Quality assessment of fetal middle cerebral and umbilical artery Doppler images using an objective scale within an international randomized controlled trial.

OBJECTIVES: To determine the quality of Doppler images of the fetal middle cerebral artery (MCA) and umbilical artery (UA) using an objective scale, and to determine the reliability of this scale, within a multicenter randomized controlled trial (Revealed versus concealed criteria for placental insufficiency in unselected obstetric population in late pregnancy (Ratio37)). METHODS: The Ratio37 trial is an ongoing randomized, open-label, multicenter controlled study of women with a low-risk pregnancy recruited at 20 weeks. Doppler measurements of the fetal MCA and UA were performed at 37 weeks. Twenty patients from each of the six participating centers were selected randomly, with two images evaluated per patient (one each for the MCA and UA). The quality of a total of 240 images was evaluated by six experts, scored on an objective scale of six items. Inter- and intrarater reliability was assessed using the Fleiss-modified kappa statistic for ordinal scales. RESULTS: On average, 89.2% of MCA images and 85.0% of UA images were rated as being of perfect (score of 6) or almost perfect (score of 5) quality. Kappa values for intrarater reliability of quality assessment were 0.90 (95% CI, 0.88-0.92) and 0.90 (95% CI, 0.88-0.93) for the MCA and UA, respectively. The corresponding inter-rater reliability values were 0.85 (95% CI, 0.81-0.89) and 0.84 (95% CI, 0.80-0.89), respectively. CONCLUSION: The quality of MCA and UA Doppler ultrasound images can be evaluated reliably using an objective scale. Over 85% of images, which were obtained by operators from a broad range of clinical practices within a multicenter study, were rated as being of perfect or almost perfect quality. Intra- and inter-rater reliability of quality assessment was very good. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Early endometrial changes following successful implantation: 2 and 3-dimensional ultrasound study.

OBJECTIVE: To study of the possible role of ultrasound (US) measurements of the endometrium in the prediction of IVF outcome. PATIENTS AND METHODS: 28 infertile women underwent US measurements of endometrial thickness and volume on day of ET and two weeks later. US measurements were compared between day of ET and two weeks later, and between those who conceived and those who did not. RESULTS: While in the group of patients who conceived (n = 7) endometrial thickness and volume rose significantly between day of hCG and two weeks later, no differences were observed in patients (n = 21) who did not. CONCLUSION: The dynamic changes in endometrial volume and thickness between day of ET and two weeks later may predict IVF treatment outcome.

Luteal phase support for patients undergoing frozen-thawed embryo transfer cycles--the required progesterone dose.

OBJECTIVE: With the recent trend toward single-embryo transfer (ET), cryopreservation of extraneous embryos is becoming increasingly prevalent. Several replacement protocols for frozen-thawed ET exist, with no consensus regarding the dosage or delivery mode of progesterone. PATIENTS AND METHODS: Hormonal replacement with only estrogen and progesterone is the most frequently used protocol in women with and without functioning ovaries in our unit. Since August 2005, we have doubled the usual daily dose of progesterone for luteal support due to a high prevalence of patients experiencing withdrawal bleeding 11-13 days after ET. We compared the outcome of frozen-thawed ET cycles using different doses of progesterone for luteal support. RESULTS: While the prevalence of embryos that survived the thawing process was significantly higher in the earlier (69%) as compared to the later period (58%), positive b-hCG pregnancy rates (17.5% vs 44.8%, respectively) and clinical pregnancy rates per transfer (7.9% vs 41.4%, respectively) were significantly higher in the later period. CONCLUSION: We conclude that high-dose progesterone supplementation in the luteal phase of frozen-thawed ET cycles results in a significantly higher clinical pregnancy rate.

GnRH agonist versus GnRH antagonist in ovarian stimulation: is the emperor naked?

OBJECTIVE: The aim of the study was to evaluate the influence of type of GnRH-analog used during controlled ovarian hyperstimulation (COH) on the outcome of in vitro fertilization (IVF) cycles. PATIENTS AND METHODS: All consecutive women aged < or = 35 years admitted to our IVF unit from January 2001 to December 2004 were enrolled in the study. Only patients undergoing up to their third IVF cycle attempt were included. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred, and clinical pregnancy rate were compared between women given GnRH-agonist or GnRH-antagonist during COH. RESULTS: Four hundred and eighty-seven consecutive IVF cycles were evaluated, 226 in the agonist group and 261 in the antagonist group. A clinical pregnancy was achieved in 93 patients in the agonist group (pregnancy rate 41.2% per cycle) and 66 patients in the antagonist grup (pregnancy rate 25.3%); this difference was statistically significant (p < 0.01). The agonist group also used significantly more gonadotropin ampoules, required longer stimulation, and had higher estradiol levels on the day of human chorionic gonadotropin administration. CONCLUSION: The midluteal long GhRH-agonist suppressive protocol should be the protocol of choice in young patients in their first three IVF cycle attempts.

The effects of maternal and fetal parameters on the quality of nuchal translucency measurement.

OBJECTIVE: To evaluate the influence of maternal and fetal parameters on the quality of fetal nuchal translucency measurement. DESIGN: This was a prospective study in 227 consecutive pregnant women undergoing nuchal translucency screening by transabdominal sonography. The same well-qualified sonographer performed all the scans and in each case the best-quality image was selected and scored according to an image scoring system (total maximum score, 9). The quality of the image was examined in relation to maternal age, weight, abdominal wall thickness, amniotic sac diameter, posterior uterine wall depth (distance between abdominal wall surface and posterior uterine wall surface), placental location, fetal crown-rump length and nuchal translucency thickness. Correlation coefficients were calculated and stepwise linear regression was used to adjust for confounders and to define the predictors for image score. RESULTS: The only two parameters that provided a significant independent contribution to the prediction of the image score were posterior uterine wall depth and fetal crown-rump length. Intravariable analysis of these two parameters demonstrated that the cut-off associated with a significant change in the image quality was 80 mm for posterior uterine wall depth (score difference, 1.06; P < 0.001) and 70 mm for crown-rump length (score difference, 0.77; P = 0.001). In the group of women with two values above these cut-off points, an average score decrease of 1.90 (P < 0.001) was observed. CONCLUSIONS: The quality of fetal nuchal translucency measurement is poorer when the fetal crown-rump length is > 70 mm and the posterior uterine wall depth is > 80 mm.

Sonographically diagnosed pelvic hematomas and postcesarean febrile morbidity.

OBJECTIVE: To evaluate the incidence of ultrasonographically-diagnosed postcesarean hematomas and correlate their presence with febrile morbidity. METHODS: Prospective study of 111 consecutive patients who had a pelvic ultrasound 4-6 days post-operatively. Ultrasonographic findings were correlated with clinical data. RESULTS: Postoperative fever was diagnosed in 28 (25%) patients. Fifteen (13.5%) women had hematomas; 10 (9%) had bladder-flap and five (4.5%) had subfascial hematomas. Only subfascial hematomas were significantly associated with post-operative fever (P = 0.01). CONCLUSIONS: Postcesarean bladder-flap hematomas are not predictive of post-operative fever. The presence of subfascial hematomas should be specifically sought in the evaluation of a febrile postcesarean patient.

Utilization of the nuchal translucency image-scoring method during training of new examiners.

Training of new examiners, utilizing 1st-trimester nuchal translucency ultrasound screening, is mandatory for obtaining reproducible measurements. This study examined the contribution of the nuchal translucency image-scoring method to the process of training and its utilization as an objective tool of image evaluation and a tool for approving qualification. The study included an evaluation of the performance of two new examiners (examiners A and B) before and after intervention, using the image-scoring method. The preintervention period included 75 images evaluated by two reviewers using general evaluation and the scoring method. The report of the scoring method was submitted to the examiners and was applied to 55 images performed afterwards. The agreement between two reviewers in classifying the first 75 images as 'accepted' or 'rejected' was tested using general evaluation versus the scoring method. The effect of the intervention was examined by comparing the quality of the images between the two time periods. A chart indicating final scores of 80 successive images analyzed by examiner A was used to set criteria for assessing qualification. Using general evaluation, the reviewers disagreed on 19 (25%) of the images, whereas using the scoring method they disagreed on only 5 (7%, p < 0.01). Comparison before and after application of the intervention demonstrated significant improvement expressed by the increased rate of better quality groups (p < 0.001) and improved mean scores from 4.31 +/- 0.31 to 6.15 +/- 0.32 (p < 0. 001). Enhanced improvement of examiner's A performance could be attributed to the intervention rather than to his learning curve. Improvement was demonstrated in all the criteria examined; however, it was significant only for images size (from 33 to 98%), amnion demonstration (from 13 to 42%), and caliper placement (from 49 to 71%). Examiner's A chart enabled us to set standards for assessing competence, based on the scoring method. These included a minimum of 40 scans, followed by more than ten sequential images of acceptable quality. The scoring method contributed to the process of training, as it made possible to objectively evaluate the images, pointed out specific errors, served as an efficient tool of intervention, and might be used for ascertaining competence. We recommend to consider its utilization in centers running 1st-trimester ultrasound screening during training new examiners.

Budd-Chiari syndrome complicating severe preeclampsia in a parturient with primary antiphospholipid syndrome.

A 27-year-old primipara with severe preeclampsia and primary antiphospholipid syndrome developed right upper quadrant pain, massive ascites, HELLP syndrome, and disseminated intravascular coagulation shortly following vaginal delivery. Computed tomography and color Doppler studies were compatible with complete thrombosis of the right hepatic veins, the Budd-Chiari syndrome. Anticoagulation was initiated, along with supportive measures, and the patient recovered completely. Imaging studies 6 months later were normal. This case demonstrates that nearly fatal forms of venous thrombosis may complicate preeclampsia in women with antiphospholipid syndrome; Doppler studies of the hepatic vein are of value in establishing the diagnosis.

Reproductive outcome after expectant management of ectopic pregnancy.

OBJECTIVE: To study fertility rates following expectant management of clinically stable ectopic pregnancies. STUDY DESIGN: Twenty of 33 patients with laparoscopically confirmed aborting tubal pregnancies managed expectantly were followed for a period of 1-5 years (mean 2.7 years). Excluded were the patients not desiring pregnancy, and patients with known impediments to fertility, such as age > 40 years and previous infertility, as well as patients lost to follow-up. RESULTS: Successful pregnancies occurred in 16 patients (80%); one patient (5%) had a repeat ectopic pregnancy. CONCLUSIONS: Expectant management is associated with a favorable reproduction outcome.

Evaluation of breast stimulation for induction of labor in women with a prior cesarean section and in grandmultiparas.

BACKGROUND: Information on the efficacy of breast stimulation for inducing labor in grandmultiparas and in women with a previous cesarean section with or without premature rupture of membranes is limited. METHODS: Retrospective study of labor data from 135 women of grand multiparity or those with a previous section with or without premature rupture of the membranes in whom labor was induced by breast stimulation. RESULTS: The success rate in achieving vaginal delivery was 84%. The duration of breast stimulation, length of labor, vaginal delivery rate, and Apgar score did not differ significantly among the four groups studied. CONCLUSION: Breast stimulation in grandmultiparas and in women with a previous cesarean section is efficacious and safe.

Pregnancy in a patient with fibrolamellar hepatocellular carcinoma.

Pregnancy in a patient with hepatocellular carcinoma is rare. Fibrolamellar hepatocellular carcinoma is a distinct clinicopathologic variant with a better prognosis. We report such a case in which pregnancy was apparently not deleterious.

Synchronous intrauterine and tubal pregnancies with subchorionic hematoma.

A case of a heterotopic pregnancy is presented. Clinical manifestations included vaginal bleeding, and on ultrasonography a subchorionic hematoma was demonstrated. The subchorionic hematoma may be regarded as blood draining from the tubal pregnancy through the uterus.

Acanthosis nigricans and hyperandrogenism in a pregnancy complicated by diabetes.

BACKGROUND: Acanthosis nigricans and hyperandrogenism have been associated with diabetes mellitus accompanied by insulin resistance. However, these manifestations have rarely been reported to occur as a result of the insulin resistance of pregnancy. CASE: A 31-year-old woman with diabetes mellitus exhibited severe insulin resistance during pregnancy. At 32 weeks, daily administration of 500 U insulin was required to maintain glycemic control. Skin lesions typical of acanthosis nigricans appeared, and free testosterone levels were elevated (10.3 pg/mL). These manifestations resolved after delivery. CONCLUSION: This case may demonstrate a correlation between reversible gestational insulin resistance and acanthosis nigricans.

Ultrarapid freezing and thawing of hamster oocytes. Morphologic parameters, trypan blue staining and sperm penetration assay for evaluating survival.

Nine hundred sixteen hamster oocytes were cryopreserved with the ultrarapid freezing method using five different cryoprotective solutions: 3 mol/L dimethylsulphoxide (DMSO) plus 0.25 mol/L sucrose, 3 mol/L DMSO, 3 mol/L propanediol plus 0.25 mol/L sucrose, 3 mol/L propanediol and 10% glycerol. One hundred eighty fresh oocytes served as controls. The viability of the oocytes was evaluated using morphologic parameters, Trypan blue staining and the sperm penetration assay. The viability rates based on morphologic parameters and Trypan blue staining were 82.3%, 65.0%, 51.4%, 33.0% and 0%, respectively, as compared to 100% in the controls. The sperm penetration rates were 27.0%, 0%, 9.8%, 0% and 0%, respectively, as compared to 94-98% in the controls. Our results indicate that among the various cryoprotective solutions used for ultrarapid freezing, 3 mol/L DMSO plus 0.25 mol/L sucrose gave the best results, with a viability rate of 82.3% and a sperm penetration rate of 27%.

Double transfer of embryos in in vitro fertilization, or is there a delayed receptivity of the endometrium?

Sixty-seven in vitro fertilization (IVF) patients who underwent ultrasonically guided oocyte pickup (OPU) after induction of superovulation with human menopausal gonadotropins were submitted to two different protocols of embryo transfer. In the first group of 33 patients, four to five embryos were transferred to the uterus 48 hr after OPU. In the second group of 34 patients two to three embryos were transferred at 48 hr after OPU and two other embryos were transferred after freezing and thawing 48 hr later (96 hr after OPU). The pregnancy rate achieved in the double embryo transfer (ET) protocol was significantly higher than in the single-ET protocol (32.4 vs. 18.2%, respectively; P less than 0.05).