Interstitial pregnancy managed medically. A case report.

BACKGROUND: Interstitial pregnancies are often associated with significant morbidity. The surgical treatment of such ectopic gestations often requires laparotomy and cornual resection, thus obliterating tubal and uterine continuity. Methotrexate has been shown to be 94% successful in the management of tubally implanted ectopic gestations, but few reports describe its use in interstitial pregnancies. CASE: An 18-year-old woman who presented with an asymptomatic interstitial pregnancy was treated successfully with intramuscular methotrexate. Laparotomy and cornual resection were avoided. No adverse effects were noted. CONCLUSION: Interstitial pregnancies can be treated successfully with intramuscular methotrexate.

The chorionic rim and low-impedance intrauterine arterial flow in the diagnosis of early intrauterine pregnancy: evaluation of efficacy.

OBJECTIVE: We undertook this study to evaluate whether sonographic imaging of an intrauterine chorionic rim or arterial flow can help diagnose an early intrauterine pregnancy. MATERIALS AND METHODS: One hundred sixty-nine women with early intrauterine pregnancies and 69 women with ectopic pregnancies underwent pelvic sonography. All sonograms were examined for a chorionic rim (an echogenic rim bordering an intrauterine fluid collection) or a double decidual sac. Of these 238 patients, 126 also underwent Doppler examination for endometrial arterial flow. RESULTS: The chorionic rim and double decidual sac had sensitivities for intrauterine pregnancy of 80% and 64%, respectively, and specificities of 97% and 100%, respectively. Intrauterine arterial flow with either peak systolic velocity greater than or equal to 15 cm/sec or resistive index less than or equal to 0.55 had a sensitivity of 70% and a specificity of 95%, Combining these two signs led to sensitivities and specificities of approximately 90%. Similar test performance was observed in patients having intrauterine pregnancies that lacked an embryo, yolk sac, or amniotic remnant. CONCLUSION: The chorionic rim and low-impedance endometrial arterial flow can indicate an intrauterine pregnancy even when the double decidual sac is not seen. These two signs are particularly useful for patients with intrauterine pregnancies that show no other sonographic findings.

Cytomegalic inclusion disease: intrauterine sonographic diagnosis using findings involving the brain.

Two second-trimester cases and one third-trimester case of intrauterine cytomegalic inclusion disease (CID) are presented, each having a different intracranial sonographic presentation. The findings are correlated with radiographic studies and the known pathophysiology. Sonographic evidence of intrauterine cerebral necrosis or calcification should alert one to the possibility of CID, particularly if other signs of in utero infection are present. A pattern of bilateral periventricular calcifications, which may be preceded by hypoechoic periventricular ringlike zones, seems to be specific for intrauterine CID. However, CID also may result in widespread cerebral destruction. If the sonographic study produces an uncertain diagnosis, sonography can still aid in the prenatal diagnosis of CID by guiding percutaneous umbilical cord blood sampling for serology or by directing amniocentesis for cytomegalovirus culture. The ability of sonography to demonstrate specific characteristics of CID in utero enables prenatal diagnosis of this disease.

Tuberculous abscess of the testicle in AIDS: sonographic demonstration.

A patient with acquired immune deficiency syndrome (AIDS) who presented with right testicular swelling is described. Sonography demonstrated diffuse enlargement and inhomogeneity of the testicle with central hypoechoic areas. Testicular abscesses were seen at surgery and Mycobacterium tuberculosis was cultured from the surgical specimen. Tuberculosis should be considered in the differential diagnosis of testicular enlargement or abscess formation in AIDS.

Ultrasound examination of adolescent females with lower abdominal pain.

We evaluated pelvic ultrasound examination in adolescent females as an aid in the diagnosis of acute and chronic lower abdominal pain resulting from suspected gynecologic disease. Of 41 subjects, 35 (85.4%) had a final diagnosis of a gynecologic disorder. Pelvic ultrasound examination was positive in 19 of 35 (54.3%). Ten positive tests had relatively specific findings that supported (seven) or helped change (three) the initial clinical diagnosis. Nine positive tests had nonspecific findings that were consistent with (six) or helped change (three) the initial diagnosis. Twenty-one negative tests helped change the initial diagnosis (13); ruled out complications of acute salpingitis (five); or discriminated between alternative diagnoses (three). One test was falsely positive. Ultrasonography was most clearly cost-effective when surgery was being considered. We conclude that pelvic ultrasound examination may be a useful diagnostic adjunct in this type of adolescent patient.

Correlation of radionuclide and ultrasound studies with biopsy findings for diagnosis of renal transplant rejection.

The diagnosis of early renal transplant rejection is of the utmost importance to the transplant recipient. Unfortunately, such a diagnosis is often extremely difficult to make. In an attempt to clarify this issue we retrospectively evaluated 35 patients with the presenting diagnosis of rejection for the correlation of comparable radionuclide (RN) and ultrasound (US) examinations with biopsy findings. In 21 patients with heavy interstitial mononuclear cell infiltration, 22 of 23 serial RN studies within forty-eight hours of biopsy were positive for rejection. Only 3 of 14 comparable US studies were positive for rejection. When examinations performed within approximately fourteen days were evaluated, 7 of 11 RN studies were positive for rejection, while 2 of 9 comparable US studies were positive for rejection. However, in 14 patients with mild or no interstitial cellular infiltration, only 6 of 13 RN studies were positive, while all 4 US examinations were negative. In the group evaluated at approximately two weeks, 2 of 6 RN studies were positive, while 0 of 5 US studies were positive. We conclude that the serial RN study is more sensitive than US examination for the diagnosis of acute rejection. US, however, proved valuable in the identification of transplant complications (i.e., fluid collections, ascites, and hydronephrosis).

Preliminary experience with a combination of clomiphene and variable dosages of menopausal gonadotropins for enhanced follicular recruitment.

A combination of clomiphene citrate and human menopausal gonadotropin was employed for enhanced follicular recruitment in an in vitro fertilization program. All patients received 50 mg of clomiphene and 1 ampule of human menopausal gonadotropin daily from cycle day 5 through cycle day 9. Follicular monitoring was begun on day 10 using a combination of ultrasound measurement of follicular size and number and determination of peripheral estradiol levels. Based on the size and number of follicles, the peripheral levels of estradiol, and the rate of follicular growth and increase in estradiol, human menopausal gonadotropin was continued at a dosage of 1 to 3 ampules/day through the day of human chorionic gonadotropin administration. Human chorionic gonadotropin was administered on the evening of the day the largest follicle reached or exceeded 20 mm in mean diameter if the estradiol levels had been rapidly rising or reaching a plateau and had exceeded a minimal level of 300 pg/ml. Using this protocol, 30 of 33 patients underwent laparoscopy, 29 patients had successful oocyte recovery, and 23 patients underwent embryo replacement, with the establishment of six clinical pregnancies.

Attenuation estimation in reflection: progress and prospects.

This monograph presents a tutorial review of the current state-of-the-art in ultrasonic attenuation estimation in reflection. Clinical indications which provide the motivation for attempting in vivo attenuation estimation are discussed. Frequency and time domain techniques and their respective tradeoffs and problems are presented. Finally, current clinical results obtained with the various techniques are summarized and further areas of study are suggested.

The attenuation of ultrasound in biological fluids.

We have measured the ultrasonic attenuation parameters alpha o and n of several biological fluids in vitro in the frequency range 2.8-6.8 MHz, using frequency shift and/or a sinc (.) sidelobe ratio technique. The parameters alpha 0 and n describe the frequency-dependent attenuation via a power-law model, i.e., alpha(f) = alpha 0 fn, where f is frequency. The samples investigated were blood, pus, cyst fluid, bile, and infected hematoma. It was found that the values of alpha o span approximately the range between 0.03-0.3 dB cm-1 MHz-n, and values of n range from about 1.1-1.3.

Attenuation of ultrasound in normal liver and diffuse liver disease in vivo.

Preliminary results of in vivo attenuation measurements of the liver have been obtained in 39 normal patients and in 35 patients with diffuse liver disease. A modified real-time sector scanner incorporating an online attenuation measurement method was used. The value of attenuation in normal liver was estimated as 0.52 +/- 0.03 dB/cm/MHz, measured at 3 MHz. Significantly higher attenuation values were obtained from patients with alcoholic and cardiac cirrhosis, and following hepatic artery infusion with chemotherapeutic agents. Lower values were obtained from patients with biliary cirrhosis, chronic active hepatitis, and diffuse infiltration by lymphoma or leukemia. Fatty infiltrated livers showed a wide range of values of 0.37-0.66 dB/cm/MHz. The results suggest that estimates of attenuation coefficients are useful in detecting the presence of diffuse liver disease.

Oral contraceptives, pregnancy, and focal nodular hyperplasia of the liver.

There is uncertainty regarding the role, if any, of oral contraceptive steroids in the development of focal nodular hyperplasia of the liver. In a 36-year-old woman, a large left hepatic lobe tumor developed that was detected after 11 years of using these drugs. The tumor regressed when administration of the drug was stopped but began to increase in size during a subsequent pregnancy. A left hepatic lobectomy during the second trimester disclosed focal nodular hyperplasia. Both contraceptive steroids and pregnancy, with high levels of endogenous sex steroids, favored tumor growth in this patient, suggesting that focal nodular hyperplasia can be steroid related.

Comparison of two clomiphene citrate dosage regimens for follicular recruitment in an in vitro fertilization program.

Clomiphene citrate (CC) (150 mg/day) is used in most clinical in vitro fertilization and embryo transfer (IVF-ET) programs to induce maturation of several preovulatory follicles rather than the one characteristic of the unstimulated cycle. This study examines whether a reduced dosage of CC will induce the maturation of a similar number of follicles. The advantage of the reduced dosage should be a decrease in the dose-dependent antiestrogenic effects of CC. Normally ovulating women undergoing treatment in an IVF-ET program received CC on cycle days 5 to 9. Thirty-six patients received 150 mg/day, and 60 patients received 50 mg/day. There were no significant differences between the groups in the number or the size of follicles as measured by ultrasonography on the day of human chorionic gonadotropin administration. All seven clinical pregnancies were in the 50 mg group (P less than 0.05). These data suggest that there is no advantage to the 150 mg/day dosage of CC as compared with 50 mg/day with respect to enhanced follicular recruitment, and the higher dosage may have a detrimental effect on pregnancy establishment.

Ultrasonic findings in fetal cyclopia. A case report.

The sonographic picture of fetal cyclopia at 33 weeks' gestation consists of a small fetal head, a central cavity replacing the cerebral lateral ventricles, lack of midline structures, absence of hemispheral vascular pattern and hydramnios. In addition, in our case a structure projecting from the fetal face correlated well with the proboscis. This sonographic feature is the clue in differentiating fetal cyclopia from other forms of alobar prosencephaly.

Follicular size and number in human in vitro fertilization.

In an attempt to maximize the success of in vitro fertilization (IVF) and embryo transfer (ET) as a treatment for human infertility, we have examined the relationship of follicular size and number to the rates of oocyte recovery, fertilization, cleavage, and ET in clomiphene citrate-stimulated cycles. The recovery of oocytes from follicles less than 20 mm in diameter was significantly reduced over that from larger follicles, and those oocytes that were obtained from smaller follicles showed a significantly lower rate of fertilization and cleavage. In addition, the overall chance that a patient would undergo ET was greater in a cycle in which more than one follicle 20 mm or larger was developing than in a cycle in which a single large follicle was developing. This latter observation suggests that attempts at laparoscopic oocyte retrieval should be confined to cycles in which more than one accessible large follicle is developing, thereby maximizing the success rate while minimizing the risk and expense for the patient.

Comparison of computed tomography and ultrasound in abdominal staging of renal cancer.

The relative accuracy of computed tomography (CT) and ultrasound in abdominal staging of renal cancer was determined in 22 patients. CT is capable of detecting tumor invasion of perinephric fat and adjacent muscles, which cannot usually be shown by ultrasound. While both CT and ultrasound demonstrate venous and retroperitoneal tumor extension, CT is more reliable since bowel gas not infrequently obscures the retroperitoneum on ultrasonic scanning. However, ultrasound will often provide valuable information; and whenever a solid renal mass is detected by echography using prone scans, abdominal scans should be obtained for staging pruposes.