Ultrasonography for the prediction of extension of trophoblastic infiltration into the tubal wall in ampullary pregnancy.

OBJECTIVE: Predictive factors of damage to the Fallopian tube may guide the treatment for patients with tubal pregnancy. The purpose of this study was to evaluate the predictive value of ultrasonographic findings in patients affected by ampullary pregnancy for the determination of the depth of trophoblastic infiltration into the tubal wall on histological examination. MATERIAL AND METHODS: 38 patients with ampullary pregnancy undergoing salpingectomy were enrolled into the study. The patients were divided into two subgroups depending on their transvaginal sonography (TVS) findings; either an ectopic gestational sac containing an embryo with cardiac activity or those with a tubal ring. The ampullary pregnancies were histologically classified according to the depth of infiltration of trophoblastic tissue into the tubal wall as follows: stage I: limited to mucosa; stage II: extension to the muscularis layer; stage III: complete infiltration of the tubal wall with or without rupture of the serosa. The association between findings on TVS and stage of trophoblastic invasion, serum beta-human chorionic gonodatropin (ß-hCG) levels was evaluated. RESULTS: Although there was no significant difference among two groups in terms of histological stage of trophoblastic infiltration (p = 0.257), patients in whom an embryo with cardiac activity had been identified were found to have higher percentage of stage II (47.8%) or stage III (8.7%) invasion. However, there was a significant difference in serum ß-hCG levels on the day of surgery among the two groups (p = 0.028). CONCLUSIONS: Ultrasonographic aspect of ampullary pregnancy is associated with depth of trophoblastic infiltration into the tubal wall and serum ß-hCG levels.

Free blastocyst and implantation stages in the European brown hare: correlation between ultrasound and histological data.

The European brown hare (Lepus europaeus) is the only species with superconception, whereby the maternal reproductive tract hosts two sets of conceptuses at different developmental stages. The embryonic development of the hare has not yet been described. To understand the mechanism of superconception, we studied oviduct transport and implantation stages by embryo flushing and live high-resolution ultrasound. Ultrasound data of implantation stages is correlated with histology. In the oviduct, a mucin coat is deposited on the zona pellucida. The blastocysts enter the uterine horns on Day 5, 1 day later than in the rabbit, and directly expand approximately threefold. Spacing is accompanied by peristaltic movement of the endometrium. The mucin coat disappears and the conceptuses attach. The yolk-sac expands in the blastocoel and syncytial knobs invade the antimesometrial endometrium. Maternal blood lacunae appear in the mesometrial endometrial folds, which are subsequently invaded by the syncytiotrophoblast. The haemochorial chorioallantoic placenta forms. The yolk-sac cavity is gradually replaced by the allantois and finally by the exocoel. The different reproductive strategies of the precocial hare and the altricial rabbit are discussed. We assume that the lagomorph-specific mucin coat and the hare-specific delay of the oviduct-uterine transition are prerequisites for superconception.

Screening for placenta accreta at 11-14 weeks of gestation.

OBJECTIVE: We sought to describe the potential value of 11-14 weeks' screening for placenta accreta (PA). STUDY DESIGN: Patients with a history of lower segment cesarean section were prospectively included between 11-13+6 weeks over a 1.5-year period. The first 258 were offered standard screening whereas the following 105 underwent screening for PA. Women were considered high-risk when the trophoblast overlapped the scar visualized by transvaginal ultrasound and low-risk otherwise. RESULTS: The group screened for PA did not differ from the nonscreened group for demographic characteristics. In all, 6 of 105 (5.8%) women were considered high-risk. In the nonscreened group, 1 case of PA was discovered during an elective repeat cesarean. In the screened population, 1 case of PA occurred in a high-risk patient allowing a conservative planned management at 35 weeks. CONCLUSION: At 11-14 weeks, ultrasound may help risk stratification for PA with a specific follow-up. Early recognition of patients at risk might improve the perinatal outcome of PA.

Exaggerated placental site mimicking placental site trophoblastic tumor: case report and literature review.

Exaggerated placental site is defined as a non-neoplastic trophoblastic lesion featuring exuberant infiltration into the endometrium and myometrium by intermediate trophoblasts and syncytiotrophoblasts. Exaggerated placental site can occur following normal or ectopic pregnancy, abortion, or hydatidiform mole. We encountered a case of reactive exaggerated placental site seven months following normal pregnancy that clinically mimicked placental site trophoblastic tumor. Few reports have described the clinical course, histopathology and differential diagnosis of exaggerated placental site; we present our patient's case together with histopathological observations and review of related literature.

Sonographic study of the decidua basalis in early pregnancy loss.

OBJECTIVES: To describe the sonographic findings in the decidua basalis layer in spontaneous early pregnancy loss and to compare them with those in normal pregnancy. METHODS: We reviewed 119 scans at 4-10 weeks' gestation from 110 patients who miscarried clinically at less than 13 weeks' gestation and 132 scans also at 4-10 weeks from 98 patients who had normal uncomplicated term pregnancies. The thickness and echogenicity of the decidua basalis layer were compared between pregnancies which suffered early loss and normal controls. RESULTS: Relative thinning of the decidua basalis was observed in cases of early pregnancy loss from 5-6 weeks onwards when compared with normal pregnancies. In embryonic pregnancies that subsequently miscarried, the decidua basalis did not show the rising trend in thickness that was observed in normal pregnancies. Shortly before and after embryonic demise, the decidua appeared relatively more echogenic compared with that in normal pregnancy and the placenta showed areas of hypoechogenicity. Embryonic demise was followed by disorganization of the decidual layer, which became difficult to recognize. Pregnancy with an empty sac showed a more gradual trend in the thinning of the decidua basalis, but the uniformity and echogenicity of the layer appeared to be relatively better preserved with time. CONCLUSION: The decidua basalis layer in pregnancies that are destined to miscarry in the first trimester differs sonographically from that in normal pregnancies. The sonographic differences are suggestive of a defective decidual-placental complex resulting from deficient trophoblastic invasion.

Risk factors for persistent trophoblastic activity after surgery for ectopic pregnancy.

BACKGROUND: The purpose of this study was to explore the value of preoperative ultrasound and human chorionic gonadotropin (hCG) monitoring to predict the occurrence of residual trophoblastic tissue after laparoscopic conservative surgery for tubal pregnancy. METHODS: During the period from January 1998 to December 1999 all 206 women undergoing treatment for ectopic pregnancy at the Karolinska hospital were included in the study. A vaginal ultrasound examination was performed and the ectopic size was measured. Serum-hCG levels were recorded preoperatively, and at days 1-2 and 14-21 after surgery. RESULTS: A diameter of 8 mm or less was observed in 13 of the 14 patients needing secondary treatment. The risk of second surgery if the finding at the preoperative ultrasound was larger than 8 mm was 1/73 resulting in a negative predictive value of 0.01. A considerable overlap in the hCG levels was found on days 1-2 after surgery between women with and without second surgery. CONCLUSIONS: Using a single cutoff point for hCG seems to be of little value as residual trophoblastic tissue can manifest itself at different times--early or late--during the postoperative period. Women with a small ectopic pregnancy as detected by preoperative vaginal ultrasound are at high risk of developing residual trophoblastic tissue. These patients should be considered by the surgeon and monitored with hCG levels until values decline and become undetectable. Management of patients with slowly but declining values can be conservative. If hCG levels are rising or do not decline, methotrexate (MTX) can be an alternative.

Human chorionic gonadotropin level as a predictor of trophoblastic infiltration into the tubal wall in ectopic pregnancy: a blinded study.

OBJECTIVE: To determine the relationship between gestational age, tubal ultrasonographic diameter, and serum hCG levels and different stages of trophoblastic infiltration of the tubal wall in ectopic pregnancy. DESIGN: Blinded prospective study. SETTING: University-based clinic in Italy. PATIENT(S): Thirty-seven consecutive patients with an ampullary ectopic pregnancy. INTERVENTION(S): Laparoscopic salpingectomy. MAIN OUTCOME MEASURE(S): Gestational age, diameter of the tubal mass as determined by transvaginal ultrasonography. and hCG level on the day of surgery. Ectopic pregnancy was classified according to the depth of trophoblastic infiltration: trophoblast limited to the tubal mucosa (stage I), extension to the tubal muscularis (stage II), or complete tubal wall infiltration up to the serosa discontinued by trophoblastic cells (stage III). RESULT(S): Fifteen patients (40.5%) had stage I tubal infiltration, 14 (37.8%) had stage II infiltration, and 8 (21.6%) had stage III infiltration. Gestational age and diameter of the tube did not differ among the three groups. The median hCG level was 1,710.5 mIU/mL (range, 113-5,635 mIU/mL) for patients with stage I infiltration. 4,690.0 mIU/mL (range, 150-21,531 mIU/mL) for patients with stage II infiltration, and 15,700.0 mIU/mL (range, 13,809-21,650 mIU/mL) for patients with stage III infiltration. All the patients with hCG levels > 6,000 mIU/mL had stage II or III invasion. CONCLUSION(S): These findings may explain why the conservative treatment of ectopic pregnancy is less successful in patients with high hCG levels than in patients with low levels. Use of radical procedures may be justified in the former group.

Implantation despite an extensive endometrial defect after hysteroscopic resection of symptom-free residual trophoblastic tissue 15 months after cesarean section.

Successful implantation occurred after embryo transfer in the presence of an extensive endometrial defect after hysteroscopic resection of residual trophoblastic tissue 15 months after cesarean section. At the end of hysteroscopic surgery the anterior uterine wall seemed smooth, although ultimately no endometrium was left in that part and in parts of the fundus. Thus implantation is possible even with extensive endometrial defects. Interesting facts in this case were, first, the long symptom-free period with residual trophoblastic tissue in the uterus, and, second, successful implantation, pregnancy, and delivery despite at least 30% of endometrial surface being irreversibly destroyed. We suggest hysteroscopic resection as the method of choice for exact and minimally traumatic removal of especially older residual trophoblastic tissue.

Sonohysterography for the diagnosis of residual trophoblastic tissue.

OBJECTIVE: To assess the efficacy, safety, and associated complications of sonohysterography for the diagnosis of residual trophoblastic tissue. METHODS: We conducted a prospective study of 23 consecutive patients admitted to our ultrasonography unit with clinical and ultrasonographic signs of retained intrauterine tissue. RESULTS: Twelve patients had hydrosonographic features suggestive of residual trophoblastic tissue (i.e., an intrauterine lesion not detachable from the uterine wall after instillation of saline), whereas in 11 cases the hydrosonographic findings were negative for retained tissue. Blood flow was detected within abnormal intrauterine masses in 4 of 12 patients with trophoblastic tissue, whereas it was not detected in any patient without retained tissue (P = .093). No complications were encountered during the procedure or the postprocedure period. None of the patients had anesthetic complications, perforation of the uterus, fluid overload, or any other surgical complication. All 12 patients underwent hysteroscopic removal of the suspected residual trophoblastic tissue, and histologic confirmation of residual trophoblastic tissue was obtained in all cases. CONCLUSIONS: Sonohysterography for detection and diagnosis of residual trophoblastic tissue is an accurate and safe procedure. Further studies comparing the efficacy of sonohysterography with that of diagnostic hysteroscopy are warranted.

Is trophoblastic thickness at the embryonic implantation site a new sign of negative evolution in first trimester pregnancy?

In this study a new sign to evaluate the evolution of pregnancy is described: the trophoblastic thickness at the embryonic implantation site. A prospective, observational study of 592 normal pregnancies with no known risk factors was carried out from January 1998 to February 1999. Serial ultrasound scans were performed from week 5 to week 12 of pregnancy. Trophoblastic thickness was measured at the embryonic implantation site to determine the significance of a difference in gestational age in weeks and a trophoblastic thickness of >/=3 mm in predicting poor prognosis in pregnancy outcome. The sensitivity of this sign in the prediction of spontaneous abortion was 82%, the specificity was 93%, the positive predictive value was 63% and the negative predictive value was 97%.

[Diagnosis of an ectopic pregnancy on a cesarean scar]. / Diagnostic d'une grossesse ectopique sur cicatrice de césarienne.

We report the diagnostic and therapeutic debate raised by an ectopic pregnancy on a cesarean scar. There were three phases. The first was to differentiate between an ongoing abortion and an ectopic pregnancy on a cesarean scar. The second was to determine whether the tissue was a mass of persistent trophoblasts or an invasive mole. Finally to determine the nature of a residual mass after chemotherapy and normalization of the beta CG level.

Transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler to detect residual trophoblastic tissue.

The value of transvaginal B-mode ultrasonography combined with color velocity imaging and pulsed Doppler to detect retained trophoblastic tissue was evaluated prospectively in a series of 40 patients with postpartum (n = 15) or postabortion (n = 25) bleeding. Color velocity imaging was used to identify color-coded blood flow signals within myometrium and/or endometrium. Flow was subjectively quantified as absent, scanty or abundant. Pulsed Doppler was used to assess blood flow impedance by calculating the resistance index. The presence of abundant flow with a lowest resistance index of less than 0.45 was considered as suspicious of residual trophoblastic tissue. Twenty-two (55%) out of the 40 patients underwent dilatation and curettage and chorionic villi were demonstrated in 15 of these. Eighteen (45%) patients were managed conservatively. None of these patients suffered complications or needed readmission for curettage, and all of them were considered as not having retained tissue. On color pulsed Doppler ultrasound examination, 15 patients had suspected retained tissue; all of these underwent curettage and residual trophoblast was found in 14 (93.3%). Out of 25 patients considered as having no residual tissue on color pulsed Doppler ultrasound examination, seven underwent curettage and chorionic villi were found in one patient (false-negative rate 6.7%) All patients managed conservatively had an unsuspicious scan. We concluded that transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler could be useful to detect retained trophoblastic tissue and to select patients suitable for conservative management.

Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively.

We report two cases of cervical pregnancy which were diagnosed by ultrasound at 5 and 8 weeks' gestation. In both cases a gestational sac was visualized below the internal os and color Doppler examination demonstrated peritrophoblastic blood flow characteristic of early implantation. Both patients were successfully treated with systemic methotrexate. Including these two cases, a total of 83 early cervical pregnancies have been reported in the literature over the last 10 years. Of these, 40 patients were primarily treated by conservative surgery, 40 by non-surgical methods using methotrexate or potassium chloride, and the remaining three by other chemotherapeutic agents. The likelihood of being cured was similar in the surgical and non-surgical groups (odds ratio 1.1; 95% confidence interval 0.4-3.2). However, patients who were primarily treated by surgery were more likely to sustain major hemorrhage (odds ratio 8.0; 95% confidence interval 2.4-26.5) and to require hysterectomy (odds ratio 7.4; 95% confidence interval 0.9-63.8) than those treated medically. This indicates that non-surgical methods should be used for primary treatment of cervical pregnancy, while surgery should be reserved for those patients in whom medical therapy is not successful.

The reliability of transvaginal ultrasonography to detect retained tissue after spontaneous first-trimester abortion, clinically thought to be complete.

In order to assess the reliability of transvaginal ultrasonography for the detection of trophoblastic tissue retained after spontaneous first-trimester abortion and clinically thought to be complete, the clinical, sonographic and pathological data of 33 women were retrospectively analyzed. The patients' mean age was 34 years (range 24-48). The mean gestational age at presentation of symptoms was 8 weeks (range 5.1-11.1). Transvaginal sonography showed that in 18 cases retained tissue was absent, and that in 15 patients, retained trophoblastic tissue was suspected. Pathological reports (following dilatation and curettage) confirmed the absence of retained tissue in 17 cases and demonstrated its presence in 16 patients (13 in whom retained tissue was suspected by sonography and three in whom retained tissue was not suspected). Sensitivity, specificity, positive predictive value and negative predictive value in our series were 81%, 94%, 93% and 83%, respectively for the detection of retained trophoblastic tissue. We conclude that transvaginal ultrasonography is a reliable method to detect the presence of retained trophoblastic tissue following spontaneous first-trimester abortion, clinically thought to be complete.

[Utero-trophoblastic interface: transitory stage in human placentation]. / L'interface utérotrophoblastique: étape transitoire de la placentation humaine.

In the past, the intervillous space of the human placenta has been studied on samples provided by spontaneous abortions. Using the endocavitary ultrasonography and the chorionoscopy in normal pregnancies, the intervillous space during the first trimester has been observed as filled by a plasmatic fraction cell free of the maternal blood. During the first trimester, the human placenta doesn't have its theoretical functional specificities.

[Blood flow measurements of neovascularization in tubal pregnancy]. / Blutflussmessungen von Neovaskularisationen bei Tubargravidität.

In a retrospective study the results of vagino- and colour flow Doppler sonography of 23 tubal pregnancies verified by surgery were documented. Due to the neovascularisation in the trophoblast tissue the vascular impedance was elevated in all cases. The mean value of all pulsatility indices was 0.85 +/- 0.2. The direct signs of tubal pregnancy were seen in only 20 cases with vaginosonography alone. The combination of vagino- and colour flow Doppler sonography offers the chance of an earlier detection (5th week of pregnancy) of a tubal pregnancy.

Transvaginal duplex Doppler ultrasonography in bleeding patients suspected of having residual trophoblastic tissue.

OBJECTIVE: To evaluate the diagnostic accuracy and clinical usefulness of high-resolution transvaginal duplex Doppler ultrasound in postpartum and post-abortion patients with excessive hemorrhage who are suspected of having residual trophoblast. METHODS: Forty-eight women with excessive hemorrhage referred for possible residual trophoblastic tissue were evaluated by transvaginal duplex Doppler ultrasonography. Based on two-dimensional imaging, the patients were divided prospectively into groups: women who had an empty uterus with a normal uterine cavity, those with a pure endometrial fluid collection and no echogenic foci, those who had a mixed endometrial fluid collection with foci of echogenicity, and those with intracavitary heterogeneous material with mixed echo patterns of fluid and solid components. In each group, Doppler studies were performed and the resistance index (RI) was calculated. The two-dimensional patterns and Doppler results were correlated with clinical and pathologic follow-up. RESULTS: Twenty-eight subjects had a normal uterine cavity and seven had a pure endometrial fluid collection; all were treated conservatively and none showed later clinical evidence of residual trophoblastic tissue. In 13 women, residual trophoblast was strongly suggested from the images of two-dimensional ultrasonography: Five showed an endometrial fluid collection with some echogenic foci, and eight exhibited intracavitary mixed echogenic material. All underwent curettage, and residual trophoblastic tissue was found in ten of the 13. The mean (+/- standard deviation) RI to flow in the myometrial arteries was 0.54 +/- 0.15 in women without residual trophoblast and 0.35 +/- 0.1 in those with residual trophoblastic tissue (P < .01). CONCLUSION: Our experience suggests that transvaginal duplex Doppler ultrasonography is an effective noninvasive method for evaluating patients with excessive postpartum and post-abortion hemorrhage who are suspected of having residual trophoblastic tissue. Its use enhances the positive preoperative diagnosis of residual trophoblastic tissue and may reduce unnecessary curettage procedures.

Empty gestational sacs diagnosed by abdominal real-time ultrasonography.

310 patients with threatened abortion were examined by ultrasound. 86 cases showed empty gestational sacs of which 14 (16%) completed their pregnancy. All sacs were evaluated (and scored) with respect to size, shape, wall definition, trophoblastic reaction and position inside the uterus. Prediction of a non-viable pregnancy from a single ultrasound examination was achieved in some cases. However, this prediction could not be made in other cases before a follow-up ultrasound examination was performed. The proposed scoring system proved to be very helpful in identifying empty gestational sacs in which serial ultrasound examinations are highly required before termination of pregnancy.

Ectopic pregnancy: transvaginal color Doppler of trophoblastic flow in questionable adnexa.

The purpose of this study was to see if color flow Doppler measurements could aid in the positive diagnosis of ectopic pregnancy when no gestational sac can be seen in the adnexa. We examined 148 women with abdominal pain and suspected ectopic pregnancy by abdominal ultrasonography, followed by vaginal ultrasonography and color Doppler when the diagnosis was still uncertain. Seventy-three patients proved to have ectopic pregnancies. Color flow with low resistance and high velocity vascular signals were observed in complex adnexal masses and in some of the corpora lutea. The resistance index for ectopic trophoblast was 0.36 +/- 0.02 SD. Color Doppler had both positive and negative discrimination of adnexal masses (P = 10(-15). The resistance index for the corpora lutea was 0.48 +/- 0.04. A cutoff value of 0.40 or less is proposed as a diagnostic index for suspected trophoblast in the adnexa. In nine cases of ectopic pregnancy, no color flow was noted. In these women, the beta-human chorionic gonadotropin level was less than 1000 mIU/ml. The clinical operative suspicion in these cases was tubal abortion. Sensitivity and specificity were 88% and 97%, respectively, in this highly selective series. Positive and negative predictive values were 97% and 89%. Color Doppler appears to be useful for the positive diagnosis of ectopic pregnancy with ultrasonography when no adnexal gestational sac is observed. Prospective randomized trials will determine the ultimate clinical value of these findings.