The impact of individual sonographer variation on the detection of small for gestational age fetuses using a third trimester growth scan.

OBJECTIVES: Detection of small for gestational age (SGA) fetuses in a third trimester ultrasound could be affected by variation in sonographer performance. METHODS: Retrospective analysis of all singleton, non-anomalous ultrasound examinations between 35+0 -36+6 weeks gestation, in a single institution where a universal 36-week scan is offered. Screen positive was defined as estimated fetal weight (EFW) <10th centile; SGA was birthweight <10th centile. Individual sonographers' distributions of head circumference (HC), abdominal circumference (AC) and femur length (FL) were used to assess sonographers' screen positive rate (SPR), detection rate (DR) and true positive rate (TPR). Univariate and multivariate regression analysis was performed to assess the association between the sonographers' mean and SD (SD) for HC, AC, FL and their SPR, DR and TPR. RESULTS: There were 27 sonographers performing more than 50 examinations per year, a total of 5691 scans. The mean incidence of SGA was 10.0%. For an overall SPR of 9.4%, the overall DR was 43.8% (95% CI: 39.6% - 48.1%) and the overall TPR was 46.5% (95% CI: 42.9% - 50.2%). Higher AC scatter (SD difference up to 11.6 mm) was associated with higher SPR (P = 0.001). Lower mean FL (difference up to 3.6 mm) was associated with higher SPR (P = 0.003) and higher DR (P = 0.002). As a result, DR varied amongst different sonographers between 14.3% and 85.7% and TPR varied between 8.3% and 100.0%. CONCLUSIONS: Monitoring of individual AC and FL distributions is a simple and effective tool for institutional quality assurance.

Hysteroscopic management of omentum incarceration secondary to uterine perforation: Case report and review of literature.

Uterine perforation is a potential complication of intrauterine procedures that can be associated with vascular or visceral injury. We report the case of a 35-year-old woman diagnosed with omentum incarceration, secondary to a uterine perforation, during a dilatation and curettage. This rare complication was successfully managed by release of incarcerated omentum hysteroscopically. Sealing of uterine wall defect was achieved by administration of intravenous uterotonic drugs, thus, avoiding a major surgery. In conclusion, this is a novel approach to a case of uterine omental incarceration. To date, there are few cases reported in the literature and only one of them was managed by hysteroscopy. Hysteroscopy alone or combined hysteroscopic and laparoscopic approach when needed, should be attempted in such cases as it is safe and minimally invasive.

Complicaciones postratamiento del prolapso apical: a propósito de un caso / Complications after the treatment of apical prolapse: A case report

Resumen ANTECEDENTES: El prolapso de órganos pélvicos es un problema que puede resolverse con una diversidad de técnicas quirúrgicas según su tipo y características personales de la paciente. CASO CLÍNICO: Paciente de 81 años, originaria de Zaragoza, España, con índice de masa corporal de 41 kg/m2, hipertensión moderada y arritmia cardiaca, en tratamiento con acenocumarol y antihipertensivos de manera crónica. Antecedentes ginecológicos: tres embarazos de término que finalizaron en partos espontáneos, del segundo nació un niño de 4200 g. La paciente acudió a consulta por rectocele, corregido mediante la colocación de un pesario de anillo. El prolapso se complicó con rectoenterocele, que precisó corrección quirúrgica. Como consecuencia de la técnica quirúrgica elegida y por tratarse de una complicación frecuente de la vía de acceso (hematoma de la cúpula vaginal), la paciente sufrió una apertura vaginal a través de la que se hernió contenido intestinal. Después de evaluar el caso se decidió efectuar una nueva corrección quirúrgica que permitiera solucionar, simultáneamente, la hernia a través de la pared vaginal y la recidiva del prolapso apical. Hoy día se encuentra con adecuada evolución (12 meses del procedimiento quirúrgico), asintomática y sin complicaciones aparentes. CONCLUSIÓN: La cirugía del prolapso apical es compleja, debido a su amplia variedad de técnicas quirúrgicas y alto índice de recidiva. Es necesario conocer las diferentes vías de acceso para ofrecer la mejor solución a las pacientes.

Abstract BACKGROUND: Pelvic organ prolapse is a pathology that offers a variety of surgical techniques depending on the type of prolapse and the characteristics of the patient. CLINICAL CASE: Patient of 81 years born in Zaragoza (Spain) with a body mass index of 41kg / m2. It presents moderate hypertension and cardiac arrhythmia in treatment with anticoagulants. Requires treatment with acenocoumarol and antihypertensive in a chronic manner. Among the gynecological antecedents, there are three full-term pregnancies that ended with spontaneous deliveries, the second of them with a birth weight of 4,200gr. In this case, we present an elderly patient who initially presented a rectocele corrected initially using a pessary of the ring. The prolapse evolved presenting a rectoenterocele that required surgical correction. As a consequence of the chosen surgical technique and a frequent complication of the vaginal approach, such as a vaginal cuff hematoma, the patient suffered a vaginal opening through which intestinal contents were herniated. After evaluating the case, a new surgical correction was required that would allow the simultaneous resolution of the hernia through the vaginal wall that presented and the recurrence of the apical prolapse. Today is the right evolution (12 months of the surgical event), asymptomatic and without apparent complications. CONCLUSION: Prolapse surgery is complex due to its wide variety of surgical techniques and its high rate of recurrence. It is necessary to be aware of the different approaches to be able to offer the best solutions to our patients.

Diagnóstico y tratamiento histeroscópico de una paciente posmenopáusica con fístula arteriovenosa uterina / Hysteroscopy diagnosis and management of uterine arterio-venous fistula in a postmenopausal woman

Resumen ANTECEDENTES: La fístula arteriovenosa uterina es una de las malformaciones vasculares más frecuentes. El sangrado vaginal abundante es un signo sugerente de este tipo de alteración. CASO CLÍNICO: Paciente de 51 años, acudió al servicio de Urgencias debido a un sangrado vaginal abundante de un mes de evolución. En la exploración física se objetivaron los genitales externos y la vagina normales, y el útero ligeramente aumentado de tamaño. La ecografía transvaginal con Doppler color solo reportó aumento de la vascularización uterina. La histeroscopia diagnóstica confirmó la coexistencia de una fístula arteriovenosa uterina. La histeroscopia quirúrgica se practicó con espéculo, pinza de Pozzi, dilatación con tallos de Hegar (9'5), coagulación con histeroscopio Storz, asa de Collins, con energía bipolar a 45 watt y suero fisiológico como medio de distensión. La malformación arteriovenosa se coaguló en diversas zonas anatómicas, hasta conseguir la obstrucción completa de la fístula. El posoperatorio trascurrió sin contratiempos. El seguimiento de la paciente fue satisfactorio, hasta la fecha no manifiesta síntomas adicionales de la alteración. CONCLUSIONES: La histeroscopia es un método efectivo, de mínima invasión y con escasa morbilidad para establecer el diagnóstico y tratamiento de las malformaciones vasculares uterinas.

Abstract BACKGROUND: Uterine arterio-venous fistula is one of the most frequent vascular malformations. A heavy vaginal bleeding should make us suspect the presence of this type of vascular malformation. CLINICAL CASE: A 51-years-old patient was admitted in Emergency Service for heavy vaginal bleeding of one month of evolution. On physical examination, external genitalia and vagina were normal but uterus had slightly increased in size. A transvaginal ultrasound with color Doppler was performed where an increase in uterine vascularization was shown. Subsequently, an office hysteroscopy was carried out confirming the diagnosis of uterine arterio-venous fistula. After a correct anesthetic evaluation, a surgical hysteroscopy was performed, using speculum, Pozzi clamp, dilation with Hegar stems up to number 9.5, coagulation resectoscope Storz Gyrus with Collins loop handle with bipolar energy at 45 watt of coagulation and physiological saline, as a means of relaxation. The arterio-venous malformation was coagulated at several levels until the obliteration of the fistula was completed. The postoperative period was favorable. In the subsequent follow-up in consultation, the patient continues asymptomatic. CONCLUSION: Hysteroscopy is an effective, minimally invasive method with low morbidity to establish the diagnosis and treatment of vascular malformations.