Intracranial lesions of congenital cytomegalovirus infection detected by ultrasound scanning.

Four cases of congenital cytomegalovirus infection associated with previously unreported intracranial lesions--paraventricular cysts and intraventricular strands and mild ventriculomegaly--are described. These findings may have serious implications regarding the long-term neurologic prognosis for infants with congenital cytomegalovirus infection.

Ultrasound-guided fetal blood transfusion for severe rhesus isoimmunization.

Four fetuses with severe rhesus isoimmunization were transfused with packed red blood cells directly into the umbilical vein. The outcome was successful in three. In one infant, this ultrasound-guided technique resulted in resolution of severe fetal hydrops at 27 weeks, allowing delivery of a healthy nonhydropic infant at 33 weeks, and in the other three infants in prolongation of the pregnancy. The last four transfusions were performed after fetal neuromuscular blockade with curare. The procedure would appear to be associated with a low risk of complication and to provide an excellent chance of a successful outcome of a fetus with severe rhesus isoimmunization even when fetal hydrops is present.

Preovulatory follicular size: a comparison of ultrasound and laparoscopic measurements.

Ovarian follicles in the immediate preovulatory period were measured with real-time or static ultrasound. Thirty-nine follicles were examined in thirty-six patients. In 29 spontaneous cycles the mean follicular diameter was 21.1 mm (range 17 to 25 mm) and the mean volume was 5.1 ml. In seven stimulated cycles the mean diameter was 18.4 mm and the mean volume was 3.5 ml. Laparoscopic needle aspiration of the follicular contents was performed within 12 hours of ultrasound examination in every case. Follicular dimensions based on the volume of aspirated fluid correlated well with the ultrasound measurements (r = 0.847; P < 0.001), which suggests that ultrasound is a useful technique for examining preovulatory follicular development.

Ultrasound control of clomiphene/human chorionic gonadotropin stimulated cycles for oocyte recovery and in vitro fertilization.

Three pregnancies have been achieved through in vitro fertilization (IVF) following clomiphene/human chorionic gonadotropin (hCG) stimulation monitored only with ultrasound. When the results of 120 stimulated cycles were compared with those from 213 spontaneous cycles during a one-year period, the clomiphene-ultrasound-hCG method led to a significantly higher laparoscopy rate as well as significantly better yields of mature oocytes and embryos for intrauterine transfer. The luteal phase was normal in the stimulated group. This ultrasound-monitored technique was simpler to manage and less costly and appears to be the current method of choice for obtaining oocytes for IVF.

Early diagnosis of pregnancy failure with transvaginal ultrasound.

Vaginal ultrasound was used to assess a consecutive series of 353 patients to determine the minimum mean gestation sac diameter at which a failed pregnancy could be diagnosed. Fetal heart movements could be demonstrated in all pregnancies with living fetuses when the mean sac diameter exceeded 1.2 cm. Vaginal ultrasound is superior to both static and transabdominal real-time ultrasound in the diagnosis of early pregnancy failure.

Demonstration of ectopic pregnancy by transvaginal ultrasound.

Transvaginal ultrasound was used in the assessment of 148 patients clinically suspected of having an ectopic pregnancy. Transvaginal ultrasound allowed earlier demonstration of an intrauterine pregnancy without confusion with a pseudosac. Of the 36 patients with an ectopic pregnancy, this was strongly suspected in 29 (81%). A live extrauterine fetus was seen in 8 (22%), ectopic trophoblast or a gestation-sac-like structure in 19 (53%), and a pelvic haematoma in 2 (6%). Transvaginal ultrasound is advocated as the technique of choice in patients suspected of having an ectopic pregnancy.

Vanishing twins: the frequency of spontaneous fetal reduction of a twin pregnancy.

This study examines the outcome of 126 twin pregnancies diagnosed by ultrasound examination at 6-16 weeks' gestation. Fifty-nine patients conceived by in vitro fertilization (IVF) and embryo transfer and had a routine scan. The 67 non-IVF pregnancies had a scan for other clinical indications including threatened abortion. When live twins were detected prior to 7 weeks'gestation, only 71% of pregnancies resulted in live twin neonates. Each fetus of a multiple pregnancy had a 19% chance of dying in utero or in the neonatal period of diagnosed prior to 7 weeks, and 11% if both were found to be alive between 7 and 10 weeks. The fetal loss rate was similar for IVF and non-IVF pregnancies.

Determination of fetal sex with ultrasound.

In a consecutive series of 137 pregnancies scanned at 24 weeks' gestation or later, the sex of 66% of infants was determined with a 2% error rate. By means of ultrasound examinations, parents may now be offered the opportunity of knowing the sex of their baby before delivery.

Amniocentesis: a comparison of 'monitored' versus 'blind' needle insertion technique.

The incidence of complications following 382 'blind' amniocenteses, in which ultrasound was used prior to but not during the procedures, was compared with those following 482 'continuously monitored' amniocenteses. The monitored technique was associated with a reduction in the incidence of blood-stained amniotic fluid, the number of attempts required to obtain fluid and with a fall in the number of spontaneous abortions from 9 (2.4%) to 4 (0.8%).

Vault haematoma after vaginal hysterectomy: an invariable sequel?

Fifty consecutive patients undergoing vaginal hysterectomy were studied prospectively by ultrasound to determine the incidence of vault haematoma and the relationship between its size and the development of postoperative pyrexia; 49 patients (98%) had a vault haematoma and 35 (70%) were febrile postoperatively. Large vault haematomas (mean diameter greater than 5 cm) were invariably associated with significant febrile morbidity, whilst 1 in 3 patients with a small haematoma was afebrile. Colporrhaphy did not influence the likelihood of haematoma formation.

Ectopic pregnancy.

Ectopic pregnancy remains a significant contributor to maternal mortality and morbidity. Despite the obstetrician's awareness of the problems, ectopic pregnancy in many cases still remains a difficult diagnosis. Over the last 10 to 15 years diagnostic ultrasound has become an established means of supplying additional and occasionally diagnostic information on those patients suspected of having an ectopic pregnancy. In essence diagnostic ultrasound can provide information regarding the presence of an intra-uterine pregnancy, a finding which goes a long way to excluding an extra-uterine pregnancy, and can show that there is no gestation sac within the uterus, a finding which raises the level of suspicion of an ectopic pregnancy. In addition to these primary uses, diagnostic ultrasound can also provide information relating to the presence or absence of both an adnexal mass and free fluid in the pouch of Douglas. All of these features, however, are open to error and their appreciation leads to a more rational approach to the interpretation of the overall ultrasound findings. In using diagnostic ultrasound in at-risk patients, side-room urinary pregnancy tests, and if necessary the more sophisticated radioimmunoassays of beta-subunit hCG, should be used in conjunction. From the authors' own studies it was concluded that an empty uterus with an adnexal mass and/or the presence of free fluid in the pelvis, together with positive biochemistry, was able to give a very high level of diagnostic accuracy for ectopic pregnancy (95 per cent). However, an empty uterus alone in the absence of an adnexal mass or free fluid in the pelvis was not of itself a reliable guide to the presence of an ectopic pregnancy even in the presence of positive biochemistry. The finding of a living fetus outside the uterus was an uncommon event (6 per cent), but if present allows an absolute diagnosis of ectopic pregnancy. Finally a negative serum hCG assay virtually excludes the possibility of an ectopic pregnancy. A scheme involving the use of urine pregnancy testing, serum hCG assays and ultrasound has been proposed for the rational management of patients suspected of having an ectopic pregnancy and whose condition is stable. In all circumstances, however, it is stressed that should the patient's condition so warrant then surgical intervention is mandatory irrespective of the ancillary findings.

Can obstetricians prevent neonatal intraventricular haemorrhage?

The possible influence of obstetric and early neonatal factors on the development of neonatal intraventricular haemorrhage (IVH) in very low birth-weight infants have been studied. Caesarean section was associated with a significantly lower incidence of IVH, this reduction being largely confined to infants of 25-28 weeks' gestation. Forceps delivery did not seem to influence the rate of occurrence of IVH if one allowed for differences in gestational age between infants delivered spontaneously and those with forceps. Similarly the use of an episiotomy at the time of delivery did not seem to reduce the incidence of IVH, and a similar lack of correlation was found with the other factors examined.

Monitoring early pregnancy with transvaginal ultrasound and choriogonadotrophin levels.

Serum human chorionic gonadotrophin levels were correlated with gestational sac size detected by transvaginal ultrasound in a series of 178 women undergoing in vitro fertilization. The improved resolution of transvaginal ultrasound enables pregnancy to be detected between 17 and 20 days post-ovum retrieval, when HCG levels were greater than an average threshold level of 1,300 IU/L. The lower HCG discriminatory zone enables improved evaluation of ectopic pregnancies. Also, higher HCG titres observed in multiple pregnancies enable estimation of implantation rates when more than one embryo is transferred.

Early detection of intrauterine pregnancy with ultrasound.

Vaginal scanning is a relatively new technique for scanning early pregnancy. In a consecutive series of 27 patients on an in vitro fertilization program (and therefore certain dates of ovulation) we have demonstrated that pregnancies may be seen within the uterus even before 5 weeks amenorrhoea and have documented their size. Ultrasound examination at this early stage may be of clinical value, particularly in patients suspected of having an ectopic pregnancy.

Fetal abdominal paracentesis in the management of gross fetal ascites.

A case of non-immunological hydrops fetalis with gross ascites is reported. Following definitive ultrasonic diagnosis, a fetal abdominal paracentesis was performed under ultrasonic control with a view to minimising fetal trauma during delivery.

Ultrasonic observation of the mechanism of human ovulation.

Nine subjects were studied by means of ultrasound to determine the precise time of ovulation and to document follicular changes immediately prior to, during, and after rupture. There were no demonstrable changes in the size of appearance of the follicle over a period of up to 7 hours prior to its rupture. In one of the four subjects in whom follicular collapse was witnessed, the follicle emptied completely within less than 1 minute. In two of the other three subjects, there was an initial rapid loss of fluid followed by a flower release of the remaining contents. This latter process took 7 minutes in the first patient and 35 minutes in the second patient. The slow phase of follicular collapse may well be an important aspect in the release of the ovum. The corpus hemorrhagicum was seen to develop within 1 hour of ovulation.

PIP: High-resolution ultrasound equipment was used to document the events occurring immediately before, during, and after human ovulation. 9 subjects were studied. No demonstrable changes in size or appearance of the follicle over a 7-hour period before rupture were seen. In 1 of 4 subjects with follicular collapse, the follicle emptied completely within less than 1 minute. In 2 of the other 3 subjects, an initial rapid loss of fluid occurred followed by a flower-like release of the remaining contents. The release took 7 minutes in Patient 1 and 35 minutes in Patient 2. The slow phase of follicular collapse may be an important aspect in ovum release. The corpus hemorrhagicum was seen to develop within an hour of ovulation completion.

Ultrasound-guided puncture for gynaecological and pelvic lesions.

A series of 34 patients who underwent a total of 37 ultrasound-guided cyst punctures and fine needle biopsies for diagnosis and treatment of pelvic lesions are reported. In all but 1 patient the lesion visualized was entered and cytological diagnosis was achieved, although 1 patient required a second attempt under general anaesthesia. Seven cysts were endometriotic; these and all the remaining cysts were benign and only 4 patients developed a recurrence of the cyst following puncture. No patient in whom the ultrasound appearance suggested a benign cyst was found to have an ovarian malignancy. Three patients with malignant lesions had a total of 4 punctures or biopsies and a final patient had a fine needle biopsy of an ovary to exclude malignancy.

The 'simple' ovarian cyst: aspirate or operate?

One hundred ultrasound-guided ovarian cyst punctures were performed in 88 patients. To minimize the risk of unexpected malignancy, only persistent or painful cysts less than 10 cm in diameter were aspirated, cysts with solid areas or multiple locules were excluded. Cytological diagnosis was not possible in 72 of the 100 fluids; of the others 20 contained cells suggestive of follicular or luteal cysts, four samples suggested endometriosis and four benign tumours of epithelial origin. Oestradiol levels were high in 54 cystic fluids, and a combination of oestradiol estimation and cytology facilitated the identification of a follicular origin. Most such patients would normally have undergone surgery, but this was eventually required in only 10 of 60 in whom the cyst fluid was clear or slightly blood-stained and in 16 of the 28 with heavily blood-stained fluid. Ultrasound-guided ovarian cyst puncture would appear to be a valid alternative to surgery for carefully selected benign ovarian cysts especially when the cyst is considered not to contain blood.

Transabdominal chorionic villus sampling.

The first 100 patients undergoing first trimester transabdominal chorionic villus sampling (placental biopsy) in our hospital are reviewed. At the time of follow up 24 patients had delivered, 68 pregnancies were at 24 weeks or more and progressing normally, 7 pregnancies were terminated and there was only 1 spontaneous miscarriage. The advantages of the transabdominal approach are discussed.