Role of the 3-Vessel and Trachea View in Antenatal Detection of Tetralogy of Fallot.

Prenatal diagnosis of tetralogy of Fallot remains less frequent compared to other major congenital heart defects. In this study, we examined how often the 3-vessel and trachea view was abnormal in a large series of prenatally diagnosed cases of tetralogy of Fallot. In addition, we compared its sensitivity to that of the traditional outflow tract views for detection of tetralogy of Fallot. We found that both views were abnormal in all fetuses with tetralogy of Fallot, showing reversed aortic-to-pulmonary valve and aortic arch isthmus-to-ductus arteriosus ratios in the outflow tract and 3-vessel and trachea views, respectively. However, as a single measured marker, the enlarged aortic arch isthmus on the 3-vessel and trachea view appears to be the most sensitive for tetralogy of Fallot.

Is the "I-Sign" in the 3-Vessel and Trachea View a Valid Tool for Prenatal Diagnosis of D-Transposition of the Great Arteries?

Prenatal diagnosis of D-transposition of the great arteries remains less frequent compared to other major congenital heart defects. In this study, we examined how often the 3-vessel and trachea view was abnormal in a large series of prenatally diagnosed cases of D-transposition of the great arteries. We found that an abnormal 3-vessel and trachea view in the shape of an "I" ("I-sign"), which represents an anteriorly displaced aorta, was present in all fetuses with D-transposition of the great arteries when a 3-vessel and trachea view was successfully obtained. Therefore we believe that the 3-vessel and trachea view can be used to reliably detect D-transposition of the great arteries during prenatal sonography.

Postoperative outcomes after robotic versus abdominal myomectomy.

BACKGROUND AND OBJECTIVES: Differences in postoperative outcomes comparing robotic-assisted laparoscopic myomectomy (RALM) with abdominal myomectomy (AM) have rarely been reported. The objective of this study was to compare surgical, quality-of-life, and residual fibroid outcomes after RALM and AM. METHODS: Consecutive patients who underwent RALM (n = 16) were compared with AM patients (n = 23) presenting with a uterine size of <20 weeks. Study patients participated in a telephone interview at 6 weeks and underwent a no-cost ultrasonographic examination at 12 weeks after surgery to obtain quality-of-life and residual fibroid outcomes. Medical records were reviewed to obtain surgical outcomes. RESULTS: Longer operative times (261.1 minutes vs 124.8 minutes, P < .001) and a 3-fold unfavorable difference in operative efficiency (73.7 g vs 253.0 g of specimen removed per hour, P < .05) were observed with RALM compared with AM. Patients undergoing RALM had shorter lengths of hospital stay (1.5 days vs 2.7 days, P < .001). Reduction of patient symptoms and overall satisfaction were equal. RALM patients were more likely to be back to work within 1 month (85.7% vs 45.0%, P < .05). Residual fibroid volume in the RALM group was 5 times greater than that in the AM group (17.3 cm(3) vs 3.4 cm(3), P < .05). CONCLUSION: RALM and AM were equally efficacious in improving patient symptoms. Although operative times were significantly longer with RALM, patients had a quicker recovery, demonstrated by shortened lengths of stay and less time before returning to work. However, greater residual fibroid burden was observed with RALM when measured 12 weeks after surgery.

Racial differences in fibroid prevalence and ultrasound findings in asymptomatic young women (18-30 years old): a pilot study.

OBJECTIVE: 1) To determine the prevalence of fibroids in asymptomatic young black and white women (ages 18-30 y); 2) to determine other differences in uterine and adnexal anatomy; and 3) to obtain preliminary data for sample size calculations. DESIGN: Pilot cross-sectional study. SETTING: Academic medical center. PATIENT(S): One hundred one nonparous black and white women, ages 18-30 years, with no known diagnosis of fibroids or clinically suggestive symptoms. INTERVENTION(S): A transvaginal ultrasound was performed in the follicular phase in all subjects. MAIN OUTCOME MEASURE(S): 1) Presence of fibroids; 2) endometrial thickness; 3) ovarian findings. RESULT(S): Of the 101 participants (mean age 24.5 ± 3.5 y), 43% self-identified as black and 57% as white. The prevalence of ultrasound-diagnosed fibroids was 15% overall (26% in black women and 7% in white women). The mean fibroid size was 2.3 ± 2.1 cm. There was a significant difference in endometrial thickness between races, even after adjusting for contraception use and fibroid presence. CONCLUSION(S): Racial differences in fibroid prevalence exist even before women become symptomatic. Findings of thicker endometrium in black women could have clinical implications and warrants further investigation.

Should uterine tandem applicators ever be placed without ultrasound guidance? No: a brief report and review of the literature.

BACKGROUND: Brachytherapy is an integral component of the curative treatment of locally advanced cervical cancer. Optimal applicator placement is associated with improvements in local control and treatment-related toxicity. Uterine perforation by the tandem is common and often undetected by orthogonal radiographs. The role of ultrasound in guiding tandem placement remains controversial. METHODS: A 55-year-old woman with International Federation of Gynecology and Obstetrics stage IIB cervix cancer underwent placement of a Fletcher-Suit-Delcos tandem and ovoids applicator. Postoperative computed tomography was used for treatment planning. RESULTS: The applicator appeared to be appropriately placed on clinical exam and orthogonal radiographs. Postoperative computed tomography revealed the tandem had perforated the anterior uterine wall. In a second procedure, the tandem was placed correctly under intraoperative ultrasonography. CONCLUSIONS: A review of the literature finds a relatively high rate of uterine perforation of the uterus that is undetected by orthogonal radiographs or clinical examination. Multiple reports support the use of real-time ultrasound for patients with especially challenging anatomy. As this report illustrates, uterine perforation is possible in any patient. Therefore, routine real-time ultrasonography should be considered for all uterine tandem insertions.

3-D ultrasound of the fetal ear and fetal autosomal trisomies: a pilot study of a new screening protocol.

OBJECTIVE: We hypothesize that the rotation of the ear in fetuses with common autosomal trisomies will be markedly different from euploid fetuses and amenable to detection by 3-D ultrasound in the render mode. METHODS: Study participants (10 weeks 4 days through 19 weeks 0 days) underwent a 3-D rendering of the fetal face and ear along with other biometric measurements prior to invasive testing. RESULTS: Of the 348 patients who underwent chorionic villi sampling (CVS) (n = 208) or amniocentesis (n = 140), 18 were diagnosed with trisomy 21, 4 with trisomy 18, and 1 with trisomy 13. Mean gestational age was 12 weeks 6 days (range: 10 weeks 6 days to 19 weeks 0 days). Ear angles were obtained in all cases; the time to obtain this angle ranged from 5 to 25 min. Thirty-two fetuses were found to have an abnormal ear angle with 23 of the 32 characterized by one of the aforementioned trisomies. CONCLUSIONS: These findings support the potential of this technique to provide valuable information in the identification of an increased-risk population. Prospective studies are needed to confirm the value of this screening modality as well as to assess its facility and ability to be incorporated into routine obstetrical practice.

Three-dimensional fast acquisition with sonographically based volume computer-aided analysis for imaging of the fetal heart at 18 to 22 weeks' gestation.

OBJECTIVE: The purpose of this study was to determine how frequently cardiac images derived from 3-dimensional (3D) volume sets, acquired by fast acquisition and evaluated with sonographically based volume computer-aided analysis (sonoVCAD), were satisfactory for prenatal screening at 18 to 22 weeks' gestation. METHODS: A prospective study of 100 women with singleton pregnancies was undertaken. Three fast acquisition 3D volume sets were obtained from each patient. Four reviewers independently evaluated the 4-chamber and 5 extracted VCAD views. Factors contributing to unsatisfactory screening were also evaluated. RESULTS: The frequency with which adequate views for cardiac screening could be obtained varied widely; some single views, such as that of the stomach, were well seen frequently, whereas others, such as the ductal arch, were well seen significantly less frequently (P < .05). A satisfactory screening examination, defined as a visualized 4-chamber, left ventricular outflow tract, right ventricular outflow tract, and axial stomach view, was obtained for 43% to 65% of patients (dependent on reviewer). Logistic regression revealed that obesity (odds ratio, 3.0; 95% confidence interval, 1.7-5.0) and a fetus with the spine toward the maternal abdomen (odds ratio, 1.7; 95% confidence interval, 1.1-2.5) were independently associated with an unsatisfactory screening examination CONCLUSIONS: Three-dimensional fast acquisition volumes evaluated with sonoVCAD did not allow a satisfactory fetal cardiac screening examination to be obtained a high percentage of the time in a general obstetric population during the second trimester. Certain patient factors, such as body habitus and fetal position, are associated with unsatisfactory 3D imaging.

Satisfactory visualization rates of standard cardiac views at 18 to 22 weeks' gestation using spatiotemporal image correlation.

OBJECTIVE: The purpose of this study was to determine the frequency with which 3 standard screening views of the fetal heart (4-chamber, left ventricular outflow tract [LVOT], and right ventricular outflow tract [RVOT]) can be obtained satisfactorily with the spatiotemporal image correlation (STIC) technique. METHODS: A prospective study of 111 patients undergoing anatomic surveys at 18 to 22 weeks was performed. Two ultrasound machines with fetal cardiac settings were used. The best volume set that could be obtained from each patient during a 45-minute examination was graded by 2 sonologists with regard to whether the 4-chamber, LVOT, and RVOT images were satisfactory for screening. RESULTS: All 3 views were judged satisfactory for screening in most patients: 1 sonologist graded the views as satisfactory in 70% of the patients, whereas the other found the views to be satisfactory in 83%. The position of the placenta did not alter the probability of achieving a satisfactory view, but a fetus in the spine anterior position was associated with a significantly lower probability that the views were regarded as satisfactory for screening (odds ratio, 0.28; 95% confidence interval, 0.09-0.70; P < .05). CONCLUSIONS: This study suggests that STIC may assist with screening for cardiac anomalies at 18 to 22 weeks' gestation.

Quality of 2- and 3-dimensional fast acquisition fetal cardiac imaging at 18 to 22 weeks: ramifications for screening.

OBJECTIVE: The purpose of this study was to evaluate the frequency with which 6 different fetal cardiac views taken during a fetal ultrasound examination at 18 to 22 weeks' gestation can be obtained satisfactorily for cardiac anomaly screening using either a 2-dimensional (2D) static or 3-dimensional (3D) fast acquisition technique. METHODS: A prospective study of 100 low-risk women undergoing an anatomic survey was performed. Standard static 2D and 3D fast acquisition volumes were obtained on all patients. The 2D and 3D images were assigned, in a random order, to be independently graded by 3 reviewers. The degree of inter-reviewer agreement was assessed through the use of the Cohen kappa statistic. The factors contributing to satisfactory imaging were evaluated by random effects logistic regression. RESULTS: A significant proportion of both 2D and 3D images were judged unsatisfactory for screening purposes. However, 2D images were significantly more likely, for all cardiac views, to be judged satisfactory (P < .05). The odds ratios for the 2D technique's being more likely than the 3D technique to provide images satisfactory for screening were 2.6 for the 4-chamber view, 2.4 for the right ventricular outflow tract, 4 for the left ventricular outflow tract, 3.2 for the 3-vessel view, 8.6 for the aortic arch, and 2.2 for the ductal arch. CONCLUSIONS: In this prospective study, static 2D imaging was significantly more likely than fast acquisition 2D imaging to yield cardiac views of high enough quality to satisfactorily screen for anomalies.

Congenital malformations of the uterus: the role of ultrasound.

Congenital uterine anomalies in women often do not cause any symptoms, except when there is an obstruction of the uterine outflow tract, which occurs infrequently. Patients with congenital uterine anomalies often go undetected or are only discovered incidentally during an evaluation for something else. Consequently, it is difficult to determine the prevalence of congenital uterine anomalies in the general population, and it appears more frequently in certain populations, namely in those with recurrent pregnancy loss or infertility. This paper will review the pathogenesis of congenital uterine anomalies and the standard classification for these anomalies. We will focus on ultrasound and other diagnostic modalities (hysterosalpingogram, laparoscopy with hysteroscopy, and magnetic resonance imaging). We will compare the accuracy and differences between these diagnostic techniques. With the development of three-dimensional ultrasound, the diagnosis of congenital uterine anomalies can be made accurately, effectively, and with less invasiveness than with other procedures. We will briefly review the treatments and pregnancy outcomes in these different anomalies.

Transvaginal ultrasound assessment of the premenopausal ovarian mass.

The evaluation of the premenopausal ovarian mass with transvaginal ultrasound and color Doppler is reviewed.

The role of ultrasound evaluation in the detection of early-stage epithelial ovarian cancer.

OBJECTIVE: Epithelial ovarian cancer kills more women than all other gynecologic malignancies combined because of our inability to detect early-stage disease. Ultrasonography has demonstrated usefulness in the detection of ovarian cancer in asymptomatic women, but its value for the detection of early-stage epithelial ovarian cancer in women of increased risk is uncertain. We examined the usefulness of sonography in the detection of early-stage epithelial ovarian cancer in asymptomatic high-risk women who participated in the National Ovarian Cancer Early Detection Program. STUDY DESIGN: Only asymptomatic women of increased risk for the development of ovarian cancer with initial normal gynecologic and ultrasound examinations were eligible to participate in the institutional review board-approved National Ovarian Cancer Early Detection Program. Participants underwent comprehensive gynecologic and ultrasound examinations every 6 months. Increased risk includes women with at least 1 affected first-degree relative with ovarian cancer; a personal history of breast, ovarian, or colon cancer; > or =1 affected first- and second-degree relatives with breast and or ovarian cancer; inheritance of a breast cancer mutation from an affected family member, or membership within a recognized cancer syndrome. RESULTS: The average age of the 4526 women who were evaluated was 46 years; 2610 women were premenopausal, and 1916 women were postmenopausal. A total of 12,709 scans have been performed since 1990. Visualization of both ovaries was noted in 98% of premenopausal and in 94% of postmenopausal women. Fourteen women had undergone unilateral salpingo-oophorectomy. Recall rates at less than the routine 6-month interval were 0.4% in the premenopausal and 0.3% in postmenopausal women. A total of 98 women with persistent adnexal masses were identified, and 49 invasive surgical procedures were performed that diagnosed 37 benign ovarian tumors and 12 gynecologic malignancies. All cancers were detected in asymptomatic women who had normal ultrasound and physical examinations 12 and 6 months before the cancer diagnosis. The detected malignancies were fallopian tube carcinoma (stage IIIC; n = 4 women), primary peritoneal carcinoma (n = 4 women; stage IIIA, 1 woman; stage IIIB, 2 women; stage IIIC, 1 woman), epithelial ovarian cancer (stages IIIA and IIIB; n = 2 women), and endometrial adenocarcinoma (stage IA; n = 2 women). Additionally 37 primary and 12 recurrent breast carcinomas were detected by physical examination. A total of 184 women with genetic predisposition (breast cancer positive) have undergone a prophylactic bilateral salpingo-oophorectomy; 23% of these procedures found atypical hyperplasia, and unexpectedly, 2 women (1%) were found to have stage III (A and B) primary peritoneal carcinoma. CONCLUSION: This study demonstrates the limited value of diagnostic ultrasound examination as an independent modality for the detection of early-stage epithelial ovarian cancer in asymptomatic women who are at increased risk for disease.

Ultrasound evaluation of the endometrium after medical termination of pregnancy.

OBJECTIVE: To determine ultrasound parameters associated with the need for clinical intervention after mifepristone and misoprostol termination of pregnancy. METHODS: Charts of patients undergoing medical termination according to a standard protocol in a 13-month period were reviewed. Endometrial thickness and the presence of gestational sac, fluid interface, or complex echoes on postprocedure ultrasonogram were recorded. Repeat doses of medication, surgical intervention, and complications were noted. Success was defined as an abortion completed after a single course of medical therapy. RESULTS: Postprocedure ultrasonograms were available for 525 of 684 patients. Endometrial thickness was measurable in 437 cases. The observed mean endometrial thickness was 4.10 +/- 1.80 mm (range 0.67-13.4 mm). Endometrial thickness was inversely proportional to the number of days after initiation of therapy when ultrasonography was performed (r = -0.22; P <.001). The endometrium was thicker in the women who had failed than in those who had a successful medical abortion (6.15 +/- 1.95 mm [range 3.35-10.0 mm] versus 4.01 +/- 1.75 mm [range 0.67-13.4 mm], respectively; P <.001), but the wide overlap in endometrial thicknesses nullified the clinical usefulness of this difference. CONCLUSION: Endometrial thickness after administration of a single dose of mifepristone and misoprostol for medical termination should not dictate clinical intervention. The decision to treat should be based on the presence of a persistent gestational sac or compelling clinical signs and symptoms.

Ultrasound and ovarian cancer.

From the published studies it would appear that ultrasound is a very sensitive tool for identifying advanced stage ovarian cancer. The identification of Stage I ovarian cancer with ultrasound screening is more problematic since only 25 to 50% of ovarian cancers are identified in low-risk and high-risk respectively using this technique. Due to the low annual prevalence of ovarian cancer routine screening of premenopausal women or low-risk women after the menopause is unlikely to be cost-effective. The subject of biologic markers to screen for ovarian cancer is addressed elsewhere in this book. It is clear that a primary screening test less expensive than ultrasound is needed. The multicenter National Cancer Institute screening program is designed to evaluate possible new markers. At this time ovarian cancer screening should be done in high-risk groups under careful investigational scrutiny. Patients who are high-risk should be carefully advised of the limitations of diagnostic ultrasound in identifying early stage disease. Transvaginal ultrasound in expert hands is sensitive but not ideally specific for discriminating benign from malignant disease. The judicious use of color Doppler evaluation may help discriminate with greater specificity.