New technologies in obstetrics and gynecology: the test of time.
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Comment↗
Biomedical subjects
I E Timor-Tritsch
Publications and source records attributed to I E Timor-Tritsch.
An approach to multifetal pregnancy reduction in a pregnancy of grand order (12 fetuses).
Our objective was to determine the best method to approach a multifetal pregnancy reduction of a patient with a multiple pregnancy of grand order (12 fetuses). Transvaginal ultrasound-guided reduction was performed in three stages. Successful outcome was achieved. The patient delivered twins at 37 weeks' gestation. The published and unpublished literature is reviewed and discussed in the light of this case. Our conclusion is that a multifetal pregnancy reduction of grand order can be performed in stages to achieve the desired number of fetuses.
Journal Article↗
In utero detection of ventriculomegaly during the second and third trimesters by transvaginal sonography.
The purpose of this study was two-fold. The first was to extend the previously developed and published nomograms of the fetal lateral ventricles from 18 weeks back to 14 weeks of gestation using transvaginal sonography, and, second, to test the performance of the nomograms by plotting the measurements of 36 fetuses whose transabdominal and/or qualitative transvaginal scans were suspicious for ventriculomegaly. In all the cases in which postnatal confirmation of the diagnosis was possible, prenatal ultrasound correctly identified the lesion. Although a total of nine nomograms was created, the clinically meaningful measurements were: the height of the occipital horn on the parasagittal plane, and the two ratios derived from the measurements performed on the parasagittal plane. In conclusion, the transvaginally generated nomograms were useful for the correct identification of fetuses with ventriculomegaly.
Journal Article↗
Transvaginal sonographic characterization combined with cytologic evaluation in the diagnosis of ovarian and adnexal cysts.
A transvaginal sonographic (TVS) scoring system using morphologic features has been developed at our institution to maximize discrimination between benign and malignant ovarian and adnexal cysts. Low (4-7) or intermediate (8-9) scores have been found to correlate with benignity, hence TVS-guided or laparoscopically directed needle aspiration of low-scoring lesions may safely be performed. High-scoring lesions (10-14) are often malignant, therefore in situ needle aspiration of such lesions is not recommended. The aim of our study was to correlate the results of TVS characterization of ovarian and adnexal cysts with the aspiration cytologic evaluation. Twenty-three of the 43 cysts studied were aspirated in situ from the patient; 20 were aspirated from resected surgical specimens. Thirty-six benign cysts had TVS scores ranging from 4 to 12, with a median score of 7. All 25 cysts that were benign by TVS and/or histology were also cytologically benign as well as an additional 11 cysts that were not resected (TVS scores: 4 to 9). Seven cytologically and histologically malignant cysts had high TVS scores (TVS scores 10-14; median = 12). The combination of TVS and needle aspiration cytology is valuable, particularly in the diagnosis of cysts having low or intermediate TVS scores and benign cytology. Aspiration of cysts or masses with high TVS scores is not recommended. This combined evaluation may allow a more limited surgical approach, such as operative laparoscopy, or, in some cases, obviate the need for operative treatment altogether.
Adnexal Diseases↗
Fetal breathing characteristics and postnatal outcome in cases of congenital diaphragmatic hernia.
OBJECTIVE: Our purpose was to determine characteristics of fetal breathing activity by recording fetal nasal fluid flow velocity in cases of congenital diaphragmatic hernia. STUDY DESIGN: Fetal breathing-related nasal fluid flow was studied in 47 patients at 34 to 41 weeks of gestation, 16 cases of antenatally diagnosed congenital diaphragmatic hernia and 31 cases of uncomplicated pregnancy. The examination was performed by ultrasonography combined with color-flow and spectral Doppler analysis. An average of 25 breath cycles from each case was determined for each of the following timing parameters: breath-to-breath interval, time of inspiration, time of expiration, and ratio of time of inspiration and time of expiration. RESULTS: In all cases with uncomplicated pregnancy fetal breathing-related nasal fluid flow was seen at the level of the nose, and the timing components of this flow were determined as control values. In two cases with diaphragmatic hernia no perinasal flow was demonstrated, although fetal breathing movements observed as chest wall movements were present. The other 14 cases with congenital diaphragmatic hernia who demonstrated perinasal flow had the following postnatal outcome: one stillbirth, five neonatal deaths (group I), and eight survived and were discharged (group II). The study revealed that the time of expiration (in milliseconds) in group II (493.2 +/- 34.3 SEM) was significantly (p = 0.0030) shorter than in group I (653.4 +/- 38.4) and in cases of uncomplicated pregnancy (633.6 +/- 18.5). The value of the time of inspiration/time of expiration ratio in group II was approximately 15% higher than in group I and approximately 30% higher than in cases of uncomplicated pregnancies. CONCLUSIONS: Observation of fetal breathing-related nasal fluid flow velocity in cases of antenatally diagnosed congenital diaphragmatic hernia provides a rationale for the hypothesis that time of expiration and the time of inspiration/time of expiration ratio may be useful in the prediction of postnatal outcome. We speculate that the changes in the group of survivors may represent a compensatory phenomenon by causing intermittent changes in the volume of fluid within the lungs.
Amniotic Fluid↗
Successful management of viable cervical pregnancy by local injection of methotrexate guided by transvaginal ultrasonography.
We evaluated the feasibility of transvaginal methotrexate injection of viable cervical pregnancies to avoid complications of the "classic" surgical procedures in use and to preserve future fertility. Five viable cervical pregnancies, at 6 to 8 weeks, were treated. In three patients a spring-loaded automated puncture device and in two a manually operated simple needle guide mated to and guided by a transvaginal ultrasonography probe were used with 21-gauge needles. The puncture and injection treatment was successful and without complications in all five cases presented. This procedure may become a useful alternative to other, more radical or complex surgical approaches.
Cervix Uteri↗
Early and simple determination of chorionic and amniotic type in multifetal gestations in the first fourteen weeks by high-frequency transvaginal ultrasonography.
OBJECTIVE: Our aim was to determine the chorionic and amniotic types in multifetal pregnancies with transvaginal ultrasonography at > or = 14 weeks' gestation. STUDY DESIGN: Two hundred twelve multifetal pregnancies were scanned transvaginally at or before 14 weeks' gestation. The number of fetuses and the chorionic and amniotic type were determined ultrasonographically. Of the 212 patients, 54 were delivered at our institution, and 43 of these 54 had pathologic evaluation of the placenta. Ultrasonographic and pathologic correlation of the chorionic and amniotic type was assessed in this group. RESULTS: Ultrasonographic evaluation of the 212 pregnancies demonstrated 64 twin, 87 triplet, 41 quadruplet, 18 quintuplet, 1 sextuplet, and 1 septuplet gestation. Nine of the twin pregnancies were monochorionic-diamniotic; two of the triplets were dichorionic-triamniotic, and four of the quadruplets were trichorionic-quadraamniotic. In the 43 patients with both ultrasonographic and pathologic assessment, there were 40 twins, five of which were monochoronic diamniotic type. All three triplets were trichorionic-triamniotic type. In all 43 transvaginal ultrasonography correctly predicted the chorionic and amniotic type as determined by the pathologic findings. CONCLUSIONS: Transvaginal ultrasonography at < or = 14 weeks can easily and accurately determine the chorionic and amniotic type in multifetal pregnancies.
Amnion↗
Transvaginal ultrasonographic characterization of ovarian masses with an improved, weighted scoring system.
OBJECTIVE: The aim of the study was to modify a previously devised morphologic scoring system with the use of transvaginal ultrasonography in the hope of improving discrimination of benign from malignant ovarian and adnexal masses. STUDY DESIGN: Transvaginal ultrasonographic images of 312 patients for a total of 350 ovarian and adnexal masses were obtained over a 3-year period. The derived morphologic data were analyzed by multiple linear regression analysis to select the best performance of the previously described scoring system by Sassone et al. in 1991. This system was thus modified in several ways including weighted point value assignments, fewer point values per variable studied, the deletion of one variable found not to be significant (wall thickness), and the inclusion of a new variable called shadowing. RESULTS: At surgery, 308 benign masses, 31 malignant masses, and 11 tumors of low malignant potential were found. The mean point value obtained was 1.8 for the benign masses, 3.9 for the tumors of low malignant potential, and 5.6 for the malignant tumors (p < 0.0005). With a cutoff of > or = 3 used as the best discriminator, the sensitivity was 96.8% and the specificity 77%. The positive and negative predictive values were 29.4% and 99.6%, respectively. CONCLUSION: Limitations of the previously devised scoring system included the arbitrary point assignments of each variable, the multiple (4 or 5) point choices for each variable, and the poor positive predictive value. This new scoring system performs well in the differentiation of benign from malignant masses, while assigning scientifically derived, therefore more valid, point values and simplifying the system overall. That the positive predictive value was not improved proves that ultrasonographically, to date we are still hampered by complex and malignant-appearing benign ovarian masses.
Adnexal Diseases↗
Detection of ovaries by transvaginal sonography in postmenopausal women.
A total of 230 apparently healthy postmenopausal women underwent transvaginal sonography and pelvic examination. The mean ovarian volume was 3.1 cm(3) with a range of 0.4-57.4 cm(3) and fewer than 5% (4.8%) of the subjects had a mean volume exceeding two standard deviations of the sample mean. Transvaginal sonography successfully imaged 64% of reported ovaries overall, although the proportion of ovaries imaged varied by sonographer. The poorer imaging rates found in this study, as compared with some previous investigations using transabdominal sonography, could be due to several factors including the type of sonography, the type of sample, the scanning time, and/or the criteria used to identify an ovary. Transvaginal sonography offers practical advantages over transabdominal sonography, but the potential loss in sensitivity, due to non-visualization of a substantial proportion of ovaries, must be formally assessed before adopting transvaginal sonography more widely as the primary screening modality.
Journal Article↗
Fetal upper respiratory tract function in cases of antenatally diagnosed congenital diaphragmatic hernia: preliminary observations.
Fetal upper respiratory tract function was studied in five cases of antenatally diagnosed congenital diaphragmatic hernia and in 16 cases of uncomplicated pregnancy at gestational ages ranging from 27 to 38 weeks. The evaluation of fetal upper respiratory tract function was performed using ultrasonography combined with color-flow and spectral Doppler analysis. In all cases with uncomplicated pregnancy, fetal breathing-related nasal and oropharyngeal fluid flow was seen at the level of the nose. The five cases with congenital diaphragmatic hernia all demonstrated fetal breathing activity by thoracic wall movement. In four of the fetuses, perinasal fluid flow was seen by the Doppler technique. The fetus with no demonstrated perinasal flow during breathing movements died in the early neonatal period and had pulmonary hypoplasia. Observation of the fetal breathing-related nasal and oropharyngeal fluid flow in cases of antenatally diagnosed congenital diaphragmatic hernia provides a rationale to hypothesize that the absence of this phenomenon is a useful marker for prenatal prediction of pulmonary hypoplasia.
Journal Article↗
The use of the transvaginal automated spring-loaded puncture device transabdominally.
Transabdominal use of a software integrated, automated, spring-loaded transvaginal puncture device is described. This device allows accurate, high-velocity needle placement into sonographically targeted areas under continuous direct vision without the use of local anesthesia. Successful use of the device in seven cases is described.
Journal Article↗
Fetal breathing-related nasal fluid flow velocity in uncomplicated pregnancies.
OBJECTIVE: Our purpose was to determine the Doppler ultrasonographic characteristics of fetal breathing-related nasal fluid flow velocity in uncomplicated pregnancies. STUDY DESIGN: Fetal nasal flow velocity was studied in 52 uncomplicated pregnancies at gestational ages ranging from 22 to 41 weeks. The evaluation of fetal breathing-related nasal fluid flow velocity was performed with ultrasonography combined with color flow and spectral Doppler analysis. RESULTS: The study revealed that the breath-to-breath interval and duration of the inspiratory phase of the fetal breathing-related nasal flow increased from 22 to 35 weeks and decreased thereafter. The breath-to-breath interval (milliseconds) at 33 to 35 weeks (1203.9 +/- 295.7 SD) was approximately twice what it was in the earliest age group (22 to 25 weeks); subsequently it decreased by approximately 25% in the term group (38 to 41 weeks). A positive correlation existed between the mean breathing-related nasal peak inspiratory flow velocity and advancing gestational age (r = 0.56, p = 0.0008), and between the inspiratory flow velocity acceleration and advancing gestational age (r = 0.53, p = 0.0076). CONCLUSION: Changes in fetal breathing activity during uncomplicated pregnancies can be determined by measurement of fetal breathing-related nasal fluid flow velocity. Our observations in uncomplicated pregnancies may be useful in future studies of these parameters in complicated pregnancies such as those at risk for pulmonary hypoplasia.
Adult↗
Multifetal pregnancy reduction by transvaginal puncture: evaluation of the technique used in 134 cases.
OBJECTIVE: This report reviews multifetal pregnancy reductions performed transvaginally and tests the feasibility and associated pregnancy loss rates with this technique. STUDY DESIGN: One hundred thirty-four consecutive multifetal pregnancy reductions were analyzed regarding different aspects of total pregnancy losses and complications. The first 40 manually performed were compared with the last 94 procedures performed with an automated puncture device and a thin needle. The losses were also analyzed as a comparison of the reduction of the lower-lying with the higher-lying fetuses located in relation to the internal os. RESULTS: A total uncorrected total pregnancy loss rate of 12.6% and a corrected loss rate of 10.6% was observed. Of the 112 pregnancies in which the lower-lying fetus was reduced, 11 losses were seen. The loss rate in the group reducing the upper fetus was three of 22. The manual versus the puncture device groups showed the same loss rate (10%); however, the manual group had a larger number of subchorionic hematomas after the procedure. CONCLUSIONS: The data are indicative of a very low maternal complication rate (infection) and an acceptable loss rate of the entire pregnancy. The loss rates compare favorable with those for multifetal pregnancy reduction performed transabdominally.
Abortion, Induced↗
Transvaginal multifetal pregnancy reduction: Which? When? How many?
This report contains the experience of our centre, using the transvaginally guided puncture procedure, to reduce the number of fetuses in a multifetal pregnancy to a lower number. The aim of the procedure was to improve perinatal outcome and/or to meet the personal desires of patients and their families. We surveyed 148 multifetal pregnancy reductions. The fetus or fetuses overlying the internal os was most commonly reduced. The total uncorrected loss of the entire pregnancy was 13.4%. The corrected pregnancy loss was 11%. Of the 63 twins left after the reduction, 33 delivered preterm. Of the 36 singletons, two delivered preterm. Our conclusion was that multifetal pregnancy reduction is a safe procedure for the mother and has an acceptable loss rate of the entire pregnancy. The reduction of a fetus overlying the internal os by the transvaginal puncture procedure seems to yield results at least as good as the transabdominally performed puncture procedures for multifetal pregnancy reduction.
Abortion, Induced↗
Diagnosis of placenta previa by transvaginal sonography.
The evolution of the sonographic diagnosis of placenta previa is reviewed with special emphasis on transvaginal sonography (TVS), which has been proved accurate at diagnosing different degrees of placenta previa, such as complete, partial, marginal and low-lying. Bleeding tendency and the need for Caesarean delivery increases when the placental edge is within 3 cm of the internal os. There is no association between bleeding and use of transvaginal probes. The early diagnosis of addition abnormalities of implantation (e.g. placenta accreta) using transvaginal colour flow Doppler widens the prospects for carefully planned patient management. In conclusion, TVS should be the principal diagnostic modality used in the work-up of an obstetric patient with vaginal bleeding. The ease of performance and the clarity and accuracy of method and the additional information about implantation that it can provide will soon make TVS the 'golden standard' in the diagnostic process of placenta previa.
Cervix Uteri↗
Nomograms of the fetal lateral ventricles using transvaginal sonography.
Nomograms of the fetal lateral ventricles were obtained by the transvaginal approach. Three hundred low-risk women with no sonographically apparent fetal anomalies were scanned prospectively in a cross-sectional study. Three measurements in the parasagittal plane, three in the midline coronal plane, and two in the posterior coronal plane were used to generate seven nomograms. Two additional nomograms reflecting two calculated ratios also were created. A mean regression line and the 5th and 95th confidence intervals were determined. We concluded that transvaginal sonography of the fetal brain generates images of both hemispheres of good enough resolution to allow several precise and reproducible measurements.
Anthropometry↗
Confirming the safety of transvaginal sonography in patients suspected of placenta previa.
OBJECTIVE: To evaluate the safety of transvaginal ultrasonography in the diagnosis of placenta previa by determining whether the angle between the cervix and the vaginal probe is sufficient for alignment of the probe with the cervix. METHODS: The angle between the axis of the cervix and that of the vaginal probe (the axis of the vagina) was measured from copies of the transvaginal ultrasound examinations of 18 patients with documented placenta previa past 20 weeks' gestation. The measurements were compared with those of gestationally matched controls without placenta previa. RESULTS: The mean angles were 63.8 degrees and 67.5 degrees, with minimum angles of 44 degrees and 48 degrees for the placenta previa and control groups, respectively. The values were not statistically different. CONCLUSION: These findings strengthen the previously undocumented presumption that the angle between the cervix and vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix. Therefore, this study supports the safety of transvaginal sonography in diagnosing and monitoring patients with known placenta previa.
Cervix Uteri↗
Standardization of ultrasonographic images: let's all talk the same language!
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Comment↗