PMID: 34605589 DOI: 10.1002/uog.24790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/06/2021] [Accepted: 09/24/2021] [Indexed: 06/13/2023]
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - G Calì
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
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Timor-Tritsch IE. A Cesarean scar pregnancy is not an ectopic pregnancy. Ultrasound Obstet Gynecol 2022; 59:424-427. [PMID: 35266211 DOI: 10.1002/uog.24877] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU Langone Health, Department of Obstetrics and Gynecology, 550 First Avenue, New York, NY, 10016, USA
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Di Mascio D, Khalil A, Rizzo G, Kasprian G, Caulo M, Manganaro L, Odibo AO, Flacco ME, Giancotti A, Buca D, Liberati M, Timor-Tritsch IE, D'Antonio F. Reference ranges for fetal brain structures using magnetic resonance imaging: systematic review. Ultrasound Obstet Gynecol 2022; 59:296-303. [PMID: 34405927 DOI: 10.1002/uog.23762] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 08/05/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the methodology of studies reporting reference ranges for fetal brain structures on magnetic resonance imaging (MRI). METHODS MEDLINE, EMBASE, CINAHL and the Web of Science databases were searched electronically up to 31 December 2020 to identify studies investigating biometry and growth of the fetal brain and reporting reference ranges for brain structures using MRI. The primary aim was to evaluate the methodology of these studies. A list of 26 quality criteria divided into three domains, including 'study design', 'statistical and reporting methods' and 'specific aspects relevant to MRI', was developed and applied to evaluate the methodological appropriateness of each of the included studies. The overall quality score of a study, ranging between 0 and 26, was defined as the sum of scores awarded for each quality criterion and expressed as a percentage (the lower the percentage, the higher the risk of bias). RESULTS Fifteen studies were included in this systematic review. The overall mean quality score of the studies evaluated was 48.7%. When focusing on each domain, the mean quality score was 42.0% for 'study design', 59.4% for 'statistical and reporting methods' and 33.3% for 'specific aspects relevant to MRI'. For the 'study design' domain, sample size calculation and consecutive enrolment of women were the items found to be at the highest risk of bias. For the 'statistical and reporting methods' domain, the presence of regression equations for mean and SD for each measurement, the number of measurements taken for each variable and the presence of postnatal assessment information were the items found to be at the highest risk of bias. For the 'specific aspects relevant to MRI' domain, whole fetal brain assessment was not performed in any of the included studies and was therefore considered to be the item at the highest risk of bias. CONCLUSIONS Most of the previously published studies reporting fetal brain reference ranges on MRI are highly heterogeneous and have low-to-moderate quality in terms of methodology, which is similar to the findings reported for ultrasound studies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - G Kasprian
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuro- and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - M Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, 'G. D'Annunzio' University, Chieti, Italy
| | - L Manganaro
- Department of Radiology, Sapienza University of Rome, Rome, Italy
| | - A O Odibo
- Division of Maternal-Fetal Medicine, University of South Florida, Tampa, FL, USA
| | - M E Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - A Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - D Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - M Liberati
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Grossman School of Medicine, New York, NY, USA
| | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Toro-Bejarano M, Mora R, Timor-Tritsch IE, Vernon J, Monteagudo A, D’Antonio F, Duncan K. Myomectomy scar pregnancy ‒ a serious, but scarcely reported entity: literature review and an instructive case. Case Reports in Perinatal Medicine 2022. [DOI: 10.1515/crpm-2021-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Uterine myomas are a frequent finding in reproductive age women with an estimated incidence 12–25%. 1. Treatment of uterine myomas to facilitate good pregnancy rates and outcome, such as hysteroscopic, laparoscopic, abdominal resection uterine artery embolization among others were evaluated in terms of pregnancy outcome. While the literature is replete of the pregnancy complication of uterine rupture after myomectomies, 2–4 there are very few publications evaluate a relatively rare pregnancy complication associated with placental implantation within the uterine cavity at the site of the previous myomectomy, namely the myomectomy scar pregnancy (MSP). Despite their relative rarity, this type of pathologically adherent placenta rightfully belongs to the well-known entity of placenta accreta spectrum (PAS).
Case presentation
We present a complicated case of MSP and review the available literature to raise attention to its clinical appearance, its prenatal diagnosis so appropriate intrapartum management can be planned.
Conclusions
Despite the rarity of MSP, continuous attention should be given at every single routinely scheduled or indication driven obstetrical US scan following myomectomies to evaluate the placental site implantation regardless of the route and technique of their initial surgical procedure.
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Affiliation(s)
- Marcela Toro-Bejarano
- Department of Obstetrics and Gynecology , New York University School of Medicine , New York , NY , USA
| | - Robert Mora
- Department of Obstetrics and Gynecology , New York University School of Medicine , New York , NY , USA
| | - Ilan E. Timor-Tritsch
- Department of Obstetrics and Gynecology , New York University School of Medicine , New York , NY , USA
| | - Jessica Vernon
- Department of Obstetrics and Gynecology , New York University School of Medicine , New York , NY , USA
| | - Ana Monteagudo
- Carnegie Imaging for Women, Icahn School of Medicine , Mount Sinai , NY , USA
| | - Francesco D’Antonio
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology , University of Chieti , Chieti , NY , Italy
| | - Karen Duncan
- Department of Obstetrics and Gynecology , New York University School of Medicine , New York , NY , USA
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Timor-Tritsch IE, Horwitz G, D'Antonio F, Monteagudo A, Bornstein E, Chervenak J, Messina L, Morlando M, Cali G. Recurrent Cesarean scar pregnancy: case series and literature review. Ultrasound Obstet Gynecol 2021; 58:121-126. [PMID: 33411387 DOI: 10.1002/uog.23577] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/18/2020] [Accepted: 09/22/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To determine the rate of recurrent Cesarean scar pregnancy (CSP) in our clinical practices and to evaluate whether the mode of treatment of a CSP is associated with the risk of recurrent CSP, as well as to review the published literature on recurrent CSP. METHODS We performed a retrospective search of our six obstetric and gynecological departmental ultrasound databases for all CSPs and recurrent CSPs between 2010 and 2019. We extracted various data, including number of CSPs with follow-up, number of cases attempting and number achieving pregnancy following treatment of CSP and number of recurrent CSPs, as well as details of the treatment of the original CSP. After analyzing the clinical data, we evaluated whether the mode of treatment terminating the previous CSP was associated with the risk of recurrent CSP. We also performed a PubMed search for: 'recurrent Cesarean scar pregnancy' and 'recurrent Cesarean scar ectopic pregnancy'. Articles were reviewed for year of publication, and extraction and analysis of the same data as those obtained from our departmental databases were performed. RESULTS Our database search identified 252 cases of CSP. The overall rate of clinical follow-up ranged between 71.4% and 100%, according to treatment site (mean, 90.9%). Among these, 105 women had another pregnancy after treatment of the previous CSP. Of these, 36 (34.3%) pregnancies were recurrent CSP, with 27 women having a single recurrence and three women having multiple recurrences, one with two, one with three and one with four. We did not find any particular single or combination treatment mode terminating the previous CSP to be associated with recurrent CSP. The literature search identified 17 articles that yielded sufficient information for us to evaluate their reported prevalence of recurrent CSP. These reported 1743 primary diagnoses of CSP, of which 944 had reliable follow-up. Data were available for 489 cases that attempted to conceive again after treatment of a previous CSP, and on the 327 pregnancies achieved. Of these, 67 (20.5%) were recurrent CSP. CONCLUSIONS On the basis of our pooled clinical data and review of the literature, recurrent CSP is apparently more common than was previously assumed based upon mostly single-case reports or series with few cases. This should be borne in mind when counseling patients undergoing treatment for CSP regarding their risk of recurrence. We found no obvious causal relationship or association between the type of treatment of the previous CSP and recurrence of CSP. Patients who become pregnant after treatment of a CSP should be encouraged to have an early (5-7-week) first-trimester transvaginal scan to determine the location of the gestation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - G Horwitz
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - F D'Antonio
- Department of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - A Monteagudo
- Carnegie Imaging for Women, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E Bornstein
- Department of Obstetrics and Gynecology, Division of MFM Lenox Hill Hospital, New York, NY, USA
| | - J Chervenak
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - L Messina
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - M Morlando
- Department of Woman, Child and General and Special Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - G Cali
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
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Paladini D, Malinger G, Birnbaum R, Monteagudo A, Pilu G, Salomon LJ, Timor-Tritsch IE. ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 2: performance of targeted neurosonography. Ultrasound Obstet Gynecol 2021; 57:661-671. [PMID: 33734522 DOI: 10.1002/uog.23616] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 06/12/2023]
Affiliation(s)
- D Paladini
- Fetal Medicine and Surgery Unit, Istituto G. Gaslini, Genoa, Italy
| | - G Malinger
- Division of Ultrasound in Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Birnbaum
- Division of Ultrasound in Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Monteagudo
- Carnegie Imaging for Women, Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - G Pilu
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - L J Salomon
- Hôpital Necker Enfants Malades, AP-HP, and LUMIERE platform, EA 7328 Université de Paris, Paris, France
| | - I E Timor-Tritsch
- Division of Obstetrical and Gynecological Ultrasound, NYU School of Medicine, New York, NY, USA
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22
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Timor-Tritsch IE, McDermott WM, Monteagudo A, Calί G, Kreines F, Hernandez S, Stephenson C, Bryk H, D'Antonio F. Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity. J Matern Fetal Neonatal Med 2021; 35:5846-5857. [PMID: 33730990 DOI: 10.1080/14767058.2021.1897564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases. MATERIAL AND METHODS This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded. RESULTS Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy. CONCLUSION The EMV developing in the background of retained placental tissue associated with CSP differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | | | - Ana Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Carnegie Imaging for Women, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calί
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Fabiana Kreines
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | - Sasha Hernandez
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | | | - Hillel Bryk
- Department of Radiology, NYU School of Medicine, New York, NY, USA
| | - Francesco D'Antonio
- Department of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Timor-Tritsch IE, Monteagudo A, Ramos J, Kupchinska S, Mastriciani F, Spier M. Three-Dimensional Coronal Plane of the Uterus: A Critical View for Diagnostic Accuracy. J Ultrasound Med 2021; 40:607-619. [PMID: 32827325 DOI: 10.1002/jum.15432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/16/2020] [Accepted: 07/05/2020] [Indexed: 06/11/2023]
Abstract
Two-dimensional transvaginal and transabdominal ultrasound (US) examinations are the suggested methods for examining the uterus. Three-dimensional (3D) US, which is not compulsory by society guidelines, provides additional uterine views, reassuring users of pathologic conditions not evident on customary sagittal and transverse views. The 3D coronal plane is rarely seen by 2-dimensional US transducers, let alone in extremely retroverted or axial uteri. Ultrasound machines nowadays feature 3D US capability. Our experience is that the coronal uterine view is a problem solver, helping diagnostic abilities of pelvic imaging. We advocate its liberal use and its acquisition in every pelvic scan. In this Pictorial Essay we present examples to demonstrate its use.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Obstetric and Gynecologic Ultrasound, New York University Grossman School of Medicine, New York, New York, USA
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joanne Ramos
- Department of Obstetrics and Gynecology, Division of Obstetric and Gynecologic Ultrasound, New York University Grossman School of Medicine, New York, New York, USA
| | - Svitlana Kupchinska
- Department of Obstetrics and Gynecology, Division of Obstetric and Gynecologic Ultrasound, New York University Grossman School of Medicine, New York, New York, USA
| | - Ferma Mastriciani
- Department of Obstetrics and Gynecology, Division of Obstetric and Gynecologic Ultrasound, New York University Grossman School of Medicine, New York, New York, USA
| | - Mihaela Spier
- Department of Obstetrics and Gynecology, Division of Obstetric and Gynecologic Ultrasound, New York University Grossman School of Medicine, New York, New York, USA
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Antoine C, Pimentel RN, Timor-Tritsch IE, Mittal K, Bennett TA, Bourroul FM. Origin of a Post-Cesarean Delivery Niche: Diagnosis, Pathophysiologic Characteristics, and Video Documentation. J Ultrasound Med 2021; 40:205-208. [PMID: 32557736 DOI: 10.1002/jum.15368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/12/2020] [Accepted: 05/19/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology
- Compassionate Ob/Gyn Care PLLC, New York, New York, USA
| | | | | | - Khush Mittal
- Department of Pathology, New York University School of Medicine, New York, New York, USA
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Timor-Tritsch IE. Cesarean scar pregnancy: a therapeutic dilemma. Ultrasound Obstet Gynecol 2021; 57:32-33. [PMID: 33387410 DOI: 10.1002/uog.23549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 06/12/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
- Department of Obstetrics and Gynecology, Division of Ob/Gyn Ultrasound, New York University Langone Health, New York, NY, USA
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Shainker SA, Coleman B, Timor-Tritsch IE, Bhide A, Bromley B, Cahill AG, Gandhi M, Hecht JL, Johnson KM, Levine D, Mastrobattista J, Philips J, Platt LD, Shamshirsaz AA, Shipp TD, Silver RM, Simpson LL, Copel JA, Abuhamad A. Special Report of the Society for Maternal-Fetal Medicine Placenta Accreta Spectrum Ultrasound Marker Task Force: Consensus on definition of markers and approach to the ultrasound examination in pregnancies at risk for placenta accreta spectrum. Am J Obstet Gynecol 2021; 224:B2-B14. [PMID: 33386103 DOI: 10.1016/j.ajog.2020.09.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and their screening performance, inconsistencies in the literature persist. In response to the need for standardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound examination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides information on the Placenta Accreta Spectrum Task Force process and findings.
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Malinger G, Paladini D, Haratz KK, Monteagudo A, Pilu G, Timor-Tritsch IE. Reply. Ultrasound Obstet Gynecol 2021; 57:174-175. [PMID: 33387405 DOI: 10.1002/uog.23564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- G Malinger
- Division of Ob-Gyn Ultrasound, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - D Paladini
- Fetal Medicine and Surgery Unit, Istituto G. Gaslini, Genoa, Italy
| | - K K Haratz
- Division of Ob-Gyn Ultrasound, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - A Monteagudo
- Carnegie Imaging for Women, Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - G Pilu
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - I E Timor-Tritsch
- Division of Obstetrical and Gynecological Ultrasound, NYU School of Medicine, New York, NY, USA
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Malinger G, Paladini D, Haratz KK, Monteagudo A, Pilu GL, Timor-Tritsch IE. ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 1: performance of screening examination and indications for targeted neurosonography. Ultrasound Obstet Gynecol 2020; 56:476-484. [PMID: 32870591 DOI: 10.1002/uog.22145] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 06/11/2023]
Affiliation(s)
- G Malinger
- Division of Ultrasound in Obstetrics & Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Paladini
- Fetal Medicine and Surgery Unit, Istituto G.Gaslini, Genoa, Italy
| | - K K Haratz
- Division of Ultrasound in Obstetrics & Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Monteagudo
- Carnegie Imaging for Women, Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - G L Pilu
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - I E Timor-Tritsch
- Division of Obstetrical & Gynecological Ultrasound, NYU School of Medicine, New York, NY, USA
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Abstract
There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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Abstract
Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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Agten AK, Monteagudo A, Timor-Tritsch IE, Thilaganathan B. Cesarean Scar Pregnancy Registry: an international research platform. Ultrasound Obstet Gynecol 2020; 55:438-440. [PMID: 31840910 DOI: 10.1002/uog.21952] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 06/10/2023]
Affiliation(s)
- A Kaelin Agten
- Fetal Medicine Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Monteagudo
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, New York, NY, USA
| | - I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Calí G, Timor-Tritsch IE, Forlani F, Palacios-Jaraquemada J, Monteagudo A, Kaelin Agten A, Flacco ME, Khalil A, Buca D, Manzoli L, Liberati M, D'Antonio F. Value of first-trimester ultrasound in prediction of third-trimester sonographic stage of placenta accreta spectrum disorder and surgical outcome. Ultrasound Obstet Gynecol 2020; 55:450-459. [PMID: 31788885 DOI: 10.1002/uog.21939] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/12/2019] [Accepted: 11/22/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To explore whether early first-trimester ultrasound can predict the third-trimester sonographic stage of placenta accreta spectrum (PAS) disorder and to elucidate whether combining first-trimester ultrasound findings with the sonographic stage of PAS disorder can stratify the risk of adverse surgical outcome in women at risk for PAS disorder. METHODS This was a retrospective analysis of prospectively collected data from women with placenta previa, and at least one previous Cesarean delivery (CD) or uterine surgery, for whom early first-trimester (5-7 weeks' gestation) ultrasound images could be retrieved. The relationship between the position of the gestational sac and the prior CD scar was assessed using three sonographic markers for first-trimester assessment of Cesarean scar (CS) pregnancy, reported by Calí et al. (crossover sign (COS)), Kaelin Agten et al. (implantation of the gestational sac on the scar vs in the niche of the CS) and Timor-Tritsch et al. (position of the center of the gestational sac below vs above the midline of the uterus), by two different examiners blinded to the final diagnosis and clinical outcome. The primary aim of the study was to explore the association between first-trimester ultrasound findings and the stage of PAS disorder on third-trimester ultrasound. Our secondary aim was to elucidate whether the combination of first-trimester ultrasound findings and sonographic stage of PAS disorder can predict surgical outcome. Logistic regression analysis and area under the receiver-operating-characteristics curve (AUC) were used to analyze the data. RESULTS One hundred and eighty-seven women with vasa previa were included. In this cohort, 79.6% (95% CI, 67.1-88.2%) of women classified as COS-1, 94.4% (95% CI, 84.9-98.1%) of those with gestational-sac implantation in the niche of the prior CS and 100% (95% CI, 93.4-100%) of those with gestational sac located below the uterine midline, on first-trimester ultrasound, were affected by the severest form of PAS disorder (PAS3) on third-trimester ultrasound. On multivariate logistic regression analysis, COS-1 (odds ratio (OR), 7.9 (95% CI, 4.0-15.5); P < 0.001), implantation of the gestational sac in the niche (OR, 29.1 (95% CI, 8.1-104); P < 0.001) and location of the gestational sac below the midline of the uterus (OR, 38.1 (95% CI, 12.0-121); P < 0.001) were associated independently with PAS3, whereas parity (P = 0.4) and the number of prior CDs (P = 0.5) were not. When translating these figures into diagnostic models, first-trimester diagnosis of COS-1 (AUC, 0.94 (95% CI, 0.91-0.97)), pregnancy implantation in the niche (AUC, 0.92 (95% CI, 0.89-0.96)) and gestational sac below the uterine midline (AUC, 0.92 (95% CI, 0.88-0.96)) had a high predictive accuracy for PAS3. There was an adverse surgical outcome in 22/187 pregnancies and it was more common in women with, compared to those without, COS-1 (P < 0.001), gestational-sac implantation in the niche (P < 0.001) and gestational-sac position below the uterine midline (P < 0.001). On multivariate logistic regression analysis, third-trimester ultrasound diagnosis of PAS3 (OR, 4.3 (95% CI, 2.1-17.3)) and first-trimester diagnosis of COS-1 (OR, 7.9 (95% CI, 4.0-15.5); P < 0.001), pregnancy implantation in the niche (OR, 29.1 (95% CI, 8.1-79.0); P < 0.001) and position of the sac below the uterine midline (OR, 6.6 (95% CI, 3.9-16.2); P < 0.001) were associated independently with adverse surgical outcome. When combining the sonographic coordinates of the three first-trimester imaging markers, we identified an area we call high-risk-for-PAS triangle, which may enable an easy visual perception and application of the three methods to prognosticate the risk for CS pregnancy and PAS disorder, although it requires validation in large prospective studies. CONCLUSIONS Early first-trimester sonographic assessment of pregnancies with previous CD can predict reliably ultrasound stage of PAS disorder. Combination of findings on first-trimester ultrasound with second- and third-trimester ultrasound examination can stratify the surgical risk in women affected by a PAS disorder. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Calí
- Department of Obstetrics and Gynaecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - A Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Kaelin Agten
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - M E Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - D Buca
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M Liberati
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - F D'Antonio
- Fetal Medicine Unit, Department of Medical and Surgical Sciences, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
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Timor-Tritsch IE, Yoon E, Monteagudo A, Ciaffarano J, Brandon C, Mittal KR, Wallach RC, Boyd LR. Ultrasound and Histopathologic Correlation of Ovarian Cystadenofibromas: Diagnostic Value of the "Shadow Sign". J Ultrasound Med 2019; 38:2973-2978. [PMID: 30927305 DOI: 10.1002/jum.15003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Cystadenofibromas (CAFs) are rare benign ovarian tumors without a widely accepted ultrasound (US) pattern. They are usually described by as thin-walled, unilocular or multilocular, and at times septated cysts with scant blood flow and no solid components. We describe a unique US feature, the "shadow sign," seen in prospectively diagnosed benign CAFs. We also provide the histopathologic basis for this typical US appearance. METHODS Ultrasound (US) examinations were performed in our obstetric and gynecologic US unit. Pathologic examinations were performed by a dedicated gynecologic pathology team. The US and pathology department's database was searched for the diagnosis of a CAF between 2010 and 2017. RESULTS We identified 20 patients who underwent transvaginal US examinations with a sole US diagnosis of a CAF, and the tumors were surgically removed. The common US feature across the 20 cases was the presence of hyperechoic avascular shadowing nodules. The correlating histologic features were unilocular or multilocular cysts with a smooth internal wall surface lined by a simple epithelium and occasional robust polypoid fibrous stroma. CONCLUSIONS This US marker helps in differentiating CAFs from borderline ovarian tumors, which do not show this US feature. We hope that recognizing the suggested shadow sign as an additional descriptor of CAFs will lead to minimizing their unnecessary removal and eliminating additional and unnecessary imaging by computed tomography and magnetic resonance imaging.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Departments of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Esther Yoon
- Surgical Pathology, New York University School of Medicine, New York, New York, USA
| | - Ana Monteagudo
- Carnegie Imaging for Women, Icahn School of Medicine, New York, New York, USA
| | - Jeanine Ciaffarano
- Surgical Pathology, New York University School of Medicine, New York, New York, USA
| | - Caroline Brandon
- Departments of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Kushbakhat R Mittal
- Surgical Pathology, New York University School of Medicine, New York, New York, USA
| | - Robert C Wallach
- Departments of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Leslie R Boyd
- Departments of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
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Timor-Tritsch IE, Foley CE, Brandon C, Yoon E, Ciaffarrano J, Monteagudo A, Mittal K, Boyd L. New sonographic marker of borderline ovarian tumor: microcystic pattern of papillae and solid components. Ultrasound Obstet Gynecol 2019; 54:395-402. [PMID: 30950132 DOI: 10.1002/uog.20283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/02/2019] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To describe and evaluate the utility of a new sonographic microcystic pattern, which is typical of borderline ovarian tumor (BOT) papillary projections, solid component(s) and/or septa, as a new ultrasound marker that is capable of distinguishing BOT from other adnexal masses, and to present/obtain histologic confirmation. METHODS In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who had undergone preoperative transvaginal ultrasound (TVS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations, associated with solid component(s), papillary projections and/or septa. From the same cases, histopathologic slides of each BOT were examined for presence of any of these microcystic features which had been identified on TVS. To confirm that the microcystic TVS pattern is unique to BOTs, we also selected randomly from our ultrasound and surgical database 20 cases of epithelial ovarian cancer and 20 cases of benign cystadenoma, for review by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to determine whether the association between microcystic tissue pattern and BOT has been described previously. RESULTS Included in the final analysis were 62 patients (67 ovaries) with preoperative TVS and surgically confirmed BOT on pathologic examination. The mean patient age at surgery was 39.8 years. The mean BOT size at TVS was 60.7 mm. Of the 67 BOTs, 47 (70.1%) were serous, 15 (22.4%) were mucinous and five (7.5%) were seromucinous. We observed on TVS a microcystic pattern in the papillary projections, solid component(s) and/or septa in 60 (89.6%) of the 67 BOTs, including 46 (97.9%) of the 47 serous BOTs, 11 (73.3%) of the 15 mucinous BOTs and three (60.0%) of the five seromucinous BOTs. On microscopic evaluation, 60 (89.6%) of the 67 samples had characteristic 1-3-mm fluid-filled cysts similar to those seen on TVS. In seven cases there was a discrepancy between sonographic and histologic observation of a microcystic pattern. The 20 cystadenomas were mostly unilocular and/or multilocular and largely avascular. None of them or the 20 epithelial ovarian malignancies displayed microcystic characteristics, either on TVS or at histology. On review of 23 published articles in the English medical literature, containing 163 sonographic images of BOT, we found that, while all images contained it, there was no description of the microcystic tissue pattern. CONCLUSION We report herein a novel sonographic marker of BOT, a 'microcystic pattern' of BOT papillary projections, solid component(s) and/or septa. This was seen in the majority of both serous and mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of benign entities and malignancies, the microcystic appearance seems to be unique to BOTs. No similar description has been published previously. Utilization of this new marker should help to identify BOT correctly, discriminating it from ovarian cancer and benign ovarian pathology, and should ensure appropriate clinical and surgical management. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I E Timor-Tritsch
- New York University School of Medicine, Langone Health, Department of Obstetrics & Gynecology, Division of Obstetrical and Gynecologic Ultrasound, New York, NY, USA
| | - C E Foley
- New York University School of Medicine, Langone Health, Department of Obstetrics & Gynecology, Division of Obstetrical and Gynecologic Ultrasound, New York, NY, USA
| | - C Brandon
- New York University School of Medicine, Langone Health, Department of Obstetrics & Gynecology, Division of Obstetrical and Gynecologic Ultrasound, New York, NY, USA
| | - E Yoon
- New York University School of Medicine, Department of Pathology, Division of Surgical Pathology, New York, NY, USA
| | - J Ciaffarrano
- New York University School of Medicine, Department of Pathology, Division of Surgical Pathology, New York, NY, USA
| | - A Monteagudo
- Carnegie Imaging for Women, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K Mittal
- New York University School of Medicine, Department of Pathology, Division of Surgical Pathology, New York, NY, USA
| | - L Boyd
- New York University School of Medicine, Langone Health, Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, New York, NY, USA
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Timor-Tritsch IE, D'Antonio F, Calí G, Palacios-Jaraquemada J, Meyer J, Monteagudo A. Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory? Ultrasound Obstet Gynecol 2019; 54:156-163. [PMID: 30677186 DOI: 10.1002/uog.20225] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 06/09/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - F D'Antonio
- Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
| | - G Calí
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - J Meyer
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - A Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Monteagudo A, Calì G, Rebarber A, Cordoba M, Fox NS, Bornstein E, Dar P, Johnson A, Rebolos M, Timor-Tritsch IE. Minimally Invasive Treatment of Cesarean Scar and Cervical Pregnancies Using a Cervical Ripening Double Balloon Catheter: Expanding the Clinical Series. J Ultrasound Med 2019; 38:785-793. [PMID: 30099757 DOI: 10.1002/jum.14736] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/06/2018] [Accepted: 06/03/2018] [Indexed: 06/08/2023]
Abstract
The efficacy of treating cesarean scar pregnancies and cervical pregnancies with the Cook® cervical ripening balloon catheter, in a multicenter office-based setting is reported. Thirty-eight women were treated. Insertion of the catheter was performed under real-time ultrasound guidance. Patients received adjuvant systemic methotrexate, prophylactic oral antibiotics, and oral pain medication. Serum human chorionic gonadotropin and ultrasound scans were followed serially until resolution. Thirty-seven patients were successfully treated, requiring no further procedures. We found that the Cook cervical ripening balloon technique is a simple, effective, outpatient, minimally invasive treatment with few complications noted in this expanded series.
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Affiliation(s)
- Ana Monteagudo
- Carnegie Imaging for Women, PLLC, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Andrei Rebarber
- Carnegie Imaging for Women, PLLC, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marcos Cordoba
- Department of Obstetrics and Gynecology, Michigan State University, East Lansing, Michigan, USA
| | - Nathan S Fox
- Carnegie Imaging for Women, PLLC, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eran Bornstein
- Lenox Hill Hospital (Northwell Health)/NYU Medical Center, New York, New York, USA
| | - Peer Dar
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Anthony Johnson
- Texas Fetal Center, Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Mark Rebolos
- New York University Langone Health, New York, New York, USA
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Kaelin Agten A, Honart A, Monteagudo A, McClelland S, Basher B, Timor-Tritsch IE. Cesarean Delivery Changes the Natural Position of the Uterus on Transvaginal Ultrasonography. J Ultrasound Med 2018; 37:1179-1183. [PMID: 29076539 DOI: 10.1002/jum.14461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess whether cesarean delivery changes the natural position of the uterus. METHODS In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery. RESULTS We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans ± SD was 18 ± 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P < .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8° ± 45.7°) versus vaginal delivery (145.8° ± 43.7°; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4° ± 51.2°) versus vaginal delivery (152.8° ± 47.7°; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6° versus 7.0°; P = .027). CONCLUSIONS Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.
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Affiliation(s)
- Andrea Kaelin Agten
- Department of Obstetrics and Fetal Medicine, St George's University Hospital NHS, London, England
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Anne Honart
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Ana Monteagudo
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
- Maternal-Fetal Medicine Associates, Carnegie Hill Imaging for Women, New York, New York, USA
| | - Spencer McClelland
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Basmy Basher
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
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Yukhayev A, Meirowitz N, Madankumar R, Timor-Tritsch IE, Monteagudo A. Uncommon second-trimester presentation of vein of Galen malformation. Ultrasound Obstet Gynecol 2018; 51:421-423. [PMID: 28295796 DOI: 10.1002/uog.17462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/15/2017] [Accepted: 03/03/2017] [Indexed: 06/06/2023]
Affiliation(s)
- A Yukhayev
- Division of Maternal-Fetal Medicine, Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, New Hyde Park, New York, USA
| | - N Meirowitz
- Division of Maternal-Fetal Medicine, Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, New Hyde Park, New York, USA
| | - R Madankumar
- Division of Maternal-Fetal Medicine, Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, New Hyde Park, New York, USA
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, USA
| | - A Monteagudo
- Carnegie Imaging for Women, Icahn School of Medicine at Mount Sinai, New York, USA
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Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, Monteaugudo A, Buca D, Forlani F, Familiari A, Scambia G, Acharya G, D'Antonio F. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51:169-175. [PMID: 28661021 DOI: 10.1002/uog.17568] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 06/16/2017] [Accepted: 06/22/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). METHODS An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis. RESULTS A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case. CONCLUSIONS CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - A Monteaugudo
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - D Buca
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - A Familiari
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - G Scambia
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
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D'Antonio F, Timor-Tritsch IE, Palacios-Jaraquemada J, Monteagudo A, Buca D, Forlani F, Minneci G, Foti F, Manzoli L, Liberati M, Acharya G, Calì G. First-trimester detection of abnormally invasive placenta in high-risk women: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51:176-183. [PMID: 28833750 DOI: 10.1002/uog.18840] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/02/2017] [Accepted: 08/07/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The primary aim of this systematic review was to ascertain whether ultrasound signs suggestive of abnormally invasive placenta (AIP) are present in the first trimester of pregnancy. Secondary aims were to ascertain the strength of association and the predictive accuracy of such signs in detecting AIP in the first trimester. METHODS An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane databases (2000-2016) was performed. Only studies reporting on first-trimester diagnosis of AIP that was subsequently confirmed in the third trimester either during operative delivery or by pathological examination were included. Meta-analysis of proportions, random-effects meta-analysis and hierarchical summary receiver-operating characteristics curve analysis were used to analyze the data. RESULTS Seven studies, involving 551 pregnancies at high risk of AIP, were included. At least one ultrasound sign suggestive of AIP was detected in 91.4% (95% CI, 85.8-95.7%) of cases with confirmed AIP. The most common ultrasound feature in the first trimester of pregnancy was low implantation of the gestational sac close to a previous uterine scar, which was observed in 82.4% (95% CI, 46.6-99.8%) of cases. Anechoic spaces within the placental mass (lacunae) were observed in 46.0% (95% CI, 10.9-83.7%) and a reduced myometrial thickness in 66.8% (95% CI, 45.2-85.2%) of cases affected by AIP. Pregnancies with a low implantation of the gestational sac had a significantly higher risk of AIP (odds ratio, 19.6 (95% CI, 6.7-57.3)), with a sensitivity and specificity of 44.4% (95% CI, 21.5-69.2%) and 93.4% (95% CI, 90.5-95.7%), respectively. CONCLUSIONS Ultrasound signs of AIP can be present during the first trimester of pregnancy, even before 11 weeks' gestation. Low anterior implantation of the placenta/gestational sac close to or within the scar was the most commonly seen early ultrasound sign suggestive of AIP, although its individual predictive accuracy was not high. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - A Monteagudo
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - D Buca
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - G Minneci
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F Foti
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M Liberati
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - G Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
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Malinger G, Paladini D, Pilu G, Timor-Tritsch IE. Fetal cerebral magnetic resonance imaging, neurosonography and the brave new world of fetal medicine. Ultrasound Obstet Gynecol 2017; 50:679-680. [PMID: 28568972 DOI: 10.1002/uog.17538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/18/2017] [Accepted: 05/25/2017] [Indexed: 06/07/2023]
Affiliation(s)
- G Malinger
- Division of Ultrasound in Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Paladini
- Fetal Medicine & Surgery Unit, G. Gaslini Children's Hospital, Genoa, Italy
| | - G Pilu
- Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
| | - I E Timor-Tritsch
- Division of Obstetrical & Gynecological Ultrasound, Department of Obstetrics and Gynecology, NYU School of Medicine, New York, NY, USA
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Bennett TA, Morgan J, Timor-Tritsch IE, Dolin C, Dziadosz M, Tsai M. Fifth recurrent Cesarean scar pregnancy: observations of a case and historical perspective. Ultrasound Obstet Gynecol 2017; 50:658-660. [PMID: 28295733 DOI: 10.1002/uog.17461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/31/2017] [Accepted: 03/03/2017] [Indexed: 06/06/2023]
Affiliation(s)
- T-A Bennett
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University Langone Medical Center, New York, NY, USA
| | - J Morgan
- New York University School of Medicine, New York, NY, USA
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University Langone Medical Center, New York, NY, USA
| | - C Dolin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University Langone Medical Center, New York, NY, USA
| | - M Dziadosz
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - M Tsai
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
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Timor-Tritsch IE, Monteagudo A, Kaelin Agten A. Recap-Minimally invasive treatment for cesarean scar pregnancy using a double-balloon catheter: additional suggestions to the technique. Am J Obstet Gynecol 2017; 217:496-497. [PMID: 28743445 DOI: 10.1016/j.ajog.2017.07.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY.
| | - Ana Monteagudo
- Carnegie Imaging for Women, PLLC, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai
| | - Andrea Kaelin Agten
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
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Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D'Antonio F. Natural history of Cesarean scar pregnancy on prenatal ultrasound: the crossover sign. Ultrasound Obstet Gynecol 2017; 50:100-104. [PMID: 27420402 DOI: 10.1002/uog.16216] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/04/2016] [Accepted: 07/08/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Advances in prenatal imaging techniques have led to an increase in the diagnosis of Cesarean scar pregnancy (CSP). However, antenatal counseling when CSP is diagnosed is challenging, and current evidence is derived mainly from small series reporting high rates of adverse maternal outcomes. The aim of this study was to ascertain the performance of prenatal ultrasound in predicting the natural history of CSP using a new sonographic sign, the crossover sign (COS). METHODS This was a retrospective analysis of early first-trimester (6-8 weeks' gestation) ultrasound images in women with morbidly adherent placenta (MAP) managed in the third trimester of pregnancy. The relationship between the gestational sac of the CSP, anterior uterine wall and Cesarean scar, defined as the COS, was analyzed to determine whether it could predict evolution in these cases. Odds ratios (ORs) were calculated and logistic regression analysis was performed to investigate the association between different types of COS (COS-1, COS-2+ or COS-2-) and the occurrence of MAP. RESULTS Sixty-eight pregnancies with MAP were included. The risk of placenta percreta was significantly higher in pregnancies with COS-1 than in those with COS-2 (OR, 6.67 (95% CI, 1.3-33.3)). When evaluating the two variants of COS-2 separately, the risk of placenta percreta was significantly higher in pregnancies with COS-1 vs COS-2+ (OR, 5.83 (95% CI, 1.1-30.2)) and this risk was even higher when comparing cases with COS-1 vs COS-2- (OR, 12.0 (95% CI, 1.9-75.7)). Logistic regression analysis showed that COS-1 was associated independently with severe forms of MAP, such as placenta percreta and increta (OR, 12.85 (95% CI, 2.0-84.0)), while COS-2+ was associated independently with placenta accreta (OR, 4.37 (95% CI, 1.1-17.0)). CONCLUSIONS Ultrasound assessment of the relationship between the gestational sac of a CSP and the endometrial line (the COS) may help to determine whether a CSP will progress towards a less severe form of MAP, amenable to postnatal treatment, and successful pregnancy outcome. Large prospective studies are needed to confirm our findings and elucidate the natural history of this condition. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Cali
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - G Minneci
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F D'Antonio
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
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Tutschek B, Blaas HGK, Abramowicz J, Baba K, Deng J, Lee W, Merz E, Platt L, Pretorius D, Timor-Tritsch IE, Gindes L. Three-dimensional ultrasound imaging of the fetal skull and face. Ultrasound Obstet Gynecol 2017; 50:7-16. [PMID: 28229509 DOI: 10.1002/uog.17436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 02/06/2017] [Accepted: 02/14/2017] [Indexed: 06/06/2023]
Affiliation(s)
- B Tutschek
- Prenatal Zurich, Zürich, Switzerland
- Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - H-G K Blaas
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, National Center for Fetal Medicine, St Olavs Hospital, Trondheim, Norway
| | - J Abramowicz
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
| | - K Baba
- Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - J Deng
- University College London, London, UK
| | - W Lee
- Baylor College of Medicine, Obstetrics & Gynecology, Houston, TX, USA
| | - E Merz
- Krankenhaus Nordwest - Centre for Prenatal Diagnosis and Therapy, Frankfurt, Germany
| | - L Platt
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - D Pretorius
- Department of Radiology, University of California San Diego, CA, USA
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, New York, NY, USA
| | - L Gindes
- Department of Obstetrics and Gynecology, Wolfson Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Mascilini F, Savelli L, Scifo MC, Exacoustos C, Timor-Tritsch IE, De Blasis I, Moruzzi MC, Pasciuto T, Scambia G, Valentin L, Testa AC. Ovarian masses with papillary projections diagnosed and removed during pregnancy: ultrasound features and histological diagnosis. Ultrasound Obstet Gynecol 2017; 50:116-123. [PMID: 27484484 DOI: 10.1002/uog.17216] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/30/2016] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To elucidate the ultrasound features that can discriminate between benign and malignant ovarian cysts with papillary projections but no other solid component in pregnant women. METHODS Thirty-four women with an ultrasound diagnosis of an ovarian cyst with papillary projections but no other solid component that had been removed surgically during pregnancy were identified from the databases of four ultrasound units. Some clinical and ultrasound information was collected prospectively. Missing information was obtained retrospectively from ultrasound images, ultrasound reports and patient records. Using prospectively and retrospectively collected data, the ultrasound appearance of the tumors was described using the terms and definitions of the International Ovarian Tumor Analysis group. The ultrasound characteristics were compared with the histological diagnosis. RESULTS Of the 34 cases included, 19 (56%) lesions were benign (16 decidualized endometriomas, one cystadenofibroma, one simple cyst, one struma ovarii), 12 (35%) were borderline tumors and three (9%) were primary invasive tumors (two immature teratomas, one endometrioid cystadenocarcinoma). The contour of the cyst papillations was smooth in 79% (15/19) of benign tumors vs 27% (4/15) of malignant tumors (P = 0.002). The cystic content showed ground-glass echogenicity in 74% (14/19) of benign tumors vs 13% (2/15) of malignant tumors (P = 0.0006). All ovarian masses with smooth papillations and ground-glass content (n = 12) were decidualized endometriomas. The papillary projections were vascularized and the color score was 3 or 4 in 88% (14/16) of decidualized endometriomas vs 42% (5/12) of borderline tumors (P = 0.013). CONCLUSIONS In pregnant women, ovarian cysts with ground-glass echogenicity and papillations with a smooth contour on ultrasound are most likely to be decidualized endometriomas. Cysts with anechoic or low-level echogenicity and papillations with an irregular contour suggest borderline malignancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Mascilini
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - L Savelli
- Gynecology and Early Pregnancy, Ultrasound Unit, Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
| | - M C Scifo
- Gynecology and Early Pregnancy, Ultrasound Unit, Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
| | - C Exacoustos
- Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - I De Blasis
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - M C Moruzzi
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - T Pasciuto
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - G Scambia
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - A C Testa
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
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Prayer D, Malinger G, Brugger PC, Cassady C, De Catte L, De Keersmaecker B, Fernandes GL, Glanc P, Gonçalves LF, Gruber GM, Laifer-Narin S, Lee W, Millischer AE, Molho M, Neelavalli J, Platt L, Pugash D, Ramaekers P, Salomon LJ, Sanz M, Timor-Tritsch IE, Tutschek B, Twickler D, Weber M, Ximenes R, Raine-Fenning N. ISUOG Practice Guidelines: performance of fetal magnetic resonance imaging. Ultrasound Obstet Gynecol 2017; 49:671-680. [PMID: 28386907 DOI: 10.1002/uog.17412] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/07/2017] [Accepted: 01/13/2017] [Indexed: 06/07/2023]
Affiliation(s)
- D Prayer
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - G Malinger
- Division of Ultrasound in Obstetrics & Gynecology, Lis Maternity Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - P C Brugger
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - C Cassady
- Texas Children's Hospital and Fetal Center, Houston, TX, USA
| | - L De Catte
- Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - B De Keersmaecker
- Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - G L Fernandes
- Fetal Medicine Unit, Department of Obstetrics, ABC Medicine University, Santo Andre, Brazil
| | - P Glanc
- Departments of Radiology and Obstetrics & Gynecology, University of Toronto and Sunnybrook Research Institute, Obstetrical Ultrasound Center, Department of Medical Imaging, Body Division, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - L F Gonçalves
- Fetal Imaging, William Beaumont Hospital, Royal Oak and Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - G M Gruber
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - S Laifer-Narin
- Division of Ultrasound and Fetal MRI, Columbia University Medical Center - New York Presbyterian Hospital, New York, NY, USA
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA
| | - A-E Millischer
- Radiodiagnostics Department, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - M Molho
- Diagnostique Ante Natal, Service de Neuroradiologie, CHU Sud Réunion, St Pierre, La Réunion, France
| | - J Neelavalli
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - L Platt
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, Los Angeles, CA, USA
| | - D Pugash
- Department of Radiology, University of British Columbia, Vancouver, Canada
- Department of Obstetrics and Gynecology, BC Women's Hospital, Vancouver, Canada
| | - P Ramaekers
- Prenatal Diagnosis, Department of Obstetrics and Gynecology, Ghent University Hospital, Ghent, Belgium
| | - L J Salomon
- Department of Obstetrics, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - M Sanz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA
| | - I E Timor-Tritsch
- Division of Obstetrical & Gynecological Ultrasound, NYU School of Medicine, New York, NY, USA
| | - B Tutschek
- Department of Obstetrics & Gynecology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany and Prenatal Zurich, Zürich, Switzerland
| | - D Twickler
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Weber
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - R Ximenes
- Fetal Medicine Foundation Latin America, Centrus, Campinas, Brazil
| | - N Raine-Fenning
- Department of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham and Nurture Fertility, The Fertility Partnership, Nottingham, UK
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Timor-Tritsch IE. Rambam Hospital is the Birthplace of the Modern Version of Transvaginal Ultrasound. Rambam Maimonides Med J 2017; 8:RMMJ.10301. [PMID: 28467765 PMCID: PMC5415370 DOI: 10.5041/rmmj.10301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The worldwide use of the transvaginal scanning route has revolutionized obstetrical and gynecologic imaging. The long, slow, and at times challenging aspects of its acceptance by the obstetrical and gynecologic community are the subject of this article. From its inception to its recent use, the dedicated doctors in the Department of Obstetrics and Gynecology at Rambam Medical Center, Haifa, Israel, were instrumental in conceiving and then collaborating with an Israeli manufacturer in the construction and worldwide use of the transvaginal ultrasound probe, resulting in the now well-known field of transvaginal sonography.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Director of Obstetrics and Gynecology Ultrasound, Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
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Kaelin Agten A, Ringel N, Ramos J, Timor-Tritsch IE, Agten CA, Monteagudo A. Standardization of peak systolic velocity measurement in enhanced myometrial vascularity. Am J Obstet Gynecol 2016; 215:802-803. [PMID: 27544329 DOI: 10.1016/j.ajog.2016.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 08/09/2016] [Indexed: 10/21/2022]
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Timor-Tritsch IE, Monteagudo A, Cali G, El Refaey H, Kaelin Agten A, Arslan AA. Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester. Am J Obstet Gynecol 2016; 215:225.e1-7. [PMID: 26899908 DOI: 10.1016/j.ajog.2016.02.028] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/26/2016] [Accepted: 02/09/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cesarean scar pregnancy (CSP) is a serious complication of pregnancy, which consists of implantation of the gestational sac in the hysterotomy scar. This condition is increasing in frequency and often poses a diagnostic challenge. Its diagnosis is dependent on visual assessment of the uterus on the longitudinal sagittal ultrasound plane. Misdiagnosing a low intrauterine chorionic sac as a CSP, or a true scar pregnancy as an intrauterine pregnancy (IUP), may lead to adverse outcomes including hysterectomy. OBJECTIVE The objective of the study is to describe a sonographic method for the differential diagnosis of CSP vs IUP in early gestation. The current study tests the hypothesis that on a first-trimester ultrasound performed between 5-10 weeks of gestation, the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus can be used for early detection of CSPs. STUDY DESIGN This is a retrospective review of electronically archived ultrasound images of IUP and CSP between 5-10 weeks of gestation. A total of 242 ultrasound images were analyzed: 185 cases of normal IUPs (including 128 in anteverted uteri, 31 in retroverted uteri, and 26 IUPs with history of cesarean delivery) and 57 cases of CSPs diagnosed from 2004 through 2015 in a single institution. The following measurements were made for each case: distance from the external cervical os to the uterine fundus, the midpoint axis of the uterus, the distance from the external cervical os to the center of gestational sacs, and the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix. RESULTS The location of the center of the gestational sac relative to the midpoint axis of the uterus between 5-10 weeks of gestation differentiated between IUP and CSP (mean 17.8 vs -10.6 mm, respectively, P = .0001), indicating that most CSPs are located proximally to the midpoint axis of the uterus whereas most normal IUPs are located distally from the midpoint of the uterus. Using location of the center of the gestational sac as a marker of CSPs between 5-10 weeks of gestation yielded the following characteristics of diagnostic accuracy: sensitivity 93.0% and specificity 98.9%. The likelihood ratio of the positive test was 84.5. The likelihood ratio of the negative test was 0.07. CONCLUSION The location of the center of the gestational sac relative to the midpoint axis of the uterus can be used as an easy method for sonographic differentiation of IUP and CSP between 5-10 weeks of gestation.
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