The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial.

PURPOSE: The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. METHODS: A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. RESULTS: 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0-7.7) vs. 4.6 (3.0-6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. CONCLUSION: Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up.

The association between uterine scar defect (niche) and the presence of symptoms.

RESEARCH QUESTION: Is there association between the presence of a uterine niche and the presence of symptoms? DESIGN: This cross-sectional study was conducted at a single tertiary medical centre. All women who underwent Caesarean section from January 2017 to June 2020 were invited to the gynaecological clinics, and requested to complete a questionnaire regarding symptoms related to the presence of a niche (heavy menstrual bleeding, intermenstrual spotting, pelvic pain, infertility). Transvaginal two-dimensional ultrasonography was performed to assess the uterus and uterine scar characteristics. The primary outcome was defined as the presence of a uterine niche, evaluated by length, depth, residual myometrial thickness (RMT) and ratio between the residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT). RESULTS: Of 524 women who were eligible and scheduled for evaluation, 282 (54%) completed the follow-up; 173 (61.3%) were symptomatic and 109 (38.6%) asymptomatic. Niche measurements, including RMT/AMT ratio, were comparable between the groups. In a sub-analysis of each symptom, heavy menstrual bleeding and intermenstrual spotting were associated with reduced RMT (P = 0.02 and P = 0.04, respectively) compared with women with normal menstrual bleeding. An RMT less than 2.5 mm was significantly more prevalent in women reporting heavy menstrual bleeding (11 [25.6%] versus 27 [11.3%]; P = 0.01] and new infertility (7 [16.3%] versus 6 [2.5%]; P = 0.001]. In logistic regression analysis, infertility was the only symptom associated with an RMT less than 2.5 mm (B = 1.9; P = 0.002). CONCLUSIONS: A reduced RMT was found to be associated with heavy menstrual bleeding and intermenstrual spotting, while values below 2.5 mm were also associated with infertility.

Evaluation of ovarian reserve in young females with non-iatrogenic ovarian insufficiency to establish criteria for ovarian tissue cryopreservation.

RESEARCH QUESTION: Can ovarian reserve parameters predict the outcome of ovarian tissue cryopreservation (OTCP) in patients ≤18 years with non-iatrogenic premature ovarian insufficiency (POI)? DESIGN: Retrospective cohort analysis carried out in a single tertiary hospital between August 2010 and January 2020. Thirty-seven patients ≤18 years with non-iatrogenic POI (27 with Turner syndrome, six with POI of unknown aetiology, three with galactosemia and one with blepharophimosis, ptosis, epicanthus inversus syndrome) were included. Three parameters were used to evaluate ovarian reserve: anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH) and transabdominal antral follicle count. Fertility preservation (most commonly OTCP) was offered if ovarian reserve was diminished and one or more parameters was positive. Follicles were counted in ovarian samples obtained at the time of OTCP. RESULTS: Ovarian reserve was diminished in 34 patients and 19 of them had one or more positive parameter. Fourteen (11 aged ≥12 years and 3 aged <12) underwent OTCP, one (14 years old) underwent ovarian stimulation and oocyte cryopreservation and four declined fertility preservation. Follicles were detected in 11 of 14 patients who underwent OTCP with one or more positive parameters (79%), and in all those (100%) who had two or three positive parameters. The median number of follicles was 27 (range 5-64) and 48 (range 21-75) in patients ≥12 years and those <12 years, respectively. CONCLUSION: This study shows that if OTCP is performed in patients with one or more positive parameters of ovarian activity, a 79% positive predictive value is achieved for the detection of follicles. The incorporation of this criterion for OTCP will minimize the risk of harvesting ovarian tissue with a low number of follicles.

Role of Gynecological Ultrasound in Evaluation of Pelvic Urologic Pathologies.

BACKGROUND: Advances in examination techniques have improved routine assessment of non-gynecological structures in the pelvis. OBJECTIVES: To describe the sonographic features of incidental urological abnormalities found during gynecological transvaginal ultrasound. METHODS: A retrospective descriptive analysis of patients who underwent gynecological ultrasound and were diagnosed with urologic findings was performed. The sonographic features of the findings including size, echogenicity, and vascularity were examined. RESULTS: Gynecological ultrasound diagnosed urological findings in nine women. Two had primary neoplasms of the urinary bladder, one had metastases to the urinary bladder, one had polyps in the distal ureters, four presented with calculus in the distal ureters (one of them was 19 weeks pregnant), and one showed diverticulum of the urethra. At presentation five women (56%) had urinary complaints. Two patients (22%) with abdominal pain with distal ureteral calculi had normal transabdominal ultrasound targeted to the urinary system prior to the gynecological sonography. CONCLUSIONS: Transvaginal ultrasound is useful in the diagnosis of urological abnormalities, mainly in the urinary bladder and the distal ureters. We suggest adding transvaginal assessment for female patients with urinary complains in whom transabdominal ultrasound of urinary system was unremarkable.

The Association Between Gastrointestinal Symptoms and Transvaginal Ultrasound Findings in Women Referred for Endometriosis Evaluation: A Prospective Pilot Study.

PURPOSE: To evaluate the relationship between gastrointestinal (GI) symptoms and transvaginal ultrasound (TVUS) findings suggestive of endometriosis. MATERIALS AND METHODS: A prospective design. Women referred for a diagnostic ultrasound due to suspicion of endometriosis completed a Rome III and Pelvic Floor Distress Inventory (PFDI-20) questionnaire for clinical, GI symptoms, before undergoing TVUS. Endometriosis was diagnosed in the presence of endometriomas and/or deeply infiltrative endometriotic (DIE) lesions. Association between lesion sites and GI symptoms was evaluated by univariate and multivariate analysis. RESULTS: The study included 241 women who presented with: dysmenorrhea (89.6 %), dyspareunia (76.3 %), chronic pelvic pain (77.2 %), dyschezia (66 %), hematochezia (15.4 %), subfertility (24.5 %). GI symptoms were present in 25.3-76.8 % and 5.4-55.6 % of Rome III and PFDI-20 questionnaire responses, respectively. TVUS findings were endometriomas (23.2 %), peritoneal adhesions (46.5 %), uterosacral ligament (26.7 %), retrocervical (11.2 %), rectosigmoid (11.2 %), intestinal (4.6 %), and bladder (0.8 %) involvement, and pouch of Douglas (POD) obliteration (15.4 %). There was a high prevalence of peritoneal adhesions, uterosacral ligament involvement, and rectosigmoid and intestinal nodules on TVUS in women with GI symptoms, up to Chi2 = 9.639 (p = 0.013) on univariate and Chi2 = 8.102 (p = 0.005) on multivariate analysis. CONCLUSION: We observed an almost 10-fold increase in DIE lesions in women with GI symptoms. We suggest that the presence of GI symptoms should prompt a referral for endometriosis evaluation and performance of a dedicated TVUS before invasive gastrointestinal procedures.

"One-stop shop" for the evaluation of the infertile patient: hystero-salpingo foam sonography combined with two and three dimensional ultrasound and sonohysterography.

Hysterosalpingo-foam sonography (HyFoSy) is considered an acceptable alternative for hysterosalpingography (HSG). By combining HyFoSy with two and three-dimensional (2D and 3D) ultrasound and hysterosonography, a complete fertility work-up can be done. We aimed to evaluate the value of a combined ultrasound examination for fertility work-up. During the study period 113 women were examined. Five of 113 (4.4%) examinations were abandoned due to intra-uterine adhesions that were detected by hysterosonography, and five (4.4%) were abandoned due to technical difficulties. Of 103 women who had completed the examination, 2D ultrasound revealed six patients with hydrosalpinx (5.8%) and sonographic signs of adenomyosis in 13 (12.6%) patients. By combining 2D ultrasound with hysterosonography, two (1.9%) fibroids that were penetrating the uterine cavity and seven (6.8%) endometrial polyps were detected. HyFoSy showed bilateral patent tubes in 58 patients (56.3%), unilateral tubal occlusion in 29 (28.1%) and bilateral tubal occlusion in 16 (15.5%). This study shows that the 'one-stop shop' examination is feasible. The combined examination had detected 16 pathological findings that would have not been detected by HyFoSy alone. Hence, it should be offered to couples undergoing routine infertility work-up.IMPACT STATEMENTWhat is already known on this subject? The accuracy of the HyFoSy alone has been evaluated in different studies, but this presented ultrasound scan is integrating 4 different modalities in one exam (2D scanning of the pelvis, 3D scanning of the uterus, hysterosonography and HyFoSy) and we were able to evaluate the female pelvic organs, including the uterine cavity, the tubes and the ovaries, in order to expand the range of diagnosed pathologies.What do the results of this study add? The concept of 'one-stop shop' for the evaluation of female pelvis in couples suffering from infertility is feasible, has comparable accuracy as HSG for tubal occlusion, and higher detection rate for uterine malformations.What are the implications of these findings for clinical practice and/or further research? We suggest to incorporate this examination in routine fertility work-up.

Esophageal atresia in twins compared to singletons: In utero manifestation and characteristics.

OBJECTIVE: Esophageal atresia with/without tracheo-esophageal fistula (EA/TEF) is more common among twins. The detection of polyhydramnios might be altered in twins, leading to EA/TEF underdiagnosis, prenatally. The aim of the study was to compare the prenatal manifestation of EA/TEF between twins and singletons. METHODS: A 12-year study of EA/TEF cases was performed at a tertiary center. Cases exhibiting (a) small/absent stomach or (b) polyhydramnios were considered "suspected"; cases with (c) esophageal pouch were considered "detected." We compared the rate and timing of appearance of these signs between the groups. RESULTS: There were 76 cases of EA/TEF, of which 17 were a co-twin. All twin pairs were EA/TEF discordant. The prevalence of EA/TEF at our center was 1:750 for twins (1:319 monochorionic and 1:1133 dichorionic) and 1:2399 for singletons. The rate of small/absent stomach, polyhydramnios and pouch in twins vs singletons was 23.5%, 47.1%, 29.4% and 39.7%, 72.4%,34.5%, respectively (P = .2, P = .09 and P = .7). Esophageal pouch was detected earlier in twins (P = .03). Twins were scanned more frequently (×1.8 times, P = .01). CONCLUSION: EA/TEF is more prevalent in twins. Despite lower rate of polyhydramnios, twins were similarly detected prenatally as singletons, and this was accomplished earlier in pregnancy; perhaps reflecting more frequent scans.

Perinatal Outcome of Twin Pregnancies Complicated by Rupture of Membranes at 13-20 Weeks: Is Selective Termination an Appropriate Management Option?

OBJECTIVE: To evaluate the outcome of twin pregnancies that were complicated by rupture of membranes at 13-20 weeks of gestation and were managed by expectant management or by selective termination. METHODS: A retrospective cohort study of all bichorionic twin pregnancies that were referred to three fetal medicine units between 2001 and 2016, due to rupture of membranes of one sac at 13-20 weeks of gestation. Women without clinical signs of infection who opted for expectant management or selective termination were included. RESULTS: 20 patients met the inclusion criteria. 7 of them were managed expectantly and 13 underwent selective termination. In the expectant management group there was one case of fetal demise and two cases of neonatal death, resulting in a survival rate of 79 %. The median gestational age at delivery was 30 weeks. 3 neonates suffered from prematurity-related complications and 2 suffered from oligohydramnios-related orthopedic complications. Following selective termination the survival rate was 50 % (all fetuses that were not reduced), the median gestational age at delivery was 39 weeks, and the neonatal outcome was favorable. The maternal outcome was favorable in both groups. CONCLUSION: Selective termination in twin pregnancies complicated by rupture of membranes at 13-20 weeks has a favorable outcome and should be offered.

Crossed ectopic kidney: prenatal diagnosis and postnatal follow-up.

OBJECTIVE: The objective of this study is to investigate prenatal diagnosis and postnatal outcome of fetuses with crossed ectopic kidney. METHOD: Cases referred for an empty renal fossa and diagnosed with crossed ectopic kidney confirmed postnatally were analyzed retrospectively over a period of 10 years. Prenatal diagnosis was established following the detection of one kidney in a normal position and a second ipsilateral kidney fed by abnormal blood vessels on Doppler flow RESULTS: Between 2005 and 2015, 185 fetuses were referred for an empty renal fossa. Crossed ectopic kidney was diagnosed in 10 of them. Associated congenital urological anomalies included two cases of double collecting system and bilateral hydronephrosis in one. Associated extra renal findings were single umbilical artery (4/10), ventricular septal defects (1/10), and persistent left superior vena cava (1/10). On postnatal follow-up, bilateral vesicoureteral reflux was diagnosed in a case who presented prenatally with bilateral hydronephrosis and two cases of mild hydronephrosis. All cases were managed conservatively. CONCLUSION: Crossed ectopic kidney should be suspected in cases presenting with an empty renal fossa and a normal positioned kidney. Thorough anatomical scan should be performed as well as periodic follow-up throughout pregnancy. Postnatal nephrological follow-up is recommended. © 2017 John Wiley & Sons, Ltd.

Feasibility of detection of the 3-vessel and trachea view using 3-dimensional sonographic volumes.

OBJECTIVES: The purpose of this study was to investigate the ability to depict the 4-chamber and 3-vessel and trachea views of the fetal heart using 3-dimensional sonography. METHODS: Three-dimensional color Doppler volumes of the fetal heart were acquired prospectively in 31 fetuses between 19 and 25 gestational weeks. The initial plane consisted of the 4-chamber view. Postprocessing included navigation within the volume solely in plane A in the caudal direction to visualize the stomach and in the cephalic direction to the plane of the 3-vessel and trachea view to visualize the pulmonary artery, the aorta, the V shape and color of the arches, the superior vena cava, and the trachea. The feasibility of showing these organs was evaluated. RESULTS: The estimated time for volume acquisition and manipulation was about 60 seconds. The detection rates for the 4-chamber view, stomach, 3-vessel view, trachea, and V sign were 100%, 93.5%, 92.0%, 77.4%, and 83.9%, respectively, with interobserver agreement of 0.76 to 1.0. CONCLUSIONS: We describe a simple technique in which a single sweep on 3-dimensional sonography starting at the level of the 4-chamber view can visualize the situs, stomach, 4-chamber view, and transverse view of the outflow tracts of the heart.

Sonographic assessment of fetal secondary palate between 12 and 16 weeks of gestation using three-dimensional ultrasound.

OBJECTIVE: To evaluate fetal secondary palate in fetuses at 12 to 16 weeks' gestation by three-dimensional ultrasound. METHODS: Between June 2006 and July 2008, volumes of palate were prospectively acquired in fetuses at gestational age of 12 to 16 weeks. Acquisition was performed when the fetus was facing the transducer with head extended at an angle of 30° to 40° to the ultrasound beam. Secondary palate was assessed off-line. RESULTS: Secondary palate was assessed in 45 fetuses with normal face anatomy and 4 fetuses with malformations of the face (one with retrognathia, one with retrognathia and micrognathia, one with cleft lip and one with cleft lip and primary palate). The secondary palate was visualized in 19/49 (38.7%) fetuses: in 2/49, only hard palate was demonstrated; in 6/49, only soft palate and in 11/49, both hard and soft palate were fully demonstrated. CONCLUSION: Information concerning evenness of secondary palate may be provided by three-dimensional ultrasound in 38.7% of examined fetuses at 12 to 16 weeks of gestation. This examination should be offered in pregnancies at high risk for cleft palate.

Three-dimensional ultrasound demonstration of the fetal palate in high-risk patients: the accuracy of prenatal visualization.

OBJECTIVE: The aim of this research was to evaluate the ability of three-dimensional (3D) ultrasound for demonstrating the palate of fetuses at high risk for cleft palate. METHOD: Fifty-seven fetuses at high risk for cleft palate were referred for specialist ultrasound at 12-40 weeks' gestation. A detailed assessment of palate was made using both two-dimensional and 3D ultrasounds on the axial plane. Antenatal diagnoses were compared with postnatal findings. RESULTS: Cleft palate was suspected in 13 (22.8%); a normal palate was demonstrated in 38 (67%), and in six (10.2%), the palate view could not be obtained. Mean gestational age at the first visit was 27 weeks 6 days (range of 12-40 weeks 3 days). Examination after delivery revealed that one of the 38 fetuses with presumed normal palate had a cleft hard palate, and one had a cleft soft palate (false negative 5%). Among the 13 fetuses with suspected cleft palate, three had an intact palate (false-positive 23%). Sensitivity, specificity, positive predictive value, and negative predictive value of detection of palatal clefts were 71.4%, 91.9%, 62.5%, and 94.4%, respectively. CONCLUSION: Using 3D technology, we diagnosed a cleft palate in 83% of high-risk cases, with 5% false negative. 3D technology might produce some technical artifacts resulting in a 23% false-positive rate.

Endometrioma increases the risk of antibiotic treatment failure and surgical intervention in patients with pelvic inflammatory disease.

OBJECTIVE: To evaluate the outcome of pelvic inflammatory disease (PID) in patients with endometriosis with and without ovarian endometrioma. DESIGN: A retrospective cohort study. SETTING: A single university-affiliated tertiary center. PATIENT(S): A total of 116 patients with endometriosis hospitalized because of PID between the years 2011-2021. Fifty-nine patients with an ovarian endometrioma component were compared with 57 patients with endometriosis without endometrioma. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The primary outcome was severe PID defined as the need for surgical intervention or drainage. Secondary outcomes included tubo-ovarian abscess, number of hospitalization days, a positive cervical bacterial culture or urine sexually trasmitted disease polymerase chain reaction (STD PCR) test, and readmission because of partially treated or relapsing PID. RESULT(S): PID in patients with endometrioma was found less likely to respond to antibiotic treatment with increased risk for surgical intervention or drainage compared with endometriosis patients without endometrioma (adjusted odds ratio, 3.5; confidence interval, 1.25-9.87). On admission, patients with endometrioma were older (26.5 vs. 31.0) and less likely to have an intrauterine device (19.3% vs. 5.1%) compared with patients without endometrioma. The rate of the tubo-ovarian abscess (52.5% vs. 19.3%) was significantly higher in patients with endometrioma. Readmission rate, positive bacterial culture, and hospitalization duration were higher in the endometrioma group; however, they did not reach statistical significance. Recent oocyte retrieval and patient's age were not associated with an increased risk of severe PID. CONCLUSION(S): Endometrioma patients with PID are less likely to respond to antibiotic treatment and present a higher risk for surgical intervention.

Identification of the fetal hippocampus and fornix and role of 3-dimensional sonography.

OBJECTIVES: The purposes of this study were to identify the fetal hippocampus and fornix using 3-dimensional sonography, to measure their curved length during pregnancy, and to describe a systematic method for volume data set analysis of the fetal hippocampus and fornix. METHODS: Three-dimensional volumes of the fetal brain were acquired prospectively in 34 patients between 14 and 37 weeks' gestation. Volumes were acquired with trans-abdominal and transvaginal transducers. All volumes were analyzed offline by 2 examiners separately. The feasibility of identifying the fetal hippocampus and fornix was analyzed. The curved length of the hippocampus-fornix structure was measured on the right and left hemispheres. RESULTS: The fetal hippocampus and fornix were identified bilaterally in 32 of 34 fetuses (94%) at gestational ages of 14 weeks 5 days to 37 weeks 1 day (mean, 23 weeks 3 days). In 1 fetus (3%), only one side was shown, and in another fetus (3%), both sides were obscured by acoustic shadows. A systematic approach for identification of the fetal hippocampus is described. Linear growth of the fetal hippocampus and fornix was shown during pregnancy and was correlated with both the gestational week and the head circumference (R = 0.71 and 0.74, respectively; P = .01). The length of the hippocampus and fornix did not differ between the left and the right hemispheres (P = .598). CONCLUSIONS: The fetal hippocampus and fornix can be identified by a systematic analysis of 3-dimensional data set volumes. The normal hippocampus and fornix show linear growth throughout pregnancy.

Outcome of twin pregnancies complicated by early second trimester rupture of membranes in one sac.

The aim of this study was to present the outcome of bichorionic twin pregnancies complicated by early second trimester rupture of membranes in one sac. Data regarding all cases of ruptured membranes at 13-20 weeks in bichorionic twin pregnancies were collected retrospectively from three fetal medicine units. Patients who have chosen to terminate the pregnancy were excluded from the study. Between January 2003 and July 2009, nine patients met inclusion criteria. Three out of nine couples decided on expectant management, and six preferred selective feticide. With expectant management one fetus died in utero and take home baby rate was 83% (5 of 6 fetuses), delivered at 27-32 weeks. When selective termination was performed, all non-reduced fetuses were born alive at 33-40 weeks. Two survivors of rupture of membranes had limb contractures, none had lung hypoplasia. One patient had clinical signs of amnionitis, which was ruled out later on pathological examination. Her post partum course was uncomplicated. Our data suggest that rupture of membranes in one sac of bichorionic twins at 13-20 weeks has favorable prognosis whether an intervention is preformed or not. Nonetheless, selective termination may have an advantage over expectant management, since gestational age at delivery was higher when selective termination was performed.

Direct Feeding at the Breast Is Associated with Breast Milk Feeding Duration among Preterm Infants.

BACKGROUND: In spite of high rates of initiating breast milk feeding (BMF) among preterm infants, a significant rate of discontinuation occurs shortly after discharge. AIM: To investigate the effect of mode (direct feeding at the breast vs. expressing) and exclusivity (breast milk combined with formula vs. breast milk only) as well as maternal perceptions on the duration of BMF among preterm infants. METHODS: The study included mothers whose infants were born before 32 weeks gestation, between January 2012 and August 2015 at Sheba Medical Center (SMC). Perinatal data were collected retrospectively from infants' computerized charts. Mothers were approached >12 months postpartum and were asked to complete a questionnaire. Those who agreed to participate were asked (during their visit to the follow-up clinic or by phone or mail) to complete a questionnaire regarding mode and duration of BMF as well as reasons for its discontinuation. Mothers were also asked about their pre-partum intentions to feed directly at the breast. RESULTS: Out of 162 eligible mothers, 131 (80.8%) initiated BMF during their intensive care unit (ICU) hospitalization. Of these, 66 (50.3%) discontinued BMF earlier than six months postpartum. BMF ≥ 6 months was significantly associated with direct feeding at the breast, duration of exclusive BMF, and singleton birth. Regression analysis revealed that direct feeding at the breast (any or only) and duration of BMF exclusivity were the only significant variables associated with BMF duration (Odds ratio (OR) 5.5 and 95% confidence interval (CI) 2.00-15.37; OR 1.5 and 95% CI 1.25-1.88, respectively). Milk supply (inadequate or nonexistent) was the most commonly reported cause for BMF discontinuation <6 months. Direct feeding at the breast was significantly associated with BMF duration and was more common among singletons. CONCLUSIONS: Direct feeding at the breast and duration of exclusive BMF are associated with duration of BMF among infants born <32 weeks of gestational age (GA). These findings suggest that targeting these two factors may play a key role in prolonging BMF duration among preterm infants.

Laparoscopic Findings Associated with Bladder Endometriosis Are Correlated with Disease Severity.

STUDY OBJECTIVE: Bladder involvement is rare in endometriosis. The prevalence is estimated to be ∼1% in patients with endometriosis. However, this figure seems to be an underestimation. The diagnosis of bladder endometriosis might be missed during laparoscopy. The aim of this study was to determine an intraoperative visual score of pelvic lesions that help the surgeon suspect bladder endometriosis. Design, Design Classification: A retrospective analysis was performed on the intraoperative photographs and videos of 69 patients with histological confirmation of bladder endometriosis. SETTING: A tertiary referral center. PATIENTS: Sixty-nine patients with bladder endometriosis were operated on in our center over a 9-year period. INTERVENTIONS: Evaluation and analysis of intraoperative laparoscopic findings. MAIN RESULTS: We found three subtypes of laparoscopic findings that can assist with diagnosing bladder endometriosis. The most prominent sign was named "kissing round ligaments" (Type K), in which the right and left round ligaments appear closer to each other than usual or even touching one another. This sign is strongly associated with full-thickness invasion of the bladder. Other laparoscopic findings that indicated bladder endometriosis were anatomical distortion (Type A) and proximal occlusion of the tubes (Type B). We further define a scoring system for the lesion that correlates with the severity of the bladder endometriosis from superficial lesions to full thickness. CONCLUSION: Bladder endometriosis is a rare condition and often remains undiagnosed. Indeed, even during surgery, bladder endometriosis can be missed if the operator is not aware of the suggestive signs. Operative laparoscopic findings may help the surgeon to diagnose bladder endometriosis, and these signs correlate with the severity of the disease.

Past, present and future ultrasonographic techniques for analyzing ovarian masses.

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.

Prenatal diagnosis of obstructive hydrocephalus associated with parvovirus B19 infection.

BACKGROUND: Intrauterine parvovirus B19 infection is a well-known cause for hydrops fetalis and fetal demise. We present a case of isolated fetal obstructive hydrocephalus caused by an intrauterine parvovirus B19 infection. CASE: A 23-year-old woman, gravida 3 para 2, was referred for fetal obstructive hydrocephalus. Although there were no signs of fetal anemia, increased maternal parvovirus B19-specific immunoglobulin G and immunoglobulin M raised the suspicion of fetal infection. This was confirmed by polymerase chain reaction in the amniotic fluid. Elective cesarean delivery was performed at 34 weeks of gestation, followed by craniotomy and placement of shunt. At the age of 20 months, the child's development was in accordance with his age, with the exception of gross motor function, which was moderately delayed. CONCLUSION: Evaluation of fetal obstructive hydrocephalus should include maternal serological tests for parvovirus B19.