Quality Requirements for the early Fetal Ultrasound Assessment at 11-13+6 Weeks of Gestation (DEGUM Levels II and III).

The early fetal ultrasound assessment at 11 - 13(+6) weeks of gestation remains the cornerstone of care despite the progress in diagnosing fetal chromosomal defects using cell-free fetal DNA (cffDNA) from the maternal circulation. The measurement of nuchal translucency (NT) allows the risk calculation for the fetal trisomies 21, 18 and 13 but also gives information on those fetal chromosomal defects which are at present unable to be detected using cffDNA. Nuchal translucency is the only auditable parameter at 11 - 13(+6) weeks and gives thus information on the quality of the first trimester anomaly scan. In addition it gives indirect information on the risks for fetal defects and for cardiac anomalies. Also the chances for a healthy live baby can be estimated. As experience with first trimester anomaly scanning increases, and the resolution of the ultrasound equipment has increased substantially, more and more details of the fetal anatomy become accessible at the first trimester scan. Therefore fetal anatomical defects and complex anomalies have become amenable to examination in the first trimester. This guideline describes compulsory and optional parameters for investigation at the first trimester scan and outlines a structured method of examining a first trimester fetus at 11 - 13(+6) weeks of gestation.

Cranial and cerebral signs in the diagnosis of spina bifida between 18 and 22 weeks of gestation: a German multicentre study.

OBJECTIVE: The aim of this article is to study secondary cranial signs in fetuses with spina bifida in a precisely defined screening period between 18 + 0 and 22 + 0 weeks of gestation. METHOD: On the basis of retrospective analysis of 627 fetuses with spina bifida, the value of indirect cranial and cerebral markers was assessed by well-trained ultrasonographers in 13 different prenatal centres in accordance with the ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) guidelines on fetal neurosonography. RESULTS: Open spina bifida was diagnosed in 98.9% of cases whereas 1.1% was closed spina bifida. Associated chromosomal abnormalities were found in 6.2%. The banana and lemon signs were evident in 97.1% and 88.6% of cases. Obliteration of the cisterna magna was seen in 96.7%. Cerebellar diameter, head circumference and biparietal diameter were below the 5th percentile in chromosomally normal fetuses in 72.5%, 69.7% and 52%, respectively. The width of the posterior horn of the lateral ventricle was above the 95th percentile in 57.7%. The secondary cranial and cerebral signs were dependent on fetal chromosome status and width of the posterior horn. Biparietal diameter was also dependent on the chromosome status with statistical significance p = 0.0068. Pregnancy was terminated in 89.6% of cases. CONCLUSION: In standard measuring planes, lemon sign, banana sign and an inability to image the cistern magna are very reliable indirect ultrasound markers of spina bifida. © 2014 John Wiley & Sons, Ltd.

Pregnancy in a non-communicating rudimentary horn of a unicornuate uterus.

BACKGROUND: The non-communicating rudimentary horn of a unicornuate uterus is the rare result of abnormal development of the Müllerian ducts during embryogenesis.  Case description: We report a rare condition of a pregnancy of eight weeks of gestation in a non-communicating rudimentary horn of a unicornuate uterus, which was diagnosed without specific symptoms and treated through laparoscopy. CONCLUSION: Early diagnosis and treatment are essential to prevent the high maternal risk of life-threatening bleeding complications. HIPPOKRATIA 2019, 23(2): 92-94.

Experience with laparoscopic assistance in vaginal hysterectomy.

OBJECTIVE: To determine safety and usefulness of laparoscopy intended to convert an abdominal into a vaginal hysterectomy. STUDY DESIGN: Forty-seven consecutive hysterectomies are retrospectively analyzed in which laparoscopy was used to accomplish a vaginal instead of an abdominal procedure which would have been performed without endoscopic surgery. RESULTS: In four patients the operation had to be converted to laparotomy due to difficult access (n = 3) or heavy bleeding (n = 1). Operation time declined during the study period, thus highlighting the importance of experience with laparoscopic technics. Major complications such as injuries of adjacent organs or delayed haemorrhage requiring a second intervention were not encountered. CONCLUSIONS: Laparoscopy in hysterectomy seems to be a valuable method to avoid laparotomy. In the future, guidelines to determine the route of surgery are to be established which include those conditions in which laparoscopy in addition to vaginal hysterectomy implies a benefit for the patient.

Differential diagnosis of sonographically detected tumours in the fetal cervical region.

Differential diagnosis of sonographically detected fetal neck tumours is difficult. The sonographic criteria for encephalomyelocele, lymphangioma/hygroma, teratoma, sarcoma, haemangioma, neuroblastoma and goitre are given on the basis of the authors' own observations and information from the literature. Elevation of alpha-fetoprotein in the amniotic fluid is a frequent but non-specific finding. Chromosome analysis after amniocentesis can be a useful supplementary procedure for assessing the prognosis and deciding upon the delivery procedure. Sonographic detection of a tumour in the fetal neck region enables preparations to be made for dystocia and postnatal dyspnoea of the newborn. The obstetrician must cooperate closely with paediatricians, neurologists, surgeons and ENT specialists.

-Chronic tubo-ovarian abscess with vaginal fistula after vaginal hysterectomy: combined laparoscopic-vaginal therapy-. / Chronischer Tuboovarialabszess mit Vaginalfistel nach vaginaler Hysterektomie: Kombinierte laparoskopisch-vaginale Therapie.

A chronic tuboovarian abscess with vaginal fistula occurring after vaginal hysterectomy was removed laparoscopically. The fistula was closed by a combined laparoscopic-vaginal procedure. A complete cure was achieved without complications.

Does Non-Placement of a Drain in Breast Surgery Increase the Rate of Complications and Revisions?

Purpose: Although surgical therapy for breast cancer has become less radical, intrasurgical placement of drains and the use of compression bandages is still standard practice. However, evidence for the clinical benefit of wound drains is controversial, and use of drains is associated with increased pain and longer hospital stays. This raises the question whether, given the latest surgical techniques, wound drainage is still medically necessary. Material and Method: A retrospective analysis was done of patients with breast cancer treated surgically between January 2009 and April 2012 in the Breast Centre Hohenlohe (n = 573). Complication rates and revision following surgery with and without placement of wound drains were compared for patients who had breast-conserving surgery (n = 425) and patients who underwent mastectomy (n = 148). Results: The baseline characteristics (age, number of resected lymph nodes, numbers of patients who had sentinel lymph node resection, tumour characteristics, receptor status and affected side) were comparable for the investigated patient groups. The overall rate of complications was 4 %. There was no significant difference with regard to complication rates after surgery with and without placement of wound drains between the group of patients with breast-conserving surgery and the group of patients with mastectomy (p = 0.68 and p = 0.54, respectively). Conclusion: Our data indicate that non-placement of a wound drain does not influence complication or revision rates after breast-conserving surgery or mastectomy.

Feto-amniotic shunting -- experience of six centres.

AIM: Foeto-amniotic shunting is an ultrasound-guided, therapeutic intervention for drainage of persistent intracavital fluid retention in severely affected foetuses with a high risk of mortality. In order to weigh up the comparatively high risk of intervention against the possible benefit, we evaluated the value of different indications, the complication rate and the time span of drains in situ. PATIENTS AND METHODS: We made a survey of all level III ultrasound centres of German-speaking countries from 1993 to 2001. Six level III centres returned the questionnaire: forty-seven foeto-amniotic shunting procedures were performed in 30 foetuses [megacystis in 18 foetuses (three of these with urinary ascites), hydrothorax in eight foetuses, hydronephrosis in two foetuses, cystic adenomatoid malformation of the lung in one foetus, ovarian cyst in one foetus]. RESULTS: The median gestational age at time of shunting was 23.5 (range 16 - 33) weeks, at time of delivery 35 (range 23 - 41) weeks. The median time span of drains in situ was 19 (range 0 - 170) days. Altogether 18 of 30 foetuses (60 %) had a benefit of foeto-amniotic shunting. CONCLUSION: The best possible selection of pregnancies which might profit from foeto-amniotic shunting is required. The decisive criteria are the underlying defect as well as the severity and progression of the disorder.

[Spontaneous regression of fetal megacystis in the 3d trimester]. / Spontane Rückbildung einer fetalen Megazystis im I. Trimenon.

The sonographic diagnosis of a fetal megacystis in the first trimester is reported that later regressed spontaneously. Therefore, at first only follow-up examinations are indicated in case of early dilatation of the fetal bladder as the outcome may be normal. The case illustrates that great caution must be exercised in predicting an unfavorable outcome of fetuses with an early dilatation of the bladder.

[The embryonal yolk sac in disordered early pregnancy]. / Der embryonale Dottersack bei gestörter Frühschwangerschaft.

The detection rate and size of the yolk sac were evaluated by means of vaginal sonography in a prospective study in 377 singleton pregnancies. 298 were normal pregnancies and 79 were spontaneous abortions, the latter of which were viable in 18 cases at the time of examination and non-viable in 61 cases. With a reliable gestational age between 5 and 10 weeks, the yolk sac was recognized in 158 of 172 normal pregnancies (91.9%), in all 14 viable but later aborted pregnancies, but only in 10 of 29 non-viable pregnancies (34.5%) (p less than 0.0000005). With a mean diameter of the chorionic cavity between 5 and 50 mm, the yolk sac was identified in 237 of 253 normal gestations (93.7%), in 16 of 18 viable but later aborted gestations (88.9%), but only in 14 of 41 non-viable gestations (34.1%) (p less than 0.0000001). A diameter of the yolk sac above 6 mm was observed in 5 of 253 normal pregnancies (2.0%), but in 7 of 29 spontaneous abortions (24.1%) (p less than 0.00005). A diameter above 7 mm was not seen in any instance of normal development but in 4 of the pathological courses (13.8%) (p less than 0.0001). It is concluded, that a yolk sac which is not visible in vaginal sonography between 5 and 10 complete weeks menstrual age or a chorionic cavity diameter between 5 and 50 mm and a yolk sac diameter above 6 mm can serve as indicators of a developmental disturbance in early pregnancy.

[Laparoscopic removal of dermoid cysts]. / Laparoskopische Entfernung von Dermoidzysten.

Benign dermoid cysts between 1.5 and 6 cm in diameter were laparoscopically removed in 9 premenopausal women. Cystectomy was performed in eight patients, and unilateral oophorectomy in one. Surgical and postoperative complications were not observed. Chemical peritonitis due to the dermoid contents can be avoided, provided, careful lavage of the peritoneal cavity is performed.

[The incidence of abortions of viable pregnancies in the first trimester]. / Zur Aborthäufigkeit vitaler Schwangerschaften im ersten Trimenon.

The spontaneous abortion rate in singleton pregnancies with sonographically proven heart activity between 5 and 13 weeks was analysed. Up to 15 weeks 8.6% of 395 patients miscarried. The abortion rate was higher in pregnancies with a gestational age < 9 weeks (12.5%), a maternal age > or = 35 years (15.5%) and vaginal bleeding (16.3%). The correlation of the abortion rate with these factors has to be taken into account when the prognosis of an individual gestation or the risk of invasive procedures is determined.

[Stress on the head of the fetus in spontaneous labor in relation to perinatal factors]. / Die Kopfbelastung des Kindes bei der Spontangeburt in Abhängigkeit von perinatalen Faktoren.

The pressure exerted on the fetal head during the second stage of labor was continuously measured in 42 spontaneous deliveries with a new instrument. The pressure values were correlated to various obstetric variables. Typically, the head pressure remained elevated beyond the end of the uterine contraction in primiparae, whereas it decreased simultaneously with the amniotic pressure in multiparae. On the average, the head pressure was higher in primiparae indicating, together with the longer lasting bearing down period, a higher resistance of the birth canal. Deliveries with pudendal block or peridural analgesia showed no differences, but these two groups differed in other factors which might have influenced the results. Infusion of oxytocin during the course of labor was associated with higher head pressure values that could not be deduced from the hormone administration per se, but from a higher resistance of the birth canal. Maternal age did not influence the head pressure. Within physiological limits, the head pressure was independent from the size of the child and the maternal pelvis.

Diagnosis of viability in early pregnancy with vaginal sonography.

The detection rate of embryonic heart action using vaginal sonography was evaluated in 363 normal singleton pregnancies in the first trimester. Visible cardiac activity was present at the earliest at a gestational age of 40 days; in addition, the smallest chorionic cavity had a mean diameter of 9.3 mm, the lowest human chorionic gonadotropin (beta-hCG) concentration (calibrated against the first international reference preparation) measured 6,770 mIU/mL, the thinnest trophoblast was 1 mm, and the shortest crown-rump length was 2 mm. Cardiac pulsations were identified in all cases either at a menstrual age greater than or equal to 46 days, a beta-hCG greater than or equal to 47,171 mIU/mL, a mean chorionic cavity diameter greater than or equal to 18.3 mm, or a trophoblast thickness greater than or equal to 5 mm. The heart rate (mean +/- SD) increased from 110 +/- 8 beats per minute (bpm) at 5 weeks menstrual age to 170 +/- 6 bpm at 9 weeks and declined thereafter to 159 +/- 3 bpm at 13 weeks. Vaginal sonography enables a rapid and reliable assessment of embryonic life in early pregnancy.

Vaginal sonography in ectopic pregnancy. A prospective evaluation.

Among 404 first-trimester pregnancies examined with vaginal sonography in a prospective study, there were 21 ectopic gestations. Considering only the initial scans, the endometrial canal showed a linear echo surrounded by an echogenic zone in 18 cases, but in three cases the uterine cavity demonstrated a small echo-free area representing blood. Free fluid within the cul-de-sac was seen in 17 patients. An adnexal tumor representing the extrauterine gestation, was detected in 19 cases. Fifteen of these masses exhibited a thick-walled ring characteristic of a gestational sac with a viable embryo in five cases and a yolk sac in one. Other cystic adnexal masses, such as corpus luteum cysts, seen in 14 of the 21 patients were not confused with the ectopic pregnancy. A correct tentative diagnosis of ectopic gestation was made in 18 patients (86%) after the initial scan and in 20 cases (95%) including four controls. There was one false-positive suspicion of ectopic gestation in a patient who actually had a spontaneous abortion. Interpretation of the sonographic image should generally be done in correlation with laboratory and clinical data. The results of the study indicate that vaginal sonography is a valuable diagnostic procedure in the evaluation for ectopic pregnancy.