A new method for analysis of non-pregnant uterine peristalsis using transvaginal ultrasound.

OBJECTIVES: To develop an objective method for analysis of uterine peristalsis using transvaginal sonography (TVS). METHODS: We performed computerized analysis of 2-5-min video recordings of TVS imaging of a midsagittal cross-section of the uterus during the proliferative and early secretory phases of 18 healthy volunteers aged 28-41 years. The contours of the fluid-endometrial interface (FEI) and the endometrium-myometrium interface (EMI) were detected in each frame, and the data from all frames were used to explore the dynamic motility characteristics of these interfaces at fixed distances from the fundus. RESULTS: The mean ± SD dominant frequency of peristalsis of the EMI along the midsagittal cross-section was 0.049 ± 0.01 Hz and that of the cavity center was 0.043 ± 0.02 Hz. The maximal amplitudes of the EMI were about 1 ± 0.25 mm, located between 7 and 17 mm from the fundus. The amplitudes of the FEI were in the range 0.05-0.2 mm. The amplitude of the cavity centerline movement was 0.94 ± 0.34 mm, located at the extremes of the unperturbed curve. CONCLUSIONS: This study provides a simple tool for analysis of uterine peristalsis characteristics using ultrasound data. This is possible at the EMI even when the FEI is invisible or incomplete, such as during the luteal phase, when an intrauterine contraceptive device is in place, and during diagnostic or medical intervention.

Feto-feto-fetal transfusion syndrome in monozygotic monochorionic triamniotic triplets: vascular evaluation by a cast model.

A unique cast model of the placenta in a rare case of feto-feto-fetal triplet transfusion syndrome (FFFTTS) allowed the demonstration of why the transfusion syndrome developed in one fetus and not in the other two in that single placenta. The vasculature anatomy of a monochorionic triamniotic triplet placenta with FFFTTS of three healthy infants (one donor, two recipients) born in the 35th week of gestation was cast by means of dental casting materials. After the cast hardened, the tissue was corroded, revealing the cast blood vessels. The diameters and lengths of the chorionic blood and intraplacental vessels of the cast placenta were measured with a digital caliper. The cast revealed two artery-artery (A-A) anastomoses on the chorionic plate between the two recipients and the donor. Seven artery-vein (A-V) deep anastomoses connected only the arteries of the donor and the veins of the two recipients. The blood vessel connections among the fetuses allowed the evaluation of a pathologic case with its own control in a single placenta. From the vascular appearance, we speculate that the A-A anastomoses between the two fetuses protected them from developing blood transfusions, but that the A-V anastomoses contributed to their development.

Deflexion of the fetal head in breech presentation. Incidence, management, and outcome.

The deflexion attitude of the fetal head in 223 consecutive breech deliveries was radiologically evaluated and classified into four grades. Additional x-ray pelvimetry was performed on all primiparas (136 cases). Extended (35 cases with deflexion angle of 90 degrees or less) and hyperextended (2 cases with angle of more than 90 degrees) variants were found in 16.4%. In the cases of hyperextension, the patients had elective cesarean section, while in cases of other variants they were delivered vaginally in the absence of other indications to cesarean section. The overall cesarean section rate was 17.5%. No cases of perinatal mortality were recorded. Two hundred and sixteen babies had a 1-minute Apgar score of 7--10, 6 had a score of 4--6, and 1 had a score of 2. Only 1 of the 7 asphyxiated babies was of the group of 35 patients classified as having an extended variant. These favorable results confirm the importance of the radiologic assessment of the deflexion angle as a clinical tool.

Midtrimester placenta previa: normal or pathologic finding.

During the years 1974-1977 ultrasonic placentography demonstrated midtrimester placenta previa (MTPP) in 123 women. The procedure was performed because of vaginal bleeding in 65 cases and prior to amniocentesis in 58 asymptomatic cases. Eighty-eight patients were found to have grade I placenta previa (PP), 12 to have grade II, 14 to have grade III, and 9 patients to have grade IV PP. These different variants of PP were correlated with the ultimate outcome of these pregnancies: Bleeding due to PP or PP at term were reasons for cesarean section in 4 cases of grade I PP, in 2 cases of grade II, in 7 cases of grade III, and in 7 out of 9 cases of grade IV PP. Among those patients who had grades III and IV PP, 13 out of 23 had premature or immature deliveries. These results suggest that finding of MTPP, especially symptomatic MTPP, should alert the physician to the clinical significance of PP later in pregnancy.

Characteristics of uterine peristalsis in spontaneous and induced cycles.

OBJECTIVE: To characterize the dynamics of the intrauterine fluid-wall interface (IUFWI) from in vivo transvaginal ultrasound images by new techniques of image processing of sagittal cross-sections of the uterus, in healthy women with normal cycles and patients treated with clomiphen citrate (CC). DESIGN: Clinical study. SETTING: An ultrasound unit in a large university-affiliated municipal hospital. PATIENT(S): Twenty-five patients with normal spontaneous cycles (group A) and nine patients treated by CC (group B). INTERVENTION(S): Transvaginal ultrasound examinations. MAIN OUTCOME MEASURE(S): Transvaginal ultrasound images were processed to carry out a computational analysis of the resultant IUFWI. RESULT(S): The amplitude and the width of the IUFWI were higher in group B, but the ratio of these measurements was similar in both groups. The frequency of wall motility of group A was lower and its pattern was more symmetrical than that of group B. CONCLUSION(S): The differences in the dynamic characteristics of spontaneous and CC-induced cycles may constitute an additional parameter that should be considered in embryo transport.

Six-year follow-up of children with intrauterine growth retardation: long-term, prospective study.

This prospective study was designed to characterize the neurodevelopmental and cognitive difficulties specific to children with intrauterine growth retardation and to detect early clinical predictors of these difficulties. Eighty-one children with intrauterine growth retardation were monitored up to 6 to 7 years of age using biometric parameters, perinatal risk questionnaires, and detailed neurodevelopmental and cognitive assessments. Forty-one children served as age-matched, appropriate for gestational age controls. A significant difference in growth parameters (P < .001), neurodevelopmental score (P < .05), and IQ (P < .05) was found between the children with intrauterine growth retardation and controls. A specific profile of difficulties in coordination, lateralization, spatial and graphomotor skills, and abundance of associated movements is typical of the children with intrauterine growth retardation and hints at possible later learning disabilities. The clinical parameters best predicting neurodevelopmental outcome were the neonatal risk score (P < .05) and the weight and height at 6 years of age (P < .05). The children with intrauterine growth retardation with neonatal complications had lower neurodevelopmental scores than the controls but no difference in IQ. Intrauterine growth retardation children diagnosed prenatally had the same neurodevelopmental and IQ scores as those diagnosed at birth, probably due to the careful perinatal and obstetric care provided. Children with intrauterine growth retardation demonstrate a specific profile of neurodevelopmental disabilities at preschool age. Early diagnosis and intervention could probably reduce these difficulties to a minimum.

Vascularity index distribution within the testis: a technique for guiding testicular sperm extraction.

Azoospermia is defined as the absence of spermatozoa in the ejaculate, although some foci of spermatogenesis may exist in the testes of these men. Currently, there are no clinical, seminal or hormonal parameters for identifying spermatogenesis within the testis sufficient for achieving genetic offspring. As a result, multiple biopsies are performed at several arbitrary sites of both testes in search of spermatozoa. We developed a power Doppler (PD) ultrasound (US) image-based technique that predicts sites with the greatest potential for spermatogenesis. PDUS images of the testes of azoospermic men were acquired at seven cross-sections to reconstruct a 3-D matrix for constructing a spatial map of preferential regions where spermatozoa are most likely to exist. This technique may obviate the need for arbitrary multiple biopsies that inflict some degree of damage upon testicular tissue, and may increase the success rate of identifying viable spermatozoa in testicular biopsies.

Cystadenofibroma of the ovary in young women.

Cystadenofibroma of the ovary, a relatively rare benign tumor, usually appears during the fourth and fifth decades. This tumor has malignant ultrasonographic features and may also macroscopically appear as malignant during surgery. Since this tumor has a rare malignant potential, it is well-advised to be aware of the possibility of a cystadenofibroma before selecting an aggressive surgical approach in young patients. We present five cases of young patients with cystadenofibromas of the ovary.

Is amniotic fluid volume influenced by a 24-hour fast?

OBJECTIVE: To assess the influence of fasting for 24 hours on the amniotic fluid index (AFI). STUDY DESIGN: The AFI of 22 parturients in the second trimester of uncomplicated pregnancy was evaluated on the morning after a 24-hour fast. Patients were prospectively matched to another group of 25 patients who did not fast. Both groups were reevaluated after one week. Two different observers, blind to each other's results, performed the examinations. RESULTS: A statistically significant difference was found in the AFI between the two groups on the day after fasting (11.73 +/- 2.12 versus 15.4 +/- 1.2, respectively; P < .01). After one week there was no difference in AFI between the two groups (15.35 +/- 1.2 and 15.42 +/- 1.2, respectively; P > .01). CONCLUSION: Fasting may reduce the amniotic fluid volume as shown by the AFI, and fluid intake may restore the normal amount of amniotic fluid volume.

Peristaltic flow in a tapered channel: application to embryo transport within the uterine cavity.

Cyclic uterine peristalsis plays a central role in assisting the transport of sperm to the fallopian tube and later in the conception process in transporting the embryo to a fundal site for implantation. Fulfillment of these essential events within the time limits of fertilization and implantation depends on concomitant intrauterine fluid motion induced by uterine wall motility. A model of wall-induced fluid flow within a finite tapered two-dimensional channel was developed to simulate intrauterine fluid flow pattern and transport phenomena due to symmetric and asymmetric wall displacements. The analysis showed that the transport phenomena are strongly dependent on the phase shift of wall displacement and the angle between the walls. The velocities, flow rates, pressure and the axial transport of massless particles are reduced to zero when contractions are completely out of phase. Cases of reflux and trapping in a tapered channel are discussed for the first time. The reflux phenomenon is most likely to occur when wall motility is asymmetric, especially when the angle between the walls increases, while trapping is enhanced as the asymmetric motility and the angle between the channel walls decrease. The relevance of the results to intrauterine fluid transport phenomena, embryo transfer and hydrosalpinx was explored.

The postnatal management of congenital cystic adenomatoid malformation.

BACKGROUND: Routine prenatal ultrasound has increased the frequency of prenatal diagnosis of congenital cystic lung malformation, such as cystic adenomatoid malformation, pulmonary sequestration, congenital lobar emphysema, and bronchogenic cyst. OBJECTIVES: To evaluate the methods of postnatal diagnosis, the optimal age for operation since surgery is always required, and the optimal extent of lung resection. METHODS: The clinical courses of 11 patients with congenital lung cysts who underwent surgical lung resection (8 lobectomies and 3 segmentectomies) were reviewed. RESULTS: The diagnosis was confirmed by computed tomography scan in all. In nine patients the diagnosis was made prenatally. Chest X-ray was normal postnatally in all patients except for two who had recurrent pneumonia. Postoperative follow-up showed excellent recovery in all operated children. One patient who underwent surgery for CCAM following episodes of severe pneumonia died from another cause 5 months later. Postoperative chest CT scan showed no residual disease in eight patients. In two who had undergone limited resection, tomography showed a small segment of residual disease in one and a suspected residual lesion in the other. CONCLUSION: With prenatal ultrasound the true frequency of congenital cystic lung anomaly appears to be higher than previously reported. Postnatal CT is mandatory to confirm or to rule out the diagnosis. The mere presence of cystic lung malformation is an indication for surgery. Complete removal of the affected lung lobe is recommended. Segmental resection may be inadequate. Early operation is tolerated well by infants and small children and we recommend that surgery be performed in children between 6 and 12 months of age.

The effect of intrauterine growth restriction on the development and health of children.

The neurodevelopmental and cognitive outcome of long-term Intrauterine Growth Restriction (IUGR) has been followed up from pregnancy to school age at the Tel Aviv Child Development Centre.

In vitro simulation of placental transport: part II. Glucose transfer across the placental barrier model.

INTRODUCTION: In utero fetal development and fetal programming for adulthood life are strongly associated with maternal-to-fetal transfer of nutrient and other substances. Gestational diabetes mellitus (GDM) is a major problem and associated with abnormal fetal development, but the mechanisms underlying glucose transport across the placenta barrier (PB) are not completely understood. METHODS: We developed a placenta simulator that can mimic feto-maternal blood circulations along with real transfer across the in vitro biological model of the PB, which is made of a co-culture of endothelial cells (EC) and trophoblast cells (TC) on both sides of a denuded amniotic membrane (AM). Maternal-to-fetal transfer of glucose was monitored over 24 h. RESULTS: The AM is highly permeable to glucose compared to the cellular structures and can serve as a substrate for the co-culture model. The transfer characteristics for glucose are independent of its initial concentration in the maternal compartment, but strongly dependent on the cellular components of the PB. The EC are more resistive to glucose transfer than the TC. The in vitro PB model is the most resistive to glucose transfer. DISCUSSION AND CONCLUSION: The good correlation between the present in vitro results with existing in vivo data demonstrated the potential of this new approach, which can be extended to study various aspects of transplacental transfer, including medications, relevant to GDM or any problem related to in utero programing.

In vitro simulation of placental transport: part I. Biological model of the placental barrier.

INTRODUCTION: The placental barrier (PB) is the thin biological membrane made of endothelial cells (EC), trophoblast cells (TC) and basal membrane that separates between maternal and fetal blood circulations within the placenta and facilitates feto-maternal transport characteristics, which are not completely understood. METHODS: An in vitro biological model of the PB model was co-cultured of human TC (HTR8) and human umbilical vein EC (HUVEC) on both sides of a denuded amniotic membrane (AM) using custom designed wells. RESULTS: Confocal and transmission electron microscopy (TEM) imaging confirmed the morphology expressions of human EC and TC. Further support on the integrity of the new PB model was obtained from the existence of tight junctions and permeability experiments with fluorescence markers of small and large molecules. The monolayer of EC demonstrated the limiting layer for the transport resistance across this complex barrier. DISCUSSION AND CONCLUSION: This new in vitro viable model mimics the architecture of the human PB and can be used in in vitro simulations of transplacental transport studies.

Anthropometry of fetal vasculature in the chorionic plate.

Normal fetal development is dependent on adequate placental blood perfusion. The functional role of the placenta takes place mainly in the capillary system; however, ultrasound imaging of fetal blood flow is commonly performed on the umbilical artery, or on its first branches over the chorionic plate. The objective of this study was to evaluate the structural organization of the feto-placental vasculature of the chorionic plate. Casting of the placental vasculature was performed on 15 full-term placentas using a dental polymer mixed with colored ink. Observations of the cast models revealed that the branching architecture of the chorionic vessel is a combination of dichotomous and monopodial patterns, where the first two to three generations are always of a dichotomous nature. Analysis of the daughter-to-mother diameter ratios in the chorionic vessels provided a maximum in the range of 0.6-0.8 for the dichotomous branches, whereas in monopodial branches it was in the range of 0.1-0.3. Similar to previous studies, this study reveals that the vasculature architecture is mostly monopodial for the marginal cord insertion and mostly dichotomous for the central insertion. The more marginal the umbilical cord insertion is on the chorionic plate, the more monopodial branching patterns are created to compensate the dichotomous pattern deficiency to perfuse peripheral placental territories.

Selective versus routine intrapartum monitoring: comparison of effects on perinatal outcome.

This study compares perinatal results of 7,604 deliveries in two successive years (1976--1977) in which no policy changes occurred other than a four-fold increase in electronic intrapartum monitoring. In the first year 15.4 per cent of births were monitored selectively. In the second year all births were monitored, with the exception of patients admitted at an advanced stage of labor and elective cesarean section. The results show no significant improvement either in intrapartum or in early neonatal mortality rates. The same results obtained in cesarean section rate and in instrumental deliveries. The only positive result is a significant reduction of low Apgar scores in the unselected monitoring group (1977). The low morbidity is considered to be a result not only of increased monitoring, but also of active management of labor, of a short duration of labor and of intensive neonatal care.

Leiomyosarcoma of the colon and rectum.

Leiomyosarcoma of the colon is an uncommon lesion and may appear throughout the colon. Early diagnosis is seldom accomplished before complications such as bleeding or obstruction appear. Sometimes it is histologically difficult to distinguish between a benign and a mlaignant leiomyoma. Some leiomyomas have biologic evidence of malignancy. Five cases of leiomyosarcoma are described, one of which was histologically diagnosed as a leiomyoma, but two years later, at laparotomy, metastases were found.

Hemodynamic model for analysis of Doppler ultrasound indexes of umbilical blood flow.

A hemodynamic model for pulsatile fluid flow in a pressurized thin-walled elastic tube was applied for the computation of volumetric blood flow and velocity profiles for a given set of system parameters at any selected location along the umbilical artery. The velocity profiles over one heart cycle provide the fetal blood flow velocity waveforms (FVW) from which the usual Doppler indexes (DI) can be derived. The model was used for a comprehensive investigation of the correlation between DI and system parameters that reflect the anatomy and physiology of umbilical blood flow. The simulations showed that the radial location of the Doppler measurement is insignificant for the calculated DI, whereas the axial site is important. The analysis showed that decreasing the diameter or increasing the length of the umbilical artery reduces fetal mean blood flow rate and increases the DI. Increasing blood viscosity tends to induce similar patterns, whereas decreasing arterial compliance or increasing blood density decreases the DI with little effect on blood flow rate. Fetal heart rate has a minor effect on both DI and fetal blood flow rate. This study provides insight into the dependence of DI on the anatomic and physiological characteristics of umbilical blood flow.