Diagnostic value and efficacy evaluation value of transvaginal color doppler ultrasound parameters for uterine scar pregnancy and sub-type after cesarean section.

OBJECTIVE: We aimed to probe the diagnostic value of transvaginal color Doppler ultrasound (TV-CDU) parameters in cesarean scar pregnancy (CSP) and CSP sub-types, and the relevant factors affecting patients' surgical effects. METHODS: Seventy-five CSP patients (all requested termination of pregnancy) were selected as the observation group, and 75 normal pregnant women with a history of cesarean section were selected as the control group. All the study subjects underwent TV-CDU and their cesarean scar muscle (CSM) thickness, minimum sagittal muscle thickness and resistance index (RI) of blood flow in the anterior wall of the lower uterine segment were calculated. The diagnostic value of CSM, minimum sagittal muscle thickness, and RI for CSP and CSP sub-types was analyzed. The patients in the observation group were grouped into the effective group and the ineffective group according to whether the surgical treatment was effective or not, and the independent factors affecting CSP efficacy were analyzed. RESULTS: The observation group had lower CSM, minimum sagittal muscle thickness and RI than the control group. CSM, RI, and minimum sagittal thickness in patients with type II CSP were lower than those in patients with type I, and these indicators in patients with type III were lower than those in patients with type II. The area under the curve (AUC) of CSM, RI and minimum sagittal muscle thickness in combination for CSP diagnosis and the AUC for CSP sub-types were higher than those of each indicator alone. Gestational sac size and CSM were independent factors affecting CSP treatment. CONCLUSION: Changes in TV-CDU parameters facilitates CSP diagnosis after cesarean section. CSM, minimum sagittal muscle thickness changes, and RI in combination possesses high value for CSP diagnosis and CSP sub-types. Gestational sac size and CSM are independent factors affecting CSP treatment.

Successful laparoscopic resection of retroperitoneal ectopic pregnancy between the abdominal aorta and inferior vena cava: A case report.

Retroperitoneal ectopic pregnancies are extremely rare; only a few cases having been reported. Here, we report laparoscopic removal of an asymptomatic retroperitoneal ectopic pregnancy from a 29-year-old woman who was referred to our hospital for a suspected ectopic pregnancy. Transvaginal ultrasound did not reveal a gestational sac in the uterus or pelvic cavity. However, abdominal contrast-enhanced computer tomography showed a gestational sac between the abdominal aorta and inferior vena cava. On laparoscopy, the gestational sac was confirmed to be in this retroperitoneal location and successfully removed with minimal bleeding. Histopathologic examination revealed chorionic villi surrounded by lymphatic tissue, suggesting lymphatic spread of the retroperitoneal ectopic pregnancy. In summary, contrast-enhanced computer tomography is very useful for locating the site of pregnancy in women suspected of having a retroperitoneal ectopic pregnancy. Timely diagnosis of a retroperitoneal ectopic pregnancy before bleeding occurs can enable their safe laparoscopic removal.

Combining deep learning and intelligent biometry to extract ultrasound standard planes and assess early gestational weeks.

OBJECTIVES: To develop and validate a fully automated AI system to extract standard planes, assess early gestational weeks, and compare the performance of the developed system to sonographers. METHODS: In this three-center retrospective study, 214 consecutive pregnant women that underwent transvaginal ultrasounds between January and December 2018 were selected. Their ultrasound videos were automatically split into 38,941 frames using a particular program. First, an optimal deep-learning classifier was selected to extract the standard planes with key anatomical structures from the ultrasound frames. Second, an optimal segmentation model was selected to outline gestational sacs. Third, novel biometry was used to measure, select the largest gestational sac in the same video, and assess gestational weeks automatically. Finally, an independent test set was used to compare the performance of the system with that of sonographers. The outcomes were analyzed using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and mean similarity between two samples (mDice). RESULTS: The standard planes were extracted with an AUC of 0.975, a sensitivity of 0.961, and a specificity of 0.979. The gestational sacs' contours were segmented with a mDice of 0.974 (error less than 2 pixels). The comparison showed that the relative error of the tool in assessing gestational weeks was 12.44% and 6.92% lower and faster (min, 0.17 vs. 16.6 and 12.63) than that of the intermediate and senior sonographers, respectively. CONCLUSIONS: This proposed end-to-end tool allows automatic assessment of gestational weeks in early pregnancy and may reduce manual analysis time and measurement errors. CLINICAL RELEVANCE STATEMENT: The fully automated tool achieved high accuracy showing its potential to optimize the increasingly scarce resources of sonographers. Explainable predictions can assist in their confidence in assessing gestational weeks and provide a reliable basis for managing early pregnancy cases. KEY POINTS: • The end-to-end pipeline enabled automatic identification of the standard plane containing the gestational sac in an ultrasound video, as well as segmentation of the sac contour, automatic multi-angle measurements, and the selection of the sac with the largest mean internal diameter to calculate the early gestational week. • This fully automated tool combining deep learning and intelligent biometry may assist the sonographer in assessing the early gestational week, increasing accuracy and reducing the analyzing time, thereby reducing observer dependence.

Risk factors for missed abortion: retrospective analysis of a single institution's experience.

OBJECTIVE: To explore the risk factors including the difference between mean gestational sac diameter and crown-rump length for missed abortion. METHODS: Hospitalized patients with missed abortion and patients with continuing pregnancy to the second trimester from Chengdu Women's and Children's Central Hospital from June 2018 to June 2021 were retrospectively analyzed. The best cut-off value for age and difference between mean gestational sac diameter and crown-rump length (mGSD-CRL) were obtained by x-tile software. Univariate and multivariate logistic regression analysis were adopted to identify the possible risk factors for missed abortion. RESULTS: Age, gravidity, parity, history of cesarean section, history of recurrent abortion (≥ 3 spontaneous abortions), history of ectopic pregnancy and overweight or obesity (BMI > 24 kg/m2) were related to missed abortion in univariate analysis. However, only age (≥ 30 vs < 30 years: OR = 1.683, 95%CI = 1.017-2.785, P = 0.043, power = 54.4%), BMI (> 24 vs ≤ 24 kg/m2: OR = 2.073, 95%CI = 1.056-4.068, P = 0.034, power = 81.3%) and mGSD-CRL (> 20.0vs ≤ 11.7 mm: OR = 2.960, 95% CI = 1.397-6.273, P = 0.005, power = 98.9%; 11.7 < mGSD-CRL ≤ 20.0vs > 20.0 mm: OR = 0.341, 95%CI = 0.172-0.676, P = 0.002, power = 84.8%) were identified as independent risk factors for missed abortion in multivariate analysis. CONCLUSION: Patients with age ≥ 30 years, BMI > 24 kg/m2 or mGSD-CRL > 20 mm had increasing risk for missed abortion, who should be more closely monitored and facilitated with necessary interventions at first trimester or even before conception to reduce the occurrence of missed abortion to have better clinical outcomes.

Development of the utero-placental circulation in cesarean scar pregnancies: a case-control study.

BACKGROUND: Cesarean scar pregnancies carry a high risk of pregnancy complications including placenta previa with antepartum hemorrhage, placenta accreta spectrum, and uterine rupture. OBJECTIVE: To evaluate the development of utero-placental circulation in the first half of pregnancy in ongoing cesarean scar pregnancies and compare it with pregnancies implanted in the lower uterine segment above a previous cesarean delivery scar with no evidence of placenta accreta spectrum at delivery STUDY DESIGN: This was a retrospective case-control study conducted in 2 tertiary referral centers. The study group included 27 women who were diagnosed with a live cesarean scar pregnancy in the first trimester of pregnancy and who elected to conservative management. The control group included 27 women diagnosed with an anterior low-lying placenta or placenta previa at 19 to 22 weeks of gestation who had first and early second trimester ultrasound examinations. In both groups, the first ultrasound examination was carried out at 6 to 10 weeks to establish the pregnancy location, viability, and to confirm the gestational age. The utero-placental and intraplacental vasculatures were examined using color Doppler imaging and were described semiquantitatively using a score of 1 to 4. The remaining myometrial thickness was recorded in the study group, whereas the ultrasound features of a previous cesarean delivery scar including the presence of a niche were noted in the controls. Both the cesarean scar pregnancies and the controls had ultrasound examinations at 11 to 14 and 19 to 22 weeks of gestation. RESULTS: The mean color Doppler imaging vascularity score in the ultrasound examination at 6 to 10 weeks was significantly (P<.001) higher in the cesarean scar pregnancy group than in the controls. High vascularity scores of 3 and 4 were recorded in 20 of 27 (74%) cases of the cesarean scar pregnancy group. There was no vascularity score of 4, and only 3 of 27 (11%) controls had a vascularity score of 3. In 15 of the 27 (55.6%) cesarean scar pregnancies, the residual myometrial thickness was <2 mm. In the ultrasound examination at 11 to 14 weeks, there was no significant difference between the groups in the number of cases with an increased subplacental vascularity. However, 12 cesarean scar pregnancies (44%) presented with 1 or more placental lacunae whereas there was no case with lacunae in the controls. Of the 18 cesarean scar pregnancies that progressed into the third trimester, 10 of them were diagnosed with placenta previa accreta at birth, including 4 creta and 6 increta. In the 19 to 22 weeks ultrasound examination, 8 of the 10 placenta accreta spectrum patients presented with subplacental hypervascularity, out of which 6 showed placental lacunae. CONCLUSION: The vascular changes in the utero-placental and intervillous circulations in cesarean scar pregnancies are due to the loss of the normal uterine structure in the scar area and the development of placental tissue in proximity of large diameter arteries of the outer uterine wall. The intensity of these vascular changes, the development of placenta accreta spectrum, and the risk of uterine rupture are probably related to the residual myometrial thickness of the scar defect at the start of pregnancy. A better understanding of the pathophysiology of the utero-placental vascular changes associated with cesarean scar pregnancies should help in identifying those cases that may develop major complications. It will contribute to providing counseling for women about the risks associated with different management strategies.

Two subtypes of surgery-categorized upper-lateral intracavitary pregnancy identified by MRI, a retrospective study.

BACKGROUND: The pregnancy outcomes in women with surgery-categorized upper-lateral intracavitary pregnancy (ULIP), previously named angular pregnancy, demonstrate higher heterogeneity than in women with ultrasonography-categorized ULIP. We aimed to use preoperative MRI and correlated clinical characteristics to explore whether the surgery-categorized ULIP comprises obstetric conditions undefined by the current ultrasonography-based diagnostic criteria. METHODS: This retrospective study involved 28 women with surgically and pathologically confirmed ULIP from January 2016 to July 2022. Two board-certified radiologists, blinded to the patients' information, independently reviewed the MRI images, and determined each MRI feature, including endometrial thickness (EMT) and peri-gestational sac (GS) endometrial interruption. Disagreements were resolved by discussion to achieve a consensus. Based on the cutoff value of EMT (11.5 mm), the patients were divided into above-cutoff EMT (n = 22) and below-cutoff EMT (n = 6) groups. RESULTS: Two subtypes of surgery-categorized ULIP were identified. Type-I ULIP (n = 22; EMT ≥ 11.5 mm), when compared to the type-II ULIP (n = 6; EMT < 11.5 mm), demonstrated lower incidence of peri-GS endometrial interruption (2/22 [9.1%] vs 6/6 [100%]; P = 0.001), higher logarithmic ß-human chorionic gonadotropin (ß-hCG) concentration (4.7 ± 0.4 mIU/ml vs 4.2 ± 0.6 mIU/ml; P = 0.026), lower rate of repeated dilatation and curettage (1/22 [4.6%] vs 4/6 [66.7%]; P = 0.003), less intraoperative blood loss (10.1 ± 6.3 ml vs 28.3 ± 18.3 ml; P = 0.001), and shorter hospital stay (2.8 ± 1.7 days vs 7.5 ± 3.8 days; P = 0.001). The peri-GS endometrial interruption negatively correlated with EMT (Odds ratio [OR] = 0.55; P = 0.001) and logarithmic ß-hCG concentration (OR = 0.08; P = 0.045). The below-cutoff EMT negatively correlated with ß-hCG concentration (OR = 0.06; P = 0.021). CONCLUSIONS: Surgery-categorized ULIP comprised two obstetric conditions among which the type-II ULIP, possessing unique imaging features undocumented in the literature, requires further attention during clinical practice.

A mathematical model to predict the probability of a successful pregnancy.

AIM: To develop a scoring system for the prediction of a successful pregnancy. METHODS: Data were collected prospectively from women diagnosed with pregnancy from January 1, 2015, to December 31, 2018. Pregnant days, hormone levels, and gestational sac diameters were recorded. Relationships among the pregnancy days, hormones, and gestational sac were analyzed by Spearman correlation analysis. A scoring system was established and stratified by the 5th, 50th, and 95th percentile of hormone levels and gestational sac diameters on different pregnancy days. Pregnancy outcomes were predicted by the scores using quadratic polynomial regression analyses. A portable desktop analyzer was developed and the performance was evaluated by receiver operating characteristic (ROC) curve. RESULTS: In 273 successful pregnancy cases, the length of gestational days was significantly correlated to beta-human chorionic gonadotropin (ß-hCG) (r = 0.74, p < 0.001) and E2 (r = 0.79, p < 0.001) levels, and the size of the gestational sac (r = 0.88, p < 0.001). Meanwhile, the size of gestational sac was positively correlated with ß-hCG (r = 0.93, p < 0.001) and E2 (r = 0.55, p < 0.001). For 273 delivery and 103 miscarriage cases included in this study, our scoring-based prediction model rendered an area under the ROC curve (AUC) of 0.86 with the sensitivity of 78.31% and the specificity of 80.83%. CONCLUSIONS: We successfully developed a scoring-based analyzer to evaluate the viability of embryos at different gestation stages and to predict the probability of a successful delivery, which would provide a reference for clinicians in postpregnancy management.

Reference intervals of gestational sac, yolk sac, embryonic length, embryonic heart rate at 6-10 weeks after in vitro fertilization-embryo transfer.

BACKGROUND: Accurately determining the normal range of early pregnancy markers can help to predict adverse pregnancy outcomes. The variance in ovulation days leads to uncertain accuracy of reference intervals for natural pregnancies. While the gestational age (GA) is accurate estimation during in vitro fertilization-embryo transfer (IVF-ET). Thus, the objective of this research is to construct reference intervals for gestational sac diameter (GSD), yolk sac diameter (YSD), embryonic length (or crown-rump length, CRL) and embryonic heart rate (HR) at 6-10 gestational weeks (GW) after IVF-ET. METHODS: From January 2010 to December 2016, 30,416 eligible singleton pregnancies were retrospectively recruited. All included participants had full records of early ultrasound measurements and phenotypically normal live neonates after 37 GW, with birth weights > the 5th percentile for gestational age. The curve-fitting method was used to screen the optimal models to predict GSD, CRL, YSD and HR based on gestational days (GD) and GW. Additionally, the percentile method was used to calculate the 5th, 50th, and 95th percentiles. RESULTS: There were significant associations among GSD, CRL, YSD, HR and GD and GW, the models were GSD = - 29.180 + 1.070 GD (coefficient of determination [R2] = 0.796), CRL = - 11.960 - 0.147 GD + 0.011 GD2 (R2 = 0.976), YSD = - 2.304 + 0.184 GD - 0.011 GD2 (R2 = 0.500), HR = - 350.410 + 15.398 GD - 0.112 GD2 (R2 = 0.911); and GSD = - 29.180 + 7.492 GW (R2 = 0.796), CRL = - 11.960 - 1.028 GW + 0.535 GW2 (R2 = 0.976), YSD = - 2.304 + 1.288 GW - 0.054 GW2 (R2 = 0.500), HR = - 350.410 + 107.788 GW - 5.488 GW2 (R2 = 0.911), (p < 0.001). CONCLUSIONS: Reference intervals for GSD, YSD, HR and CRL at 6-10 gestational weeks after IVF-ET were established.

"Pseudogestational Sac" and Other 1980s-Era Concepts in Early First-Trimester Ultrasound: Are They Still Relevant Today?

OBJECTIVES: To determine whether an intrauterine round or oval fluid collection ("saclike structure") can prove to be either an intrauterine pregnancy or intrauterine fluid in conjunction with an ectopic pregnancy (sometimes termed "pseudogestational sac") and whether ultrasound features, including the presence or absence of an echogenic rim, "double sac sign" (DSS), or "intradecidual sign" (IDS), are helpful for establishing the diagnosis or predicting the prognosis. METHODS: We identified all sonograms obtained from women with positive serum human chorionic gonadotropin results at our institution between January 1, 2012, and June 30, 2018, meeting the following criteria: presence of an intrauterine saclike structure without a yolk sac or embryo; no extraovarian adnexal mass; and follow-up information identifying the location of the pregnancy as intrauterine or ectopic. Study authors reviewed sonograms in all cases and recorded the following information: presence or absence of each of an echogenic rim around the collection, a DSS, and an IDS, as well as the mean sac diameter. The indications for the initial ultrasound examinations were recorded. RESULTS: A total of 649 sonograms met the inclusion criteria. Of these, 598 fluid collections showed an echogenic rim, 182 a DSS, and 347 an IDS (findings not mutually exclusive). In all 649 cases, a subsequent sonogram or other clinical follow-up confirmed that the patient had an intrauterine pregnancy. That is, none of the fluid collections proved to be a pseudogestational sac. In total, 41.2% were live at the end of the first trimester, and 58.8% miscarried. The prognosis was better in cases with, compared to without, an IDS (P = .01, χ2 ), but no ultrasound feature was clinically useful for ruling in or excluding a good prognosis. CONCLUSIONS: In a woman with positive human chorionic gonadotropin results and no extraovarian adnexal mass, the ultrasound finding of an intrauterine saclike structure is virtually certain to be a gestational sac. Ultrasound features of the structure are of no diagnostic or clinically useful prognostic value. Concepts introduced 30 to 40 years ago when ultrasound equipment had far lower resolution than currently, including a DDS, an IDS, and a pseudogestational sac, have no role today in assessing early pregnancy.

Local intra-gestational sac methotrexate injection followed by dilation and curettage in treating cesarean scar pregnancy.

PURPOSE: To assess the safety and efficacy of local intra-gestational sac methotrexate injection followed by dilation and curettage (D&C) in treating cesarean scar pregnancies (CSP). METHOD: Medical records of CSP patients treated with local intra-gestational sac methotrexate injection followed by dilation and curettage were analyzed at the Maternal and Child Hospital of Guangxi Zhuang Autonomous Region, China. RESULTS: Thirty-one patients were included in this study. The mean gestational age, sac diameter and thickness of the uterine scar were 49.6 ± 7.7 days, 1.8 ± 0.6 cm and 0.30 ± 0.15 cm, respectively. The median pretreatment serum ß-human chorionic gonadotropin (ß-HCG) level was 40,887 mIU/mL, with the 25th and 75th percentiles at 19,852 and 74,552, respectively. The median blood loss during D&C was 20 mL with the 25th and 75th percentiles at 10 mL and 50 mL. Following D&C, a Foley's balloon catheter compression was implanted in 26 (83.9%) patients due to active uterine bleeding. All patients had a ß-HCG regression time of ≤ 4 weeks after D&C. While 30 patients (96.8%) had a uterine recovery time of ≤ 4 weeks, and 29 patients (93.5%) had resumption of menstruation of less than 6 weeks. Three patients (9.7%) had complications. One of them suffered from massive vaginal bleeding and underwent s blood transfusion. There were no other complications, such as pelvic infection and uterine rupture during the procedures. And no patient was converted to surgical resection or uterine artery embolization. Overall, 30 patients (96.8%) were treated successfully. CONCLUSION: Local intra-gestational sac methotrexate injection followed by D&C with the aid of a Foley's balloon catheter compression appears to be a safe and effective treatment for CSP. Further randomized controlled trials are suggested to confirm these findings.

Hysteroscopic Intact Removal of an Angular Pregnancy with a 5Fr Electrode.

STUDY OBJECTIVE: Angular pregnancy is a rare and life-threatening condition in which the embryo is implanted in the lateral angle of the uterine cavity, medial to the uterotubal junction and round ligament. Angular pregnancy is associated with a high risk of uterine rupture of about 23% [1]. No consensus has been achieved regarding the diagnostic and therapeutic approach of angular pregnancy [2]. Thus, the aim of this study was to report a case of hysteroscopic treatment of an angular pregnancy in a 34-year-old women. DESIGN: Step-by-step video presentation of the surgical treatment (Canadian Task Force classification III). SETTING: Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy. PATIENT: A 34-year-old woman. Written informed consent was obtained from the patient. INTERVENTION: Hysteroscopy. MEASUREMENTS AND MAIN RESULTS: A 34-year-old woman was admitted to our Department with pelvic pain at 6 weeks of gestation. ß-Human chorionic gonadotropin (ß-hCG) was 5331 mIU/mL. The transvaginal ultrasound showed a gestational sac of 15 × 11 mm in the left uterine angle of an embryo without cardiac activity. The woman opted for a conservative approach with multiple-dose methotrexate [3]. Five days later the ß-hCG increased to 7589 mIU/mL with no regression of pregnancy at the transvaginal ultrasound. Therefore, a surgical approach was offered to the patient [4,5]. Laparoscopy showed normal salpinges, whereas hysteroscopy identified the gestational sac in the left uterine angle. A 5Fr bipolar electrode was used to open the gestational capsular decidua. The chorionic villi were progressively separated from the implantation site. Using grasping forceps we removed the specimen for histologic examination. Histologic examination confirmed the diagnosis of angular pregnancy. On the second postoperative day ß-hCG was 1131 mIU/mL, and the patient was discharged the day after. At the 1-month follow-up visit, ß-hCG and transvaginal ultrasound were negative for pregnancy. The office hysteroscopy showed an empty uterine cavity at 3-months' follow-up. CONCLUSION: Our case shows that hysteroscopy may be used as a diagnostic and therapeutic tool for angular pregnancy, providing a unique image of the intact removal of the gestational sac.

To evaluate the feasibility of magnetic resonance imaging in predicting unusual site ectopic pregnancy: a retrospective cohort study.

OBJECTIVE: To evaluate the accuracy of pelvic MRI in the diagnosis of unusual ectopic pregnancy (EP), when ultrasound (US) examination is inconclusive. METHODS: We retrospectively reviewed the medical records of 150 patients with suspected EP. Clinical, US and MRI features of 15 unusual EPs were analysed. Two radiologists independently reviewed each case resolving by consensus any diagnostic discrepancy. Interobserver agreement was assessed using the Cohen κ test. RESULTS: MRI displayed a gestational sac-like structure surrounded by a thick wall in all cases. The thick wall displayed hyperintensity in 41 %, isointensity in 35 % and hypointensity in 24 % of cases on T1-weighted images. Diffusion- and fat saturation T1-weighted images were the most accurate sequences, as they enabled identification of 15/15 and 14/15 patients, respectively. Although US was false negative in detecting cervical and uterine infiltration underlying the caesarean scar, MRI was able to identify the invasion. Interobserver agreement was very good for all sequences (κ=0.892-1.0). CONCLUSIONS: MRI plays an important role in the early diagnosis of unusual EP. It should be considered after negative US findings, providing accurate evaluation of the site and the possible infiltration of these lesions, which help in the management of these patients. KEY POINTS: • MRI is being increasingly used as a problem-solving modality in ectopic pregnancy. • MRI plays an important role in early diagnosis of unusual ectopic pregnancy. • Knowledge of MRI features in EP is essential to determinate appropriate management.

The impact of gestational sac size on the effectiveness and safety of high intensity focused ultrasound combined with ultrasound-guided suction curettage treatment for caesarean scar pregnancy.

OBJECTIVE: To evaluate the correlation between the gestational sac size and the effect and safety of high intensity focused ultrasound (HIFU) combined with ultrasound-guided suction curettage for caesarean scar pregnancy (CSP). METHODS: Seventy-six patients with CSP were enrolled. Based on their gestational sac size, patients were divided into three groups: Group 1 (n = 16, 10-20 mm), Group 2 (n = 28, 21-30 mm) and Group 3 (n = 32, >30 mm). All of them were treated by HIFU combined with ultrasound-guided suction curettage. Baseline characteristics, parameters and adverse events of HIFU, and intraoperative hemorrhage during ultrasound-guided suction curettage were recorded. RESULTS: The median treatment time and average treatment intensity of HIFU in Group 3 were significantly higher than Group 1 (p < .05); the median HIFU treatment power in Group 2 and Group 3 were both significantly higher than that of Group 1 (p < .05). The median sonication time of HIFU in Group 3 was significantly longer than patients in the other two groups (p < .05). The size of the gestational sac had a positive correlation with all the above-mentioned parameters of HIFU and blood loss during ultrasound-guided suction curettage (p < .05). No statistically significant differences were observed among the three groups in the duration of vaginal bleeding post-curettage and the time necessary for serum ß-hCG to return to normal levels (p > .05). CONCLUSIONS: HIFU combined with ultrasound-guided suction curettage is a safe and effective clinical approach for CSP. Gestational sac size is a meaningful factor for predicting the efficacy and safety of HIFU treatment and hemorrhage during ultrasound-guided suction curettage.

First trimester pregnancy ultrasound findings as a function of method of conception in an infertile population.

PURPOSE: The aim of this study was to determine whether first trimester ultrasound measurements of crown rump length (CRL) and gestational sac diameter (GSD) differ depending on the method of conception among infertile women. METHOD: Infertile women, ages 21-50 years old, who conceived viable, singleton pregnancies via fresh embryo transfer (ET), frozen ET, non-in vitro fertilization (IVF) fertility treatment, or spontaneously were included in this observational cohort study at an academic fertility practice. Embryonic growth trajectories defined by the CRL and GSD at 6 and 8 weeks' gestation were analyzed and compared among the methods of conception. RESULTS: Crown rump length at 6 weeks' gestation was smaller for conceptions achieved via fresh ET compared with frozen ET in a natural cycle (1.50 vs. 2.50 mm, p = 0.017). Crown rump length was smaller at 8 weeks' gestation in conceptions achieved via fresh ET compared to frozen ET in a programmed cycle (16.13 vs. 17.02 mm, p = 0.039). CONCLUSION: Among infertile women, embryo growth may differ between fresh and frozen ET as early as 6 and 8 weeks' gestation.

Medical management of miscarriage: Predictive factors of success.

Medical management of miscarriage is an acceptable option available to women, and has advantages of providing timely treatment, while avoiding exposure to surgery and anaesthesia. This retrospective cohort study aimed to determine factors predictive of successful medical management, utilising a single dose protocol of 800 µg vaginal misoprostol. In this cohort, the success rate was 67% (199/296), and smaller mean gestational sac diameter independent of gestational age predicted success (P = 0.046). Success is not significantly related to parity, miscarriage type, pelvic pain or vaginal bleeding at the outset of treatment.

A logistic model to predict early pregnancy loss following in vitro fertilization based on 2601 infertility patients.

BACKGROUND: According to previous studies, even after embryonic cardiac activity is detected, the pregnancy loss rate remains 3-4 %. The objectives of this study were to investigate the differences in ultrasound parameters between a miscarriage group and an ongoing pregnancy group during the 1(st) trimester and to build a logistic model to predict early pregnancy loss (EPL) after the appearance of embryonic cardiac activity in patients who have undergone in vitro fertilization embryo transfer (IVF-ET) treatment. METHOD: A total of 2601 patients with early singleton pregnancies with embryonic cardiac activity were retrospectively analyzed after IVF from January 2010 to June 2011. Transvaginal sonography (TVS) was performed at 6 to 10 weeks of gestational age (GA). The mean gestational sac diameter (MSD), crown-rump length (CRL), fetal heart rate (FHR), and yolk sac diameter (YSD) were measured by TVS. RESULTS: A total of 2400 patients had an ongoing pregnancy and an additional 201 (7.7 %) patients miscarried during the first trimester after fetal cardiac activity had been established. The maternal age (MA) and infertility duration were much greater, and the MSD, CRL, and FHR were much lower in the miscarriage group than in the ongoing pregnancy group after IVF (P < 0.05). The prediction model utilized the following equation: the possibility of EPL = exp(z)/(1 + exp(z)), where z = -21.456 + (0.114 × MA) + (4.305 × × GA) - (0.043 × MSD) - (0.359 × CRL) - (0.091 × FHR) + 2.243 (fluid collection present around the gestational sac (GS)) + 2.519 (when YSD < 3) or - 0.347 (when YSD > 5.5). CONCLUSION: The MA, MSD, CRL, YSD, FHR, infertility duration, and fluid collection around the GS were each correlated with EPL after IVF in infertile patients. A logistic model is a useful tool for predicting EPL after the appearance of embryonic cardiac activity (area under the curve [AUC] = 0.909).

Role of MRI in the early diagnosis of tubal ectopic pregnancy.

OBJECTIVE: To determine the role of MRI in the early diagnosis of tubal ectopic pregnancy (EP). METHODS: Clinical and MRI features of 27 cases of tubal pregnancy were reviewed. RESULTS: A thick-walled gestational sac (GS)-like structure was demonstrated lateral to the uterus in all cases. On T2-weighted images, the thick wall typically exhibited 3 discrete rings in 22 cases (81 %), among which 17 cases (63 %) displayed small vessels and 6 cases (33 %) exhibited small areas of fresh haemorrhage inside the thick wall. The contents demonstrated non-specific liquid in 26 %, papillary solid components in 56 %, and fresh blood or fluid-fluid level in 19 % of the cases. Dilatation of the affected fallopian tube associated with hematosalpinx was demonstrated in 18 cases (67 %) and marked enhancement of the tubal wall was observed in 22 cases (81 %). No correlation was found between the size of the GS and the estimated gestational age (r = 0.056). CONCLUSION: MRI plays an important role in the early diagnosis and management of tubal pregnancy. The characteristic MRI features include a GS-like structure with a "three rings" appearance on T2-weighted images, presence of solid components in the sac, dilatation of the affected fallopian tube with hematosalpinx, and tubal wall enhancement. KEY POINTS: • MR imaging has served as a problem-solving procedure in ectopic pregnancy. • MR imaging features can be criteria for early diagnosis of tubal pregnancy. • Detailed assessment of ectopic implantation is necessary for management decision-making.

Sonographic Parameters for Prediction of Miscarriage: Role of 3-Dimensional Volume Measurement.

OBJECTIVES: To evaluate the value of volume measurement using 3-dimensional sonography for prediction of miscarriage. METHODS: We prospectively enrolled 188 singleton pregnant women at 5 to 9 weeks' gestation. The 3-dimensional sonographic gestational sac volume and yolk sac volume were measured together with the fetal heart rate, gestational sac diameter, and yolk sac diameter. For each sonographic parameter, nomograms were created; z scores were calculated for each measurement, and the values were compared between miscarriage and ongoing pregnancy groups. Sonographic parameters for prediction of miscarriage were evaluated by multivariate analysis, and the screening performance was assessed by a receiver operating characteristic curve. RESULTS: Among the 188 pregnancies, 30 (16.0%) had miscarriage. Multivariate analysis showed that fetal heart rate below the 5th percentile (odds ratio, 6.43), gestational sac diameter below the 5th percentile (odds ratio, 4.87), gestational sac volume below the 5th percentile (odds ratio, 5.25), and yolk sac diameter below the 2.5th or above the 97.5th percentile (odds ratio, 15.86) were significant predictors of miscarriage (P = .018; P = .018; P = .033; and P < .001, respectively). At a false-positive rate of 30%, the detection rate for miscarriage in screening by a combination of fetal heart rate, gestational sac diameter, gestational sac volume, and yolk sac diameter was 77.8%. CONCLUSIONS: A small-for-gestational-age gestational sac volume is a significant sonographic predictor of miscarriage, as are fetal bradycardia, a small gestational sac diameter, and a small or large yolk sac diameter.

[Measurement of gestational sac volume in the first trimester of pregnancy]. / Merení objemu gestacního vácku v I. trimestru gestace.

OBJECTIVE: The aim of our study was to measure the volume of gestational sac and amniotic sac in physiological pregnancies and missed abortion. We wanted to create nomograms for individual weeks of gestation. DESIGN: Retrospective cohort study. SETTING: Institute for the Care of Mother and Child, Prague. METHODS: The study randomized 413 women after spontaneous conception. The patients were divided into two groups: women with physiological pregnancy and childbirth in the period (374), and women with pregnancy terminated by missed abortion. Both groups were performed measurement volume of gestational and amniotic sac in the first trimester of pregnancy. Analysis was performed using 4D View software applications, and volume calculations were performed using VOCAL (Virtual Organ Computer Aided anaLysis). RESULTS: We have created the first in the Czech Republic nomograms volumes of gestational and amniotic sac in physiological pregnancies and missed abortion. We performed a correlation between the size of gestational sac and prosperity pregnancy. CONCLUSION: In our study we found no correlation between the volume of gestational sac and the development of the pregnancy.

Diagnostic utility of contrast-enhanced computed tomography for ectopic pregnancy.

INTRODUCTION: Contrast-enhanced computed tomography (CECT) is an emergent diagnostic imaging modality to identify the bleeding site and survey the abdominal cavity. The diagnostic utility of CECT for ectopic pregnancy (EP) has not been well-investigated. The objective of this study was to evaluate the characteristics of CECT findings in patients with EP and extract specific findings that could contribute to the identification of implantation sites. METHOD: We conducted a retrospective study, reviewing suspected EP cases between April 2015 and March 2018 in our hospital. Clinical symptoms, blood test results, transvaginal sonography findings, and surgical and pathologic findings from the medical records were assessed. CECT images were evaluated by a certified radiologist and gynecologist retrospectively in consensus. The following were selected as positive findings for specific determination of the ectopic implantation site: the ectopic gestational sac, lateralization of the hemoperitoneum around the adnexa on either side, and extravascular leakage of the contrast agent outside the uterine cavity. RESULTS: CECT was performed in 41 women with an EP. The ectopic implantation site was detectable on CECT in 90.2% (37/41), whereas it was noted in 70.0% (32/41) on transvaginal ultrasonography (TVS). Of nine patients with an EP with an undetectable implantation site on TVS, six were positive for the specific determination of the ectopic implantation site on CECT. CONCLUSION: CECT has the potential to predict ectopic implantation sites with high-level sensitivity. As CECT is an urgent diagnostic imaging tool to be used in an emergent setting, it may be a good option for EP diagnosis when the availability of magnetic resonance imaging is limited.