Mean Sac Diameter Research Articles

Open aneurysmorraphy following branched and fenestrated endovascular repair of complex thoracic aneurysms

ObjectiveWe present a review of our hybrid management (endovascular + open surgery) of large thoracic aortic aneurysms (>80 mm). The strategy comprises a primary endovascular repair using thoracic endovascular aortic repair (TEVAR), and/or fenestrated and branched endografts (FBEVAR), followed by open thoracotomy and aneurysmorraphy, specifically without the need for aortic cross-clamping. MethodsWe performed a retrospective review of all patients who had undergone aneurysmorraphy via thoracotomy following TEVAR and FBEVAR in two high-volume aortic centers between December 2017 and March 2024. We performed aneurysmorraphy in two clinical situations: (1) in the setting of a planned staged treatment, shortly after TEVAR or FBEVAR in young patients with aneurysm diameter >100 mm; and (2) as a secondary intervention during follow-up for patients with persistent sac enlargement and aneurysm diameters >80 mm. The primary end points were 30-day survival and aneurysm-related mortality during follow-up. Secondary endpoints were sac size evolution, perioperative and postoperative complications, freedom from further reintervention, and late aortic complications. ResultsTwelve patients underwent aneurysmorraphy following TEVAR and/or FBEVAR during the study period. Mean patient age was 60 ± 12 years, and the mean sac diameter before thoracotomy was 101 ± 25 mm. Endovascular embolization of intercostal arteries prior to aneurysmorraphy was performed in four patients. The 30-day survival rate was 100%. During the mean follow up period of 21 months, two patients died—one of COVID and another of intra-cerebral hemorrhage. No aneurysm-related mortality occurred, and sac regression was achieved in all patients except one experiencing aortic growth below the aneurysmorraphy. ConclusionsThis study demonstrates that thoracic aneurysmorraphy performed after TEVAR and FBEVAR for complex thoracic aneurysms is a safe and effective technique. This procedure allows the eradication of endoleaks and an immediate sac volume reduction, which prevents aorta-bronchial or esophageal fistulation and secures the endovascular repair; the reduction of the aneurysm mass effect restores normal lung parenchyma expansion. This hybrid management strategy drastically reduces the morbidity associated with standard open surgery performed for thoracic endograft explantation.

Characteristics Associated With Faster Human Chorionic Gonadotropin Resolution in C-Section Scar and Cervical Ectopic Pregnancies After Treatment With Double Balloon Catheter [ID 2683550

INTRODUCTION: C-section scar (CSP) and cervical (CXP) ectopic pregnancies are increasing in frequency and associated with significant maternal morbidity. Recently, double balloon catheter (DBC) has been shown as a successful treatment option, but data are limited regarding timing of human chorionic gonadotropin (hCG) resolution. We aimed to define characteristics associated with decreased time to hCG resolution. METHODS: This is a retrospective cohort study of CSPs and CXPs at a single tertiary center treated with DBC placement between 2018 and 2023. Institutional review board approval was obtained. The primary outcome was resolution of serum beta-hCG less than 5 within 30 days. Predictor variables included initial hCG levels, mean sac diameter, and DBC inflation volume. Multivariable logistic regression was used to adjust for gestational age and initial hCG. RESULTS: Thirty-three pregnancies were included; 13 (39%) had resolution of hCG in less than 30 days and 20 (61%) had resolution in greater than or equal to 30 days. Mean sac diameter less than 10 mm and initial hCG less than or equal to 25,000 were significantly associated with hCG resolution less than 30 days (77% versus 40%, aOR 7.18 [95% CI, 1.23–58.8] and 92% versus 60%, aOR 10.38 [95% CI, 1.39–239.98], respectively). There was no significant difference between lower balloon fill amount and hCG resolution. CONCLUSION: After treatment with DBC, most patients require greater than 30 days for hCG resolution. However, patients with mean sac diameter less than 10 mm and initial hCG less than or equal to 25,000 have higher odds of hCG resolution within 1 month, providing a framework for counseling of patients opting for this method.

The MISOPRED score: Development and validation of a clinical scoring system to predict the effectiveness of Misoprostol treatment for early pregnancy loss.

Misoprostol treatment for early pregnancy loss has varied success demonstrated in previous studies. Incorporating predictors in a single clinical scoring system would be highly beneficial in clinical practice. To develop and evaluate the accuracy of a scoring system to predict misoprostol treatment outcomes for managing early pregnancy loss. Retrospective cohort and validation study. Patients discharged from the gynecologic emergency department from 2013 to 2016, diagnosed with early pregnancy loss, who were treated with 800 mcg misoprostol, administrated vaginally were included. All were sonographically reevaluated within 48-72 hours. Patients in whom the gestational sac was not expelled or with endometrial lining >30 mm were offered a repeat dose and returned for reevaluation after seven days. A successful response was defined as complete expulsion. Clinical data were reviewed to identify predictors for successful responses. The scoring system was then retrospectively evaluated on a second cohort to evaluate its accuracy. Multivariate logistic regression was performed to identify factors most predictive of treatment response. The development cohort included 126 patients. Six factors were found to be most predictive of misoprostol treatment effectiveness: nulliparity, prior complete spontaneous abortion, gestational age, vaginal bleeding, abdominal pain, and mean sac diameter, yielding a score of 0-8 (the MISOPRED score), where 8 represents the highest-likelihood of success. The score was validated retrospectively with 119 participants. Successful response in the group with the lowest likelihood score (score 0-3) was 9%, compared with 82% in the highest likelihood score group (score 7-8). Using the MISOPRED score, approximately 15% of patients previously planned to receive misoprostol treatment can be referred for surgical management. MISOPRED score can be utilized as an adjunct tool for clinical decision-making in cases of Early pregnancy loss. To our knowledge, this is the first scoring system suggested to predict the success rate in these cases.

Using simple clinical and ultrasound variables to develop a model to predict first trimester pregnancy viability

IntroductionEarly prediction of pregnancies destined to miscarry will allow couples to prepare for this common but often unexpected eventuality, and clinicians to allocate finite resources. We aimed to develop a prediction model combining clinical, demographic, and sonographic data as a clinical tool to aid counselling about first trimester pregnancy outcome. Material and methodsThis is a prospective, observational cohort study conducted at Queen Charlotte’s and Chelsea Hospital, UK from March 2014 to May 2019. Women with confirmed intrauterine pregnancies between 5 weeks and their dating scan (11–14 weeks) were recruited. Participants attended serial ultrasound scans in the first trimester and at each visit recorded symptoms of vaginal bleeding, pelvic pain, nausea and vomiting using validated scoring tools. Pregnancies were followed up until the dating scan (11–14 weeks). Univariate and multivariate analyses were performed to predict first trimester viability. A model was developed with multivariable logistic regression, variables limited by feature selection, and bootstrapping with multiple imputation was used for internal validation. Results1403 women were recruited and after exclusions, data were available for 1105. 160 women (14.5 %) experienced first trimester miscarriage and 945 women (85.5 %) had viable pregnancies at 11–14 weeks’ gestation. The average gestational age at the initial visit (calculated from the menstrual dates) was 7 + 1 weeks (+/-12.2 days). A multivariable logistic regression model was developed to predict first trimester viability and included the variables: mean gestational sac diameter, presence of fetal heart pulsations, difference in gestational age from last menstrual period and from mean sac diameter on ultrasonography, current folic acid usage and maternal age. The model demonstrated good performance (optimism-corrected area under curve (AUC) 0.84, 95 % CI 0.81–0.87; optimism-corrected calibration slope 0.969). ConclusionWe have developed and internally validated a model to predict first trimester viability with good accuracy prior to the 11–14 week dating scan, which now needs to be externally validated prior to clinical use.

Risk factors associated with the failure of initial treatment for cesarean scar pregnancy.

To explore the factors related to cesarean scar pregnancy (CSP) treatment failure under different treatment strategies. This is a cohort study that consecutively included 1637 patients with CSP. Characteristics including age, gravidity, parity, previous uterine curettages, time since the last cesarean section, gestational age, mean sac diameter, initial serum β-human chorionic gonadotropin, distance between gestational sac and serosal layer, CSP subtype, classification of blood flow abundance, fetal heartbeat presence, and intraoperative bleeding were recorded. Four strategies were performed separately on these patients. Binary logistic regression analysis was used to analyze the risk factors for initial treatment failure (ITF) under the different treatment strategies. The treatment methods failed in 75 CSP patients, and succeeded in 1298 patients. The analysis found that the presence of a fetal heartbeat was significantly associated with ITF of strategy 1, 2 and 4 (P < 0.05); sac diameter was associated with ITF of strategy 1 and 2 (P < 0.05); gestational age was associated with initial treatment failure of strategy 2 (P < 0.05). There was no difference of the failure rate between ultrasound-guided evacuation and hysteroscopy-guided evacuation for CSP treatment with or without uterine artery embolization pretreatment. Sac diameter, fetal heartbeat presence, and gestational age were all associated with CSP initial treatment failure.

The Angiographic and Clinical Follow-up Outcomes of the Wide-Necked and Complex Intracranial Aneurysms Treated With LVIS EVO-Assisted Coiling.

The Low Profile Visible Intraluminal Support EVO (LVIS EVO) is a self-expandable braided stent, which was recently introduced for the treatment of intracranial aneurysms. Full visibility of the stent and a relatively high metal coverage ratio are the unique features of the LVIS EVO. To assess the safety, efficacy, and midterm durability of LVIS EVO stent-assisted coiling for the treatment of wide-necked intracranial aneurysms. The endovascular databases were reviewed to identify patients treated with LVIS EVO-assisted coiling. The technical success and immediate clinical/angiographic outcomes were assessed. Periprocedural and delayed complications were evaluated. The follow-up angiographic/clinical outcomes were investigated. The preprocedural/follow-up neurological statuses were assessed with the modified Rankin Scale. One hundred three aneurysms in 103 patients (63 females) with a mean age of 54.9 ± 11.3 years were included. The mean maximum sac diameter was 6.2 ± 2.9 mm. The procedural technical success rate was 100%. Immediate postprocedural angiography showed complete occlusion in 77.7%. The mean duration of the angiographic follow-up was 8.8 ± 3.6 months. Follow-up angiography showed complete aneurysm occlusion in 89% of the 82 patients with angiographic follow-up. Recanalization was observed in 7.3% of 82 patients. Two patients (2.4%) required retreatment. In addition, 8.7% of the patients had at least 1 complication, and 2.9% of the patients developed a permanent morbidity. All patients had mRS scores ≤2. The results of this study demonstrate that SAC with LVIS EVO is a relatively safe, efficient, and durable treatment for wide-necked and complex intracranial aneurysms.

Methotrexate/mifepristone-combined with embryo removal in the treatment of caesarean scar pregnancy.

The aim of this study was to compare the effect of different administration modalities of methotrexate (MTX)/mifepristone in the initial medication stage, followed by embryo transfer in the treatment of caesarean scar pregnancy (CSP). A retrospective analysis of 66 CSP patients who received treatment in our hospital from January 2015 to July 2021 was performed, and participants were divided into three groups: Group one (n=14) received mifepristone followed by embryo removal treatment, Group two (n=29) received MTX followed by embryo removal, and Group three (n=23) received a methotrexate/mifepristone combined treatment followed by embryo removal. The basic findings were analysed, along with the curative effects between the three groups. Risk factors predicting additional treatment after initial intervention failure were analysed. There were statistically significant differences in gestational age, hospitalization days, costs, myometrial thickness, cardiac activity, and mean sac diameter between groups (p<0.05) after grouping by eight weeks. The initial intervention success rates were 92.86%, 89.66%, and 65.22% in Group one, two, and three, respectively (p<0.05), while the complication rates were 14.29%, 6.90%, and 26.87%, respectively (p>0.05). After grouping according to eight weeks of gestational age, the difference in initial serum β-hCG between Group two and three was statistically significant (p<0.05). Mean sac diameter was a risk factor for additional treatment after initial intervention failure, with an odds ratio of 1.113 (p<0.05). A cut-off of 22.75 mm was a preferable indicator. MTX/mifepristone followed by embryo removal is a reliable way to treat CSP. Mean sac diameter was a risk factor for additional treatment after initial intervention failure.

Fourfold Improved Odds of a Good First Trimester Outcome Once a Yolk Sac Is Seen in Early Pregnancy.

To compare first trimester prognosis when an early pregnancy sonogram demonstrates a gestational sac with yolk sac versus gestational sac without yolk sac. Our study comprised 823 transvaginal sonograms without identifiable embryo performed at least 35 days from last menstrual period (LMP), in which mean sac diameter was <16 mm and first trimester outcome (live or early pregnancy loss) was known. We recorded the presence or absence of yolk sac, first trimester outcome, and several clinical features: maternal age, time since LMP, and presence or absence of vaginal bleeding. We compared the likelihood of a successful first trimester outcome in cases with a visible yolk sac to those without a yolk sac. At the end of the first trimester, 113 of 270 (41.9%) cases without a yolk sac and 414 of 553 (74.9%) with a yolk sac were live (P < .000001, chi-square). This corresponds to an odds ratio of 4.14 for the presence of yolk sac, a result confirmed by logistic regression. Advanced maternal age, ≥42 days since LMP, and vaginal bleeding all carried an increased risk of loss (P < .000001, chi-square). Outcome was better with a visualized yolk sac than without a yolk sac, regardless of number of risk factors (P < .001, chi-square). The odds of successful first trimester outcome are 4-fold higher when a yolk sac is seen on an early pregnancy sonogram than when no yolk sac is seen. For any level of risk, based on maternal age, vaginal bleeding, and time since LMP, outcome is significantly better when a yolk sac is seen.

New Sri Lankan Crown Rump Length Chart

Introduction Accurate pregnancy dating is important for many aspects of obstetric care at individual level as well as population level. Traditionally, pregnancy dating has done by adding 9 months and 7 days to the last menstrual period (LMP) using Naegele’s formula. Determination of gestational age by ultrasound is more precise. Most commonly used parameters are mean sac diameter, gestation sac volume, crown-rump length (CRL), biparietal diameter (BPD), head circumference (HC) and femur length (FL). After 24 weeks, gestational age cannot be accurately determined by ultrasound scans. The biological variability of CRL is small and growth is very rapid. There are many factors that can affect CRL such as measurement errors, differences in growth rates between individuals, fetal sex and maternal conditions such as diabetes mellitus. A correctly performed measurement of CRL is the most accurate way of estimating the gestational age in early pregnancy from 8 weeks to 13 weeks + 6 days. Objectives Our study aims were to prepare a new Crown Rump Length chart with Sri Lankan population data and to compare new CRL chart with existing intergrowth CRL chart. Method Prospective observational study with recruitment of subjects by Quota sampling technique was carried out from April 2015 to March 2016. Spontaneously conceived uncomplicated singleton pregnancies with normal Body Mass Index (BMI) 18.5 - 23 kg/m2 were recruited at the time of registration to antenatal care. Consenting woman with known LMP with regular cycles in preceding 3 months were undergone ultrasound examination only once at gestational age (GA) ranging from 8 weeks to 13 weeks + 6 days. If ultrasound dating was different from LMP dating by more than 5 days in pregnancies with POA less than 9 weeks and dating differences more than 7 days in pregnancies between 9 weeks and 14 weeks were excluded. Pregnancies complicated with uncertain viability, congenital anomalies and spontaneous miscarriage were excluded from statistical analysis. Data collection done with pre-tested interviewer administered form and analysis was carried out using the Statistical Package for Social Sciences (SPSS) version 21. Results A total of 653 subjects were recruited for the study and 557 turned up for ultrasound dating assessment. Dating discrepancy and multiple pregnancies excluded 31 subjects, uncertain viability and spontaneous miscarriage excluded 15 subjects resulting 511 subjects for final statistical analysis. The mean CRL increased with GA almost linearly from day 56 to 97. Conclusions We have produced new CRL chart based on Sri Lankan data and it can be used for clinical practice in Sri Lanka. There is no statistically significant difference between our CRL chart and intergrowth CRL chart.

Effect of a copper intrauterine device on HLA-G and IGF-II levels during pregnancy

ObjectiveAn intrauterine device (IUD) is one of the most effective reversible contraceptive methods currently available. Women who use IUDs may become pregnant, albeit rarely, and many such women continue to use IUDs. Because it is difficult to remove or it may cause miscarriage. This study measured the changes in human leucocyte antigen-G (HLA-G) and insulin-like growth factor II (IGF-II) levels in the decidua and villi to explore the effect of a copper IUD on embryonic development. DesignA total of 54 samples of decidual and villus tissue were collected from pregnant women with IUDs (27 samples) or without IUDs (27 samples). Hematoxylin-eosin staining was used to identify morphological characteristics. Immunohistochemistry was used to detect HLA-G and IGF-II; the protein expression levels were measured via Western blotting. ResultsHLA-G was expressed on the membranes of trophoblasts of villus tissues and the glandular epithelium, and in stromal cells of decidual tissues, in both the IUD and control groups. IGF-II was expressed in the glandular epithelium and cytoplasm of trophoblasts and decidual cells in both groups. Compared to the control group, IGF-II expression was significantly reduced in villus tissues of the IUD group (p < 0.05). The mean sac diameter was significantly positively correlated with IGF-II expression in the villi (p < 0.05). ConclusionsA copper IUD may affect embryonic development by regulating the expression of villus IGF-II.

Gradient boosted trees with individual explanations: An alternative to logistic regression for viability prediction in the first trimester of pregnancy

BackgroundClinical models to predict first trimester viability are traditionally based on multivariable logistic regression (LR) which is not directly interpretable for non-statistical experts like physicians. Furthermore, LR requires complete datasets and pre-established variables specifications. In this study, we leveraged the internal non-linearity, feature selection and missing values handling mechanisms of machine learning algorithms, along with a post-hoc interpretability strategy, as potential advantages over LR for clinical modeling. MethodsThe dataset included 1154 patients with 2377 individual scans and was obtained from a prospective observational cohort study conducted at a hospital in London, UK, from March 2014 to May 2019. The data were split into a training (70%) and a test set (30%). Parsimonious and complete multivariable models were developed from two algorithms to predict first trimester viability at 11–14 weeks gestational age (GA): LR and light gradient boosted machine (LGBM). Missing values were handled by multiple imputation where appropriate. The SHapley Additive exPlanations (SHAP) framework was applied to derive individual explanations of the models. ResultsThe parsimonious LGBM model had similar discriminative and calibration performance as the parsimonious LR (AUC 0.885 vs 0.860; calibration slope: 1.19 vs 1.18). The complete models did not outperform the parsimonious models. LGBM was robust to the presence of missing values and did not require multiple imputation unlike LR. Decision path plots and feature importance analysis revealed different algorithm behaviors despite similar predictive performance. The main driving variable from the LR model was the pre-specified interaction between fetal heart presence and mean sac diameter. The crown-rump length variable and a proxy variable reflecting the difference in GA between expected and observed GA were the two most important variables of LGBM. Finally, while variable interactions must be specified upfront with LR, several interactions were ranked by the SHAP framework among the most important features learned automatically by the LGBM algorithm. ConclusionsGradient boosted algorithms performed similarly to carefully crafted LR models in terms of discrimination and calibration for first trimester viability prediction. By handling multi-collinearity, missing values, feature selection and variable interactions internally, the gradient boosted trees algorithm, combined with SHAP, offers a serious alternative to traditional LR models.

The incidence and importance of the pseudogestational sac revisited

In a pregnancy of unknown location, an intrauterine fluid collection may represent either the early gestational sac of an intrauterine pregnancy, or as reported in previous literature, the pseudogestational sac of an ectopic pregnancy. Various sonographic features have been used to distinguish these 2 entities, but the clinical relevance of the pseudogestational sac remains unclear. To establish the incidence and relative rate of intrauterine fluid collection among ectopic and intrauterine pregnancies and to determine if the size of the collection differs between ectopic and intrauterine pregnancies STUDY DESIGN: We performed a retrospective cohort study of women with pregnancies of unknown location and pelvic or abdominal pain or bleeding. We calculated the incidences of intrauterine fluid collections among ectopic and intrauterine pregnancies, including both ongoing pregnancies and spontaneous abortions, given that that our focus was location and not viability. We calculated the relative risk of ectopic pregnancy if an intrauterine fluid collection was present, adjusting for age and vaginal bleeding. We compared the incidences of ectopic and intrauterine pregnancies among those with and without intrauterine fluid collections. Among those with collections, we compared the mean sac diameter between ectopic and intrauterine pregnancies in continuous and categorical fashions. We evaluated 1236 women presenting with a pregnancy of unknown location. The rates of ectopic and intrauterine pregnancies (including spontaneous abortions) were 13.1% and 63.9%, respectively, with the remainder lost to follow-up. On ultrasound, 452 women (36.6%) had an intrauterine fluid collection. Eight of 162 ectopic pregnancies (4.9%) had a collection, compared with 363 of 789 intrauterine pregnancies (46.0%) (P=.01). Of the ectopics with a fluid collection, 5 had an adnexal mass. The presence of intrauterine fluid collection decreased the risk of ectopic pregnancy (adjusted relative risk, 0.09; 95% confidence interval, 0.05-0.19) after adjusting for age and the presence of bleeding. Among those with an intrauterine fluid collection, the rate of ectopic pregnancy was 2.2%, and the rate of intrauterine pregnancy was 97.8%; among those without a collection, the rate of ectopic pregnancy was 26.7%, and the rate of intrauterine pregnancy was 73.3%. The mean sac diameter did not differ between ectopic and intrauterine pregnancies, whether analyzed continuously or categorically. In the presence of an intrauterine fluid collection, the rate of ectopic pregnancy is very low. The size of the intrauterine fluid collection in a woman with a pregnancy of unknown location cannot be used to distinguish between a gestational sac and a pseudogestational sac. Pseudogestational sacs are uncommon and of little clinical consequence. In assessing pregnancies of unknown location, clinicians should incorporate the entire clinical picture, including other sonographic findings, to avoid incorrect or delayed diagnoses.

Using Ultrasound for Pregnancy Failure in Patients with 1st Trimester Recurrent Pregnancy Loss

Background: Pregnancy loss is the interruption and/or termination of pregnancy, either spontaneously or intentionally, before the fetus develops sufficiently to survive. About 80% of abortions occur in the first 12 weeks of pregnancy. Objective: To determine the accuracy of U/S parameters in predicting early pregnancy failure in pregnant with history of 1st trimesteric recurrent pregnancy loss. Patients and methods: This was a prospective study that included 120 pregnant females with history of first trimesteric recurrent pregnancy loss. It was conducted in Obstetrics and Gynecology Department, Menoufia University Hospitals, and Rashid General Hospital, Al-Bahira, Egypt during the period from April 2019 until August 2020. Results: There is no significant difference between miscarriage group and ongoing pregnancy group regarding risk factors and demographic data (p > 0.05). In addition, crown-rump length (CRL) below 5th percentile for gestational age (GA) category more significantly prevalent in the miscarriage group compared to the ongoing pregnancy group. While, mean gestational sac diameter (MGSD) below 5th percentile for GA, caudal displacement of gestational sac (GS) or irregular GS could predict subsequent miscarriage. Embryonic heart rate/Fetal heart rate (EHR/FHR) below 5th percentile for GA was statistically significantly more prevalent in the miscarriage group than in ongoing pregnancy group. Abnormally large YSD (> 95th percentile for GA), absent yolk sac (YS), floating YS, deformed, irregular or hypo-echoic YS could predict subsequent miscarriage. Uterine artery resistance index (RI), pulsatile index (PI) and systolic/diastolic (S/D) ratio did not differ significantly between the miscarriage group compared to the ongoing pregnancy group across the various gestational ages. Conclusion: 1st trimester U/S parameters are useful diagnostic tool to prognosis pregnancy outcome among patients with history of recurrent 1st trimester pregnancy loss.

Evaluating the Transvaginal Ultrasound Diagnostic Criteria for Abnormal First-Trimester Pregnancy With Follow-Up Into the Third Trimester and Validation of Results.

To evaluate the current ultrasound diagnostic criteria for non-viable pregnancy in the first trimester. We conducted a retrospective chart review involving 3 tertiary care institutions. Consecutive first-trimester ultrasound reports between January 2013 and June 2016 were reviewed. All first-trimester ultrasound examinations performed to assess pregnancy viability with adequate imaging or clinical follow-up were included. Inclusion criteria based on follow-up were adequate imaging to document ongoing intrauterine pregnancy or clinical follow-up demonstrating viability or non-viability. Data on mean sac diameter (MSD), yolk sac presence/diameter, embryo presence/length, presence of a heartbeat, and heart rate were collected. This was followed by a retrospective validation review of another consecutive cohort. Two hundred and forty-five examinations with a viable-pregnancy outcome and 301 examinations with a non-viable pregnancy outcome were reviewed. The main predictor of non-viable pregnancy was an MSD of ≥20 mm in the absence of a yolk sac (positive predictive value [PPV] 100%; 95% CI 93%-100%), embryo (PPV 100%; 95% CI 90%-100%), or heartbeat (PPV 100%; 95% CI 96%-100%]). Other predictors of non-viability were a measurable embryo without a yolk sac (PPV 100%; 95% CI 91%-100%), yolk sac diameter ≥8 mm (PPV 100%; 95% CI 91%-100%), and absence of heartbeat with an embryo ≥3 mm (PPV 100%; 95% CI 97%-100%). These findings were confirmed in a validation cohort of 45 viable and 53 non-viable pregnancies, with the exception of 1 case of viable pregnancy with no heartbeat and an embryo length 3.3 mm. Based on the median daily growth of 1.2 mm in the viable cohort, 21% of follow-up ultrasound examinations were performed too early for an MSD threshold of 20 mm and 55%, for an MSD threshold of 25 mm. In our cohort, MSD ≥20 mm in the absence of yolk sac or an embryo with heartbeat always predicted a non-viable pregnancy.

Pulmonary arteriovenous malformation (PAVM) embolization: prediction of angiographically-confirmed recanalization according to PAVM Diameter changes on CT

BackgroundTo assess pulmonary arteriovenous malformation (PAVM) recanalization after embolization based on PAVM diameter changes on computed tomography (CT), with pulmonary angiography used as a gold standard.MethodsA retrospective review was done of patients from 2008 to 2019 with a PAVM treated with endovascular embolization. The treatment outcome was determined by conventional angiography. Follow-up pulmonary angiography was performed when recanalization was suspected on CT, or embolization of all lesions in multiple PAVM patients could not be completed in a single session. Patients who had no preprocedural or follow-up CT were excluded. Draining vein, feeding artery, and venous sac diameter were measured on CT, and diameter reduction rates were compared with the widely-used, binary 70 % criteria.ResultsForty-one patients with 114 PAVMs were treated during the study period. Eight patients with 50 PAVMs met the inclusion criteria. Mean vein, artery, and venous sac diameter reduction rates were as follows: 59.2 ± 9.3 %, 47.5 ± 10.6 %, and 62.6 ± 13.2 %, respectively, in the occluded group and 5.4 ± 19.5 %, 11.3 ± 17.7 %, and 26.8 ± 14.2 %, respectively, in the recanalized group. The area under the receiver operating characteristic curves for PAVM recanalization for the draining vein was 1.00, showing a better result than the artery (0.97) and sac (0.99). Patients showed > 42 % draining vein diameter reduction in the occluded group and < 32 % in the recanalized group. The widely-used 70 % criteria showed low specificity for predicting recanalization (draining vein, 7.3 %; venous sac, 41.7 %) but 100 % sensitivity for both the draining vein and venous sac.ConclusionsThe widely-used 70 % binary criteria showed limited performance in predicting outcomes in this angiographically-confirmed case series. Further investigations are warranted to establish a strategy for detecting recanalization after PAVM embolization.

Корреляции в патогенезе неразвивающейся беременности

Objective. To improve the quality of life and outcome by consecutive pregnancy in patients based on the analysis of correlations and differences in markers for the diagnosis by early pregnancy loss (EPL) in early gestation period (up to 12 weeks). Patients and methods. 100 patients aged 18 to 40 years diagnosed with early pregnancy loss (EPL) at 7–8 and 9–10 weeks of obstetric term were examined. The types of EPL were identified by ultrasound criteria; correlations and differences in the EPL mechanism during early pregnancy were determined. Time characteristics of the gestational sac (GS) development from conception to miscarriage and the duration of persistence of an empty sac in the uterine cavity before the diagnosis of EPL were recorded. Molecular genetic testing of the chorion in 42 women with EPL was performed by multi-locus quantitative fluorescent polymerase chain reaction (PCR). The method of manual vacuum aspiration under the control of hysteroscopy was developed, followed by the administration of antibacterial, antiviral, and immunomodulatory therapy with Viferon® rectal suppositories at a dose of 1,000,000 IU 1 suppository twice a day at 12-hour intervals for 10 days and Viferon® gel 36,000 IU on the vaginal region of the cervix at a dose of 2 mL twice a day for 7 days. Results. The period of hospital admission for patients with embryonic miscarriage (EM) as the type of EPL prevailed between 8 and 10 weeks, on the average – 9.5 weeks of obstetric term, in contrast to empty sac (ES, 7–8 weeks). The period of the GS development in ES ranged from 17 to 36 days (2.3 to 5.1 weeks); in EM – 4 to 9 weeks (26 to 69 days) in 96% of patients, and the embryo development was from 3–4 to 6–7 weeks from conception (21 to 49 days). There was a 1.2-week difference in the desynchronization of the development of GS and an embryo. A significant positive correlation between gestational age (before diagnosis) and β-hCG levels (26,348 ± 18,289 mIU/mL) in patients without bloody discharge at the time of hospitalization was observed. However, there was a desynchronization of lag in β-hCG levels by an average of 3 times (8661 ± 7701 mIU/mL) in the presence of bloody discharge, although the sizes of GS according to mean sac diameter (MSD) were comparable (28 ± 13 mm and 30 ± 11 mm). There was a complete lack of synchronization of the abnormal development of GS, an embryo, β-hCG levels, and the duration of GS persistence in the uterine cavity after miscarriage. The following correlations occurred in the pathogenesis of EPL: chromosomal abnormalities (45% in EM and 40% in ES), history of gynecological and viral diseases (49% in EM and 41% in ES). Correlational differences in the developmental period of GS according to MSD, an embryo, the period of persistence in the uterine cavity after miscarriage, the uterine size, and mean β-hCG levels (at week 8-10) in EM were at different gestation periods before the onset of manifestation of miscarriage. Conclusion. Determination of correlation dependencies and differences in the results of monitoring diagnostic markers of different types of EPL makes it possible to develop a personalized approach to the choice of gestational sac aspiration, antibacterial, antiviral, and immunomodulatory therapy with Viferon® (interferon α-2b with antioxidant complex) for a successful consecutive pregnancy and its outcome. Key words: anembryonic pregnancy, embryonic miscarriage, correlations, pathogenesis by early pregnancy loss, early pregnancy loss, persistence of empty sac, β-hCG

Combining early (

Placental related adverse pregnancy outcomes such as fetal growth restriction have significant short- and long-term implications for both mother and fetus. This study aimed to determine if conventional and novel early first trimester ultrasound measures are associated with small for gestational age (SGA) neonates. In addition, we aimed to assess whether a combination of ultrasound measures, maternal characteristics and biochemistry improved the prediction of this adverse pregnancy outcome. This was a prospective cohort study including ultrasound measurements: trophoblast thickness (TT), trophoblast volume (TV), mean uterine artery pulsatility index, crown-rump length, fetal heart rate, mean sac diameter (MSD) and yolk sac diameter. Biochemical markers considered in the analysis were placental growth factor (PIGF), pregnancy - associated plasma protein A (PAPP-A), beta human chorionic gonadotropin and alpha fetoprotein. Regression models were fitted for ultrasound parameters using multiples of the median (MoM). All measures were compared with normal birthweight (BW) ≥10th centile and SGA (BW<10th centile). Logistic regression analysis was used to create a clinical prediction model for SGA based on maternal characteristics, ultrasound measurements at <11weeks gestational age and maternal biochemistry collected at 10-14weeks. As compared to pregnancies delivered of babies with normal BW (n=1068), MoM values for TT, TV, MSD, PAPP-A and PIGF were significantly reduced (P<0.05) in pregnancies delivered of SGA babies (n=73). The proposed logistic regression model includes maternal height, TV and PIGF resulting in an area under the receiver operator curve 0.70 (95% CI 0.63-0.76) for the prediction of SGA. A significantly decreased TV, measured <11weeks gestation, is predictive of BW<10th centile. With addition of maternal height and PIGF, this three-marker algorithm provided a reasonable predictive value for the development of SGA later in pregnancy.

First-Trimester Prognosis When an Early Gestational Sac is Seen on Ultrasound Imaging: Logistic Regression Prediction Model.

To determine the factors that jointly and independently affect first-trimester outcome of very early intrauterine pregnancies (those whose sonogram shows a gestational sac with no identifiable yolk sac or embryo) and develop a mathematical model and Web-based calculator that computes prognosis based on these factors. Our study population included 590 very early pregnancies scanned between January 1, 2012, and June 30, 2018, with known outcomes (live or spontaneous loss) at 14 weeks. We recorded patient age, mean sac diameter (MSD), human chorionic gonadotropin (hCG) rise, and presence/absence of: vaginal bleeding, history of infertility, prior miscarriage, and pregnancy via assisted reproductive technology. We assessed the correlation between each of these factors and outcome and performed stepwise logistic regression to determine the subset that independently correlated with outcome. Patient age, MSD, hCG rise, vaginal bleeding, history of infertility, and assisted reproductive technology pregnancy were significantly correlated with outcome (P < .05, t test for age and MSD, χ2 for the others). Stepwise logistic regression identified age, MSD, hCG rise, and vaginal bleeding as the subset of factors that independently predicted outcome. The regression model's area under the receiver operating characteristic curve was 0.823. We incorporated the regression model into a Web-based calculator (https://tinyurl.com/Prognosis-PD) that predicts the outcome of an early intrauterine pregnancy based on these 4 key variables. The prognosis of very early intrauterine pregnancies is related to several clinical, biochemical, and sonographic factors. The factors that independently correlate with first-trimester outcome are patient age, MSD, hCG rise, and vaginal bleeding. The logistic regression model predicts outcome based on these variables.

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

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). 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. Thirty-one patients were included in this study. The mean gestational age, sac diameter and thickness of the uterine scar were 49.6±7.7days, 1.8±0.6cm and 0.30±0.15cm, respectively. The median pretreatment serum β-human chorionic gonadotropin (β-HCG) level was 40,887mIU/mL, with the 25th and 75th percentiles at 19,852 and 74,552, respectively. The median blood loss during D&C was 20mL with the 25th and 75th percentiles at 10mL and 50mL. 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 β-HCG regression time of ≤ 4weeks after D&C. While 30 patients (96.8%) had a uterine recovery time of ≤ 4weeks, and 29 patients (93.5%) had resumption of menstruation of less than 6weeks. 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. 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.

Combination of conservative treatment and temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection for cervical pregnancy: A retrospective study

IntroductionWe investigated whether temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection (LUA clipping-TCR) is an effective minimally invasive treatment for the management of cervical pregnancy. Materials and methods: This study is a retrospective clinical case series conducted at Teine Keijinkai Hospital from January 2014 to June 2019. Nine cervical pregnancies among 164 ectopic pregnancies were retrospectively examined. The intervention involved performing LUA clipping-TCR on villous tissue. Information on patient characteristics, clinical data, and surgical details was collected from medical records and surgical videos. ResultsThe mean (range) age of the patients was 33 years (29–41 years); and mean gestational sac diameter, 12.8 mm (5–24 mm). Five patients had a history of intrauterine procedures. Three patients had a positive fetal heartbeat. The mean (range) preoperative serum hCG level (mIU/mL), surgical time (min), uterine artery blocking time (min), and amount of surgical blood loss (ml) were 14,040 (2880–41,367), 82 (62–120), 42 (21–68), and 57 (10–200), respectively. The mean decrease in serum hCG level (second postoperative day) and duration until resumption of menstruation were 79.7 % (70–86.7 %) and 46 days (35–80 days), respectively. The hospitalization period was 2–3 days, with no evidence of persistent ectopic pregnancy. Live birth was achieved in four cases. DiscussionOur results confirm previous findings and provide new evidence that LUA clipping-TCR is effective for cervical pregnancy management and fertility preservation, respectively. Future large-scale prospective studies to compare different cervical pregnancy management methods are required.