Three-dimensional ultrasound radiance mode imaging of a uterine lipoleiomyoma.

In this case report the diagnosis of a uterine lipoleiomyoma is depicted by means of a three-dimensional radiance mode. The advent of radiance or silhouette mode as a new tool in ultrasound diagnosis is intended to assist by generating additional realistic image visualization and a better distinction among different tissues.

Septo uterino completo acompañado de doble cérvix y tabique vaginal / Complete septate uterus with double cervix and septate vagina

El objetivo del siguiente trabajo consiste en presentar a 2 pacientes con las mismas alteraciones en el sistema genital que no se incluyen en la clasificación clásica de las malformaciones müllerianas debido a que presentan estas alteraciones de manera combinada. El correcto diagnóstico de las mismas es fundamental para un manejo adecuado, ya que en estos 2 casos saber que las pacientes tienen un útero septo completo con doble cuello y tabique vaginal nos permitirá realizar la resección del septo uterino y del tabique vaginal respetando el cuello, y así favorecer su pronóstico ginecológico y obstétrico (AU)

The aim of this study was to present two patients with the same alterations in their genital system. These alterations are not included in the classical classification of Müllerian malformations because of their co-occurrence. An accurate diagnosis is essential for correct management, because the identification of septate uterus with double cervix and septate vagina in these two patients will allow us to resect the two septa, leaving the cervix intact, thus improving gynecological and obstetric symptoms (AU)

HDlive 3D ultrasound and follicular development.

Two-dimensional (2D) ultrasonography is the fundamental technology on which diagnosis, management, and control in reproductive medicine depends. Over the years there have been efforts to improve 2D ultrasound image quality. In recent years, a series of software has appeared that has generated enormous interest. The goal of these modes has been to improve image quality and diagnostic accuracy. HDlive incorporates a movable virtual adjustable light source which, as it penetrates, produces selective illumination with respective shadows that result from the structures where light is reflected. This combination of light and shadow results in spectacular images which appear much more real than those obtained with conventional 3D ultrasonography.

Multimodality 3-dimensional volumetric ultrasound in obstetrics and gynecology with an emphasis in HDlive technique.

HDlive (high-definition live or real-time US), a new ultrasound software, combines a movable virtual adjustable light source in a software that calculates the proportion of light reflecting through surface structures, depending on light direction. The light source can be manually positioned to illuminate the desired area of interest. The ultrasound technician can control light intensity to create shadows that enhance image quality. HDlive is an innovation that will render even more realistic images of fetal anatomy and of gynecologic lesions. The full potential of this new technology is yet to be determined and deserves scientific evaluation.

Endometrial receptivity: evaluation with ultrasound.

An adequate endometrial receptivity is a crucial factor for embryo implantation. We describe endometrial morphology (endometrial appearance or pattern, endometrial thickness, volume, and delimitation), based on the concepts and possibilities of the new ultrasound modalities (3-dimensional/4-dimensional ultrasound, automatic volume calculation, virtual organ computer-aided analysis, tomographic ultrasound image, inverse mode, and 3-dimensional Doppler angiography) as markers of endometrial receptivity.

HDlive ultrasound images in assisted reproduction treatment.

The volume ultrasound technology software known as the HDlive technique represents an innovative tool, a step towards an even more realistic anatomical visualization of pelvic organ structures. HDlive can help improve physician-patient communication with the aid of life-like images and might prove useful in the field of assisted reproduction treatment. The clinical application of this novel ultrasound technology in assisted reproduction treatment deserves scientific evaluation.

Alta definición ecográfica en tiempo real (HDLive US) en Obstetricia y Ginecología

Los ultrasonidos de alta definición en tiempo real (HDLive US) incorporan un software que calcula la propagación de la luz a través de superficies y en relación con la dirección de la misma. Esta fuente de luz puede ser posicionada libremente con el fin de iluminar las áreas de interés deseadas, permitiendo así imágenes de mejor calidad, una mayor sensación de profundidad y una visión más sencilla de superficies fetales. Mostramos casos de embriones y fetos normales, así como algunas malformaciones para señalar las posibilidades de esta nueva tecnología. El auténtico potencial de esta nueva tecnología esta aún por revelar. La HDLive representa, en nuestra opinión, una verdadera innovación y un paso más hacia una visión anatómica mucho más realista de estructuras normales y patológicas fetales.

High definition real time ultrasound (HDLive US) incorporates software that calculates the propagation of light through surface structures in relation to light direction. This light source can be freely positioned in order to illuminate the desired area of interest allowing better image quality, better sensation of deepness and easier visualization of fetal surfaces. Cases of normal embryos, fetuses and common fetal malformations are shown. The full potential of this new technology is still to be revealed. HDlive represents, in our opinion, an innovative tool and a step towards an even more realistic anatomical visualization of normal and malformed fetuses.

Valores de hormona antimülleriana (HAM) y recuento de folículos antrales (RFA) en casos con fallo reproductivo previo / Anti-Müllerian hormone values and antral follicle count in patients with prior reproductive failure

Objetivo. Determinar si la HAM y el RFA pueden emplearse para predecir reserva ovárica. Sujetos y métodos. Se compara el RFA y los valores de la HAM en FIV/ICSI: bajas, normo y altas respondedoras, las primeras con fallos de TRA previos (un FIV/ICSI). El RFA se llevó a cabo con US 3D con modos superficie, inverso y AVC. Resultados. Existió correlación entre HAM y RFA. Ambos reflejan la reserva ovárica. Las diferencias entre normo y bajas respondedoras fueron significativas. RFA, HAM y edad mostraron ser los mejores parámetros. Las diferencias entre normo y altas respondedoras fueron igualmente significativas, mostrando ser predictivos de hiperestimulación. El grupo de número de ovocitos recuperados (<=5 vs >5) mostró ser predictivo de maduración, no de calidad embrionaria ni de pronóstico reproductivo. Conclusiones. La determinación de HAM y RFA no permite negar un nuevo intento FIV, pero obligan a informar a la pareja de las bajas probabilidades de éxito. Valores de HAM y RFA superiores a 27,21pmol/L y 15 folículos son riesgo de hiperestimulación. El pronóstico reproductivo muestra alto índice de cancelaciones (22% de ciclos iniciados) muy bajo de gestaciones (16,7%), con solo un 6,2% de embarazos evolutivos. Valores bajos de HAM (<9,28pmol/L) predicen mal pronóstico con un 72,7 y 64,5% de sensibilidad y especificidad. La mejor aproximación predictiva es la combinación HAM más RFA, con un área bajo la curva de 82% (AU)

Objective. To determine whether anti-Müllerian hormone (AMH) and antral follicle count (AFC) could be used as predictors of ovarian reserve. Subjects and methods. We compared AFC and AMH values in IVF/ICSI in low, normal and high responders. Low responders had undergone previous assisted reproduction technologies (ART) and had experienced at least one IVF failure.AFC was carried out with US 3D surface, inverse mode, and automatic volume calculation. Results. AMH and AFC were correlated and reflected the actual ovarian reserve. Differences between normal and low responders were significant. The best predictors of ovarian reserve were AMH, AFC and age. Differences between normal and high responders were also significant and were predictors of hyperstimulation. Grouping patients according to oocyte recovery (<= vs. >5) was predictive of maturation but was not predictive of embryo quality or reproductive outcome. Conclusions. Low AMH values (<9.28pmol/L) predicted poor outcomes with a sensitivity and specificity of 72.7% and 64.5%. The best predictive approach was the combination of AMH plus AFC, resulting in an area under the curve of 82.2%. AMH and AFC above 27.21pmol/L and 15 follicles indicated a high risk of hyperstimulation. The reproductive outcome showed a very high cancelation rate (22% of initiated cycles), very low pregnancy rates (16.7%) and only 6.2% of ongoing pregnancies. Determination of AMH and AFC levels should not be used to reject candidates for IVF treatment but to inform patients with low levels of the very poor probability of success and the use of other alternatives (AU)

Gestación heterotópica en un embarazo espontáneo / Heterotopic pregnancy in a spontaneous pregnancy

La gestación heterotópica es aquella en la que coexisten gestación intra y extrauterina. La incidencia es baja en embarazos espontáneos, aumentando con técnicas de reproducción asistida; por tanto, su diagnóstico precisa un alto índice de sospecha. Presentamos el caso clínico de una primigesta de 34 años, sin antecedentes, con gestación actual espontánea, que consultó por spotting e hipogastralgia. En la ecografía se objetivaron un saco gestacional intrauterino y una masa anexial izquierda compatible con gestación ectópica. Tras la sospecha de gestación heterotópica se realizó una salpingectomía laparoscópica y un legrado evacuador de la gestación intrauterina detenida. La anatomía patológica confirmó el diagnóstico (AU)

Heterotopic pregnancy consists of simultaneous intra and extrauterine pregnancy. The incidence is low in spontaneous pregnancies, but these pregnancies are more common when assisted reproductive technologies are used; therefore, diagnosis requires a high index of suspicion. We report the case of a 34-year-old woman with no history of interest and a spontaneous pregnancy, who presented with spotting and hypogastralgia. An ultrasound scan showed an intrauterine gestational sac and left adnexal mass consistent with ectopic pregnancy. As a heterotopic pregnancy was suspected, laparoscopic salpingectomy and curettage of the miscarriage were performed. Pathological analysis confirmed the diagnosis (AU)

Síndrome de Ogilvie: una complicación poscesárea / Ogilvie's syndrome, a caesarean complication

El síndrome de Ogilvie es una seudoobstrucción aguda de colón en ausencia de obstrucción mecánica, se trata típicamente de una complicación que aparece tras cirugías, sobretodo de cadera y cesáreas. Es de difícil diagnóstico, sobre todo por tener clínica similar al íleo paralítico, aunque con una gravedad muy superior. Sus complicaciones por excelencia son la isquemia y la perforación, que cuando se establecen pueden tener una mortalidad de hasta el 50%. Se trata de un caso con evolución tórpida poscesárea y que, a pesar del tratamiento médico, se complicó con perforación de ciego, acabando en una hemicolectomía derecha (AU)

Ogilvie's syndrome is acute colonic pseudo-obstruction without mechanical obstruction, is a tipical complication of caesareas and hips surgery. It is difficult to diagnose, mainly, by having clinic similar to paralytic ileus, but with a much higher gravity. Its complications are ischemia and perforation, which can have when establishing a mortality rate of up to 50%. This is a case with bad evolution after caesarea and that despite the medical treatment is complicated with cecal perforation, finishing in a right hemicolectomy (AU)

Fetal megacystis: differential diagnosis.

The purpose of our retrospective observational series was to determine whether the sonographic characteristics of fetal megacystic bladders can be used to reliably establish the most likely diagnosis in fetuses with this condition. The sonographic records of pregnant patients referred to our institutions over a 10-year period who were found on initial 2-dimensional sonography to be carrying fetuses with megacystis were examined for evidence of a keyhole sign, bladder thickness, amniotic fluid index, and fetal sex. When available, 3-/4-dimensional sonography, Doppler angiography, tomographic ultrasound imaging, virtual organ computer-aided analysis, and automatic volume calculation were used as part of the detailed fetal anatomic survey. Twenty fetuses with megacystis were identified. Seventeen were male; 2 were female; and 1 had ambiguous genitalia. All male fetuses with megacystis originally had a diagnosis of prune belly syndrome. The diagnosis for 10 male fetuses with a keyhole sign was changed to megacystis secondary to posterior urethral valves. The fetus with ambiguous genitalia had prune belly syndrome. One of the female fetuses had a diagnosis of urethral atresia, and the diagnosis for the other female fetus was megacystis-microcolon-intestinal hypoperistalsis syndrome. In conclusion, in fetuses with megacystic bladders, it is possible to distinguish between cases with prune belly syndrome, posterior urethral valves, urethral atresia, and megacystis-microcolon-intestinal hypoperistalsis syndrome by a detailed anatomic survey using 2- and 3-/4-dimensioinal sonographic techniques.

Umbilical cord cysts: evaluation with different 3-dimensional sonographic modes.

OBJECTIVE: The purpose of this series was to determine whether the use of different 3-dimensional (3D) sonographic modes allows better definition of umbilical cord cysts and pseudocysts in utero. METHODS: Two cases of umbilical cord cysts and 1 of a pseudocyst were analyzed and compared with 2-dimensional (2D), 3D, angiopower Doppler, tomographic ultrasound imaging (TUI), virtual organ computer-aided analysis (VOCAL), and automatic volume calculation (AVC) sonographic modes. All cases were followed during pregnancy. A karyotype analysis was also obtained. RESULTS: Three-dimensional sonography, TUI, and VOCAL allowed clear visualization and evaluation of the sizes, locations, and numbers of umbilical cord cysts. A clear differentiation between a pseudocyst and the yolk sac was obtained with AVC and angiopower Doppler sonography. The 3D sonographic surface mode allowed better visualization of other accompanying fetal malformations. CONCLUSIONS: Three-dimensional sonography allows for a more accurate diagnosis and provides a clearer visualization of malformations than 2D imaging. Cysts and pseudocysts can be defined much more accurately by using the different modes described here.

La malformación arteriovenosa uterina. Una lesión más frecuente y grave de lo sospechado / Uterine arteriovenous malformation: a more common and serious condition than suspected

Introducción: La malformación arteriovenosa uterina es una patología de presentación más frecuente de lo relatado y de consecuencias, en algunos casos, muy severas. Material y método: Se describen 8 casos. Resultados y discusión: La malformación arteriovenosa uterina; de origen congénito, infrecuente, o secundario a procesos obstétricos, se caracteriza por la presencia de un ovillo vascular, formado por dilataciones arteriovenosas, de localización intramiometrial que se extiende, solo en los casos congénitos, a otras zonas vasculares de la pelvis menor. Cursa siempre con un evento hemorrágico intenso. El diagnóstico es ecográfico Doppler y confirmación con angiografía. Es condición "sine qua non" una Beta-hCG negativa o su negativización previa. El tratamiento hoy recomendado es la embolización. Se describen los avances en el diagnóstico y tratamiento en base a 8 casos propios (AU)

Introduction: Uterine arteriovenous malformation (AVM) is more common than it is reported to be and is a potentially life-threatening condition often secondary to uterine trauma or pregnancy. Congenital origin is also reported but is less common. Material and methods: Eight cases are described. Results and discussion: AVM is characterised by the presence of an intra-myometrial arteriovenous skein. Congenital cases may extend to vascular zones of the minor pelvis and/or other organs. The onset of AVMs is usually severe bleeding. Doppler ultrasound is the first diagnosis approach, but, angiography remains the gold standard for diagnostic evaluation. A previous negative pregnancy test is a “sine qua non” condition. Embolization is the more acceptable form of treatment. The therapeutic advances in their diagnosis and treatment are described, based on 8 personal cases (AU)

Embarazo ectópico intersticial: tratamiento laparoscópico / Interstitial ectopic pregnancy: laparoscopic treatment

El embarazo ectópico intersticial es una entidad rara, que representa el 2-4% de los embarazos ectópicos. Es de difícil diagnóstico tanto por su ubicación como por su rareza. El tratamiento de elección es la laparoscopia.Presentamos un caso de embarazo ectópico intersticial en el que la laparoscópia nos sirvió tanto de diagnóstico como de tratamiento (AU)

The interstitial ectopic pregnancy is a rare condition, accounting for 2-4% of all ectopic pregnancies. It is difficult to diagnose both for its location and for its rarity. The treatment of choice is laparoscopic management. We present a case of interstitial ectopic pregnancy in which laparoscopy was useful in two ways, as a diagnostic tool and for its treatment (AU)

Estudio de la torsión ovárica fetal intrauterina mediante ecografía 3D / Study of the intrauterine fetal ovarian torsion by 3D echography

Los quistes ováricos fetales son la causa más frecuente de masa quística intraabdominal diagnosticada prenatalmente, con una incidencia en torno al 30 por ciento. Normalmente son un hallazgo casual en una ecografía de rutina y no se encuentran anomalías asociadas. Pueden resolverse espontáneamente o presentar complicaciones como rotura del quiste, hemorragia intraquística y torsión ovárica. Las diferentes opciones de tratamiento incluyen el manejo conservador, la punción con aspiración del quiste antenatal o neonatal o la quistectomía laparoscópica o por laparotomía. Tras su diagnóstico se recomiendan estudios ecográficos seriados, donde nos será de utilidad la ecografía 3D, ya que esta modalidad de ecografía nos permitirá reconstruir en tres planos el aparato reproductor femenino y estudiar con detalle numerosas patologías tanto uterinas como anexiales. Su uso en combinación con la ecografía Doppler mejora sustancialmente el diagnóstico precoz de las tumoraciones ginecológicas.

Fetal ovarian cysts are the most common cause of prenatally diagnosed intra-abdominal cystic mass, with an incidence around 30 percent. They are usually an incidental finding on a routine ultrasound and anomalies are not associated. They may be resolved spontaneously or lead to complications such as cyst rupture, intracystic hemorrhage and ovarian torsión. Treatment options include conservative management, antenatal or neonatal cyst aspiration, laparoscopic cystectomy and laparotomy. Afterthe diagnosis, serial ultrasound studies are recommended, 3D ultrasound will be useful for us, since this form of ultrasound allows us to reconstruct in three planes the female reproductive system and study in detail a number of both uterine and adnexal pathology. Its use in combination with Doppler ultrasonography improves significantly the early diagnosis of gynecologic tumors.

Reducing blood loss at myomectomy with use of a gelatin-thrombin matrix hemostatic sealant.

OBJECTIVE: To evaluate the hemostatic efficacy and handling of gelatin-thrombin matrix in abdominal myomectomy. DESIGN: Prospective and randomized trial. SETTING: University teaching hospital. PATIENT(S): Women (n = 50) with uterine fibroids with a uterine size equivalent to > or =16 weeks gestation. INTERVENTION(S): Gelatin-thrombin matrix (FloSeal Matrix; Baxter Healthcare Corp., Fremont, CA) was delivered to the site of the uterine bleeding during myomectomy. MAIN OUTCOME MEASURE(S): Patient age, parity, number of myomas, operative time, blood loss, transfusion, intraoperative and postoperative complications, and length of hospitalization were evaluated. RESULT(S): The average blood loss during surgery was 80 +/- 25.5 mL for the FloSeal group and 625 +/- 120.5 mL for the control group. Intraoperative blood transfusion was necessary in five patients from the control group. Postoperative blood loss was 25 +/- 5 mL for the FloSeal group and 250 +/- 75 mL for the control group. Length of the postoperative hospital stay was 2.5 +/- 1.2 days for FloSeal group and 4.5 +/- 1.3 for the control group. No major immediate or delayed complications were observed in either group. CONCLUSION(S): Reductions in hemorrhage in FloSeal-treated women undergoing a myomectomy are encouraging, and provide evidence for the ability of gelatin-thrombin matrix to reduce blood loss when applied immediately and directly to bleeding uterine tissue.

Expression of vascular endothelial growth factor receptors in the endometrium of septate uterus.

OBJECTIVE: To compare the messenger RNA (mRNA) expression of vascular endothelial growth factor (VEGF) receptors (KDR, Flt-1, and sflt) in the different endometrial locations of septate uterus and normal uterus. DESIGN: Prospective, observational study. SETTING: University teaching hospital. PATIENT(S): Twelve women with complete septate uterus undergoing hysteroscopic metroplasty and 12 women with normal uterus. INTERVENTION(S): Endometrial tissue samples were obtained from the endometrium covering the septum and the endometrium lining the lateral wall of the uterus. Moreover, endometrial samples were obtained from patients with normal uterus. MAIN OUTCOME MEASURE(S): Differences in the mRNA expression of VEGF receptors between the endometrial samples of septate and normal uterus. RESULT(S): The mRNA expression of VEGF receptors, both KDR and Flt-1, was significantly lower in the endometrium lining the septum as compared with the endometrium covering the lateral wall of septate and normal uterus. Conversely, no differences were observed in mRNA expression in the soluble receptor sflt between the different endometrial samples studied. CONCLUSION(S): The results suggest that a local defect of both VEGF transmembranous receptors (KDR and Flt-1) in the endometrium covering the septal area may be responsible for the clinical comportment of this müllerian anomaly.

Cotyledonoid dissecting leiomyoma of the uterus.

We describe a cotyledonoid dissecting leiomyoma in a 33-year-old nulliparous woman treated by laparoscopy.

Tumor de Brenner bilateral benigno / Bilateral benign Brenner tumor

El tumor de Brenner es un tumor raro que representa aproximadamente el 1,5 por ciento de los tumores de ovario. Se define como un tumor de células transicionales compuesto por células uroteliales dispuestas en agregados sólidos o quísticos embebidos en un estroma fibroso. Se clasifica en tumor de Brenner benigno (95 por ciento), borderline (3-4 por ciento) y maligno (1 por ciento). Presentamos el caso clínico de una paciente de 91 años intervenida por una tumoración anexial gigante en la que el estudio anatomopatológico reveló la presencia de un tumor de Brenner bilateral benigno asociado a dos cistoadenomas serosos de ovario derecho.

Brenner's tumor is a rare tumor that represents approximately 1.5 percent of the tumors of ovary. It is defined as a tumor of transitional cells composed by cells uroteliales arranged in solid or cystic acccumulations absorbed in a fibrous estroma. It qualifies in tumor of benign Brenner (95 percent), borderline (3-4 percent) and malignantly (1 percent). We present the clinical case of a 91-year-old patient controlled by a giant anexial mass in whom the pathology study (biopsy) revealed the presence of a tumor of bilateral benign Brenner associated with two cistoadenomas serous of right ovary.