Mean Sac Diameter Research Articles

Intrauterine ectopic pregnancy - ultrasound typing and treatment.

To analyze the correlation between ultrasound typing and treatment modality of patients with an intrauterine ectopic pregnancy (cervical and cesarean scar). We retrospectively enrolled 65 patients diagnosed with cesarean scar pregnancy (CSP) or cervical pregnancy (CP) between February 2014 and May 2018. The cases were divided into two types according to the ultrasound presentation with a gestational sac (GS, type I) or a heterogeneous mass (HM, type II). Type I was further divided into type Ia (< 8 weeks) and type Ib (≥ 8 weeks); type II was defined as type IIa (with poor or no vascularity) and type IIb (with rich vascularity). Three treatment methods were applied in each group. Of included cases, there were 53 CSP and 12 CP. There was no significant difference between Type I and Type II groups in any variable. The beta human chorionic gonadotropin (β-hCG) level and gestational age of type IIb were significantly higher compared to type IIa (p < 0.05). There was a positive correlation between ultrasound categories and treatment methods (rs = 0.723, p = 0.000). Analysis of CSP cases of initial treatment failure indicated success rate of initial dilation and curettage (D&C) was dependent upon ultrasonic types, mean sac diameter, gestational age, hCG level, and number of cesarean sections. The features of ultrasound imaging might provide an additional reference for the selection of clinical treatment methods.

Outcomes of the Gore Excluder Iliac Branch Endoprosthesis Using Division Branches of the Internal Iliac Artery as Distal Landing Zones

Purpose: To evaluate the outcomes of the Gore Excluder Iliac Branch Endoprosthesis (IBE) using division branches of the internal iliac artery (IIA) as distal landing zones. Materials and Methods: Between January 1, 2014, and December 31, 2018, 74 patients (mean age 74±7 years; 72 men) treated for aortoiliac or common iliac artery aneurysms had an IBE deployed with distal landing of the side branch within the main trunk (n=60) of the internal iliac artery (IIA) vs within a division branch (n=25). Thirteen (17%) patients received bilateral IBE implantations for a total of 85 vessels evaluated. Early endpoints were technical success, 30-day mortality, 30-day major adverse events (MAEs), and 30-day major access complications. Late endpoints were survival, primary and secondary IIA patency, freedom from IIA branch instability, freedom from new-onset buttock claudication, and aneurysm sac diameter changes. Time-dependent outcomes were reported as Kaplan-Meier curves with differences assessed using the log-rank test. Estimates are presented with the 95% confidence interval (CI). Results: The overall technical success rate was 97%, with 1 technical failure per group (p=0.43). Two patients, one from each group, died within 30 days (p=0.43). No significant differences were seen in the rates of 30-day MAEs (7% vs 17%, p=0.35) or major access complications (9% vs 11%, p>0.99) for patients receiving distal landing in the main trunk vs a division branch, respectively. The mean follow-up for the entire cohort was 19±12 months. The overall 1-year survival rate was 94% (95% CI 74% to 99%). The primary and secondary patency rates at 1 year were 98% (95% CI 88% to 99%) vs 95% (95% CI 72% to 99%, p=0.72) and 98% (95% CI 88% to 99%) vs 100% (p=0.41) for the main trunk vs division branch groups, respectively. Freedom from IIA branch instability estimates were also similar at 1-year follow-up [93% (95% CI 82% to 97%) vs 90% (95% CI 66% to 97%), p=0.29], as were the freedom from new-onset buttock claudication estimates [98% (95% CI 86% to 99%) and 94% (95% CI 67% to 99%), respectively; p=0.62]. Mean sac diameter change was 5.4±5.3 mm, not significantly different between the groups (p=0.85). Conclusion: Use of the posterior or anterior division of the IIA as a distal landing zone for the Gore Excluder IBE was safe and efficacious in the midterm. This technique may permit extending indications for endovascular repair of aortoiliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Long-term assessment is needed to affirm the efficacy of this technique.

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

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. 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. 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. 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.

Multicenter experience in translumbar type II endoleak treatment in the hybrid room with needle trajectory planning and fusion guidance

ObjectiveThe objective of this study was to evaluate the efficacy of treating type II endoleaks (T2Ls) after aortic endovascular repair with image guidance translumbar puncture using intraoperative cone beam computed tomography with preprocedure computed tomography angiography fusion in hybrid operating rooms. MethodsTwenty-six consecutive T2L patients in three different institutions were treated between March 2015 and September 2017 by direct translumbar puncture of the abdominal aortic aneurysm (AAA) sac after previous endovascular aortic repair. All patients were treated at a single setting in a cardiovascular hybrid operating room with a workstation featuring needle trajectory planning and guidance software. Aneurysm sac size change from the index treatment, freedom from recurrent endoleak after treatment, demographics, risk factors, and procedure factors were analyzed with univariate analysis. ResultsAll patients (N = 26; 19 male, 7 female; age range, 59-95 years; mean body mass index, 27.44 ± 3.06 kg/m2) underwent treatment for AAA sac expansion or symptoms. Four patients had failed to respond to previous catheter-directed T2L treatment. The most common risk factors included hypertension, hypercholesterolemia, coronary artery disease, tobacco use, and diabetes. Time to initial endoleak diagnosis ranged from 2 to 1914 days (average, 404 days). Aneurysm size after initial repair was 60.3 ± 7.5 mm; sac size had increased 10.1 ± 6.5 mm at the time of treatment. Onyx (Medtronic, Irvine, Calif) or glue (n-butyl cyanoacrylate) and coil embolization was used in 20 cases, and 6 patients were treated with coiling alone. There was no difference between the patients treated with coils alone and those treated with coils or glue (P > .05) in terms of freedom from failure. Total procedure time was 75.9 ± 40.7 minutes; contrast material volume, 19.9 ± 29 mL; fluoroscopy time, 13.74 ± 12.2 minutes; and radiation dose, 121.16 ± 167.7 mGy. After embolization, the mean sac diameter decreased by 2.2 mm to 67.5 ± 9.8 mm. Average follow-up period was 214 days. In 19 patients, the sac reduced in size between 0.2 and 19.1 mm per 100 days; in 2 patients, there was continued AAA expansion (3.4-4.3 mm per 100 days); there was no change in the sac size in 5 patients after the procedure. There were no AAA ruptures during the study period. Once T2L was treated, the recurrence rate was low at 11.5%. ConclusionsThis initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L compared with transarterial or transcaval embolization because of its high success rate and technical ease.

First-trimester ultrasound features associated with subsequent miscarriage: A prospective study.

First-trimester miscarriage is common, with women increasingly offered an ultrasound scan early in the first trimester to assess the status of their pregnancy. Ultrasound is uniquely situated to significantly impact the clinical management of these women. This study aims to determine whether there were any differences in the early ultrasound appearances of pregnancies that continued to be viable or resulted in miscarriage before 12 weeks gestation. This was a prospective cohort study including ultrasound measurements: mean sac diameter (MSD), yolk sac diameter (YSD), crown-rump length (CRL), fetal heart rate (FHR), trophoblast thickness, trophoblast volume (TTV) and mean uterine artery pulsatility index (meanUAPI). Regression models were fitted for each parameter and Z-scores compared between cohorts that progressed or miscarried after the scan but before 12 weeks gestation. Logistic regression analysis was used to create a prediction model for miscarriage prior to 12 weeks gestation based on the standardised ultrasound measurements recorded during the early first-trimester scan. Comparison of Z-Scores for meanUAPI, TTV, FHR and MSD demonstrated significant variation between the two groups. The proposed logistic regression model resulted in an area under the receiver operator curve of 0.81. At a false-positive rate of 30%, the model resulted in a sensitivity of 76% (95% CI 64-89%). The combination of FHR, meanUAPI, TTV in a prediction model for miscarriage may prove to be of value for ongoing pregnancy management in the first trimester.

AAN 4. A 14-Year Single-Center Review of Inflammatory Abdominal Aortic Aneurysm Repair

The objective of this study was to review our experience with the contemporary management of inflammatory abdominal aortic aneurysms (IAAAs) involving either open surgery (OS) or endovascular aneurysm repair (EVAR). There were 120 consecutive patients (mean age, 70 ± 8 years; 97 male patients) undergoing IAAA repair between 2004 and 2017 included. Primary outcomes were all-cause mortality and AAA-related mortality. Freedom from reintervention, presence of hydronephrosis (HF) caused by perianeurysmal fibrosis, and renal insufficiency (defined as absolute serum creatinine value >2 mg/dL or an increased value >0.5 mg/dL vs the baseline one) before and after repair at the last follow-up were considered secondary end points. EVAR was performed according to the instructions for use of each device. Mean follow-up was 41 (range, 0-168) months; 110 (92%) patients were treated by OS and the remaining 10 (8%) by EVAR. Mean sac diameter was 69 (±14) mm. Twenty-one (17%) patients had a ruptured IAAA. The 30-day mortality was 5.9% (n = 7), with all deaths in the OS group (P = 1). Overall survival was 70%, 59%, and 30% at 1 year, 2 years, and 5 years, respectively. Elective survival was 96%, 93%, and 79% at 1 year, 2 years, and 5 years (EVAR vs OS, P = . 45). Eleven (9%) aneurysm-related deaths occurred, two in the EVAR group and nine in the OS group (P = .23). Freedom from reintervention was 94%, 92%, and 83% at 1 year, 2 years, and 5 years, respectively. Reintervention was more frequent in the EVAR vs the OS group (55.6% vs 4.6%; P < .001). HF occurred in 26 (22%) and 17 (14%) patients before and after repair, respectively. Repair resolved HF in 17 patients, whereas a new HF occurred after repair in another 8 patients. The Table reports results on HF and renal insufficiency before and after repair for both OS and EVAR groups as well as independent predictors of mortality at multivariate analysis. In this 14-year single-center study, a ruptured IAAA showed up in nearly one of five patients with a high mortality rate. EVAR could be a reasonable option to decrease the mortality rate in such complex patients; however, EVAR did not seem to offer any benefits for HF and renal insufficiency vs OS. More patients and long-term data are still needed.TableOutcomes and predictors for mortalityResultsOS (110), No. (%)EVAR (10), No. (%)P valueAAA-related deaths9 (8.2)2 (20).2330-Day mortality7 (6.4)01HF before repair25 (24)2 (22)1HF after repair13 (12)4 (44.4).03Renal insufficiency before repair7 (6.5)1 (11).51Renal insufficiency after repair8 (7.4)3 (33).04Dialysis3 (2.7)01Predictors for mortalityOR95% CIP valueOS3.51.6-4.8.02Age >80 years1.31.1-1.6.001Urgent repair34.911.6-47.8.036HF before repair8.691.3-56.3.025Anticoagulation therapy9.42.6-14.8.036AAAc, Abdominal aortic aneurysm; CI, confidence interval; EVAR, endovascular aneurysm repair; HF, hydronephrosis; OR, odds ratio; OS, open surgery. Open table in a new tab

AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations.

AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations.

The Psychobiology and Genetics of Human Personality

To describe the incidence, management, and complications of cesarean scar pregnancy (CSP) and define risk factors for conversion from medical to surgical treatment of CSP.Retrospective clinical study (Canadian Task Force classification II-3).Tertiary medical center.All patients who were admitted and treated for CSP between 2008 and 2016.The cohort was divided according to management, and demographic, clinical, and sonographic data were collected. Rates of conversion were compared between groups, and risk factors necessitating conversion were sought.Forty-six cases of CSP were identified. The incidence of CSP has increased from 0.05% to 0.09% of all deliveries. A regression model for absolute numbers of CSP predicted an additional 0.47 CSP each year (p = .03). The most common treatment modalities were systemic treatment with methotrexate (28.2%) and ultrasound-guided intrasac injection of KCl with systemic treatment of methotrexate (58.7%). The mean sac diameter (MSD) of cases that were converted was 11.2 mm larger than in cases that were not converted (p < .001). No patients with an MSD <10 mm or a trophoblastic mass <20 mm3 were converted to surgical management. Maximal levels of beta human chorionic gonadotropin (β-hCG) were significantly associated with the risk of conversion. Only 6.3% of patients with a β-hCG level <10,000 IU at presentation were converted from medical to surgical management. There was no significant association between fetal cardiac activity and conversion from medical to surgical management.CSP has emerged as an important phenomenon in modern obstetrics and gynecology, and its frequency appears to be on the rise. The preferred method of treatment remains unclear; however, it is possible that a large MSD and trophoblastic mass at presentation should prompt surgical treatment.

Cesarean Scar Pregnancies: Incidence and Factors Associated with Conversion to Surgery from Medical Management

To describe the incidence, management, and complications of cesarean scar pregnancy (CSP) and define risk factors for conversion from medical to surgical treatment of CSP. Retrospective clinical study (Canadian Task Force classification II-3). Tertiary medical center. All patients who were admitted and treated for CSP between 2008 and 2016. The cohort was divided according to management, and demographic, clinical, and sonographic data were collected. Rates of conversion were compared between groups, and risk factors necessitating conversion were sought. Forty-six cases of CSP were identified. The incidence of CSP has increased from 0.05% to 0.09% of all deliveries. A regression model for absolute numbers of CSP predicted an additional 0.47 CSP each year (p = .03). The most common treatment modalities were systemic treatment with methotrexate (28.2%) and ultrasound-guided intrasac injection of KCl with systemic treatment of methotrexate (58.7%). The mean sac diameter (MSD) of cases that were converted was 11.2 mm larger than in cases that were not converted (p < .001). No patients with an MSD <10 mm or a trophoblastic mass <20 mm3 were converted to surgical management. Maximal levels of beta human chorionic gonadotropin (β-hCG) were significantly associated with the risk of conversion. Only 6.3% of patients with a β-hCG level <10,000 IU at presentation were converted from medical to surgical management. There was no significant association between fetal cardiac activity and conversion from medical to surgical management. CSP has emerged as an important phenomenon in modern obstetrics and gynecology, and its frequency appears to be on the rise. The preferred method of treatment remains unclear; however, it is possible that a large MSD and trophoblastic mass at presentation should prompt surgical treatment.

Multicenter Experience in Translumbar Type II Endoleak Treatment in the Hybrid Room With Needle Trajectory Planning and Fusion Guidance

The objective of this study was to evaluate the efficacy of treating type II endoleaks (T2Ls) after aortic endovascular repair with image guidance translumbar puncture using intraoperative cone beam computed tomography with preprocedure computed tomography angiography fusion in hybrid operating rooms. There were 26 consecutive T2L patients in three different institutions treated between March 2015 and September 2017 using direct translumbar puncture of the abdominal aortic aneurysm (AAA) sac after previous endovascular aortic repair. All patients were treated at a single setting using a needle trajectory planning and guidance software (Needle ASSIST; GE Healthcare, Chicago, Ill). All patients (n = 26; 19 men, 7 women; age range, 59-95 years; mean body mass index, 27.44 ± 3.06 kg/m2) underwent treatment for AAA sac expansion or symptoms. Four patients had failed to respond to previous catheter-directed T2L treatment. Time to initial endoleak diagnosis ranged from 2 to 1914 days (average, 404 days). Aneurysm size after initial repair was 60.27 ± 7.5 mm; sac size had increased 10.12 ± 6.5 mm at the time of treatment. Onyx (ev3, Covidien, Plymouth, Minn) or glue (n-butyl cyanoacrylate) and coil embolization were used in 20 of 26 cases; 6 patients were treated with coiling alone. Total procedure time was 75.9 ± 40.7 minutes, contrast material volume was 19.9 ± 29 mL, fluoroscopy time was 13.74 ± 12.2 minutes, and radiation dose was 121.16 ± 167.7 mGy. After embolization, the mean sac diameter decreased by 4.3 mm to 64.6 ± 9.3 mm. The average follow-up period was 214 days. In 18 patients, the sac reduced in size from 0.2 to 47.62 mm/100 days; in 3 patients, there was continued AAA expansion (0.6 to 4.31 mm/100 days); there was no change in the sac size in 4 patients after the procedure. Once treated, the recurrence rate of T2L was low (Fig). The patients with sac growth tended to be associated with higher body mass index and baseline estimated glomerular filtration rate levels (P = .09). This initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent midterm efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L after endovascular aortic repair going forward.

Measurement error of mean sac diameter and crown-rump length among pregnant women at Mulago hospital, Uganda

BackgroundUltrasonography is essential in the prenatal diagnosis and care for the pregnant mothers. However, the measurements obtained often contain a small percentage of unavoidable error that may have serious clinical implications if substantial. We therefore evaluated the level of intra and inter-observer error in measuring mean sac diameter (MSD) and crown-rump length (CRL) in women between 6 and 10 weeks’ gestation at Mulago hospital.MethodsThis was a cross-sectional study conducted from January to March 2016. We enrolled 56 women with an intrauterine single viable embryo. The women were scanned using a transvaginal (TVS) technique by two observers who were blinded of each other’s measurements. Each observer measured the CRL twice and the MSD once for each woman. Intra-class correlation coefficients (ICCs), 95% limits of agreement (LOA) and technical error of measurement (TEM) were used for analysis.ResultsIntra-observer ICCs for CRL measurements were 0.995 and 0.993 while inter-observer ICCs were 0.988 for CRL and 0.955 for MSD measurements. Intra-observer 95% LOA for CRL were ± 2.04 mm and ± 1.66 mm. Inter-observer LOA were ± 2.35 mm for CRL and ± 4.87 mm for MSD. The intra-observer relative TEM for CRL were 4.62% and 3.70% whereas inter-observer relative TEM were 5.88% and 5.93% for CRL and MSD respectively.ConclusionsIntra- and inter-observer error of CRL and MSD measurements among pregnant women at Mulago hospital were acceptable. This implies that at Mulago hospital, the error in pregnancy dating is within acceptable margins of ±3 days in first trimester, and the CRL and MSD cut offs of ≥7 mm and ≥ 25 mm respectively are fit for diagnosis of miscarriage on TVS. These findings should be extrapolated to the whole country with caution. Sonographers can achieve acceptable and comparable diagnostic accuracy levels of MSD and CLR measurements with proper training and adherence to practice guidelines.

Occurrence of anembryonic pregnancy with use of levonorgestrel subdermal implant (JADELLE\xae): a case report

BackgroundProgestin-only subdermal implants are one of the most effective contraceptive methods. Anembryonic pregnancy is not reported as a possible outcome in cases of contraceptive failure of these products. We present a rare case of anembryonic pregnancy occurring in a woman with levonorgestrel-releasing implant (JADELLE®).Case presentationA 31-year-old Cameroonian (black African) housewife with a JADELLE® implant for 13 months, consulted at our hospital for a 1-month history of pelvic pain, prolonged menstrual bleeding, and spotting. She had a last normal menstrual period 8 weeks 1 day prior to presentation. On examination, there was suprapubic tenderness and blood trickling from her cervix. Despite a negative qualitative urine pregnancy test, an empty intrauterine gestational sac with mean sac diameter of 28 mm was visualized on pelvic ultrasound. Dilation and curettage with suction was done and she had complete relief from symptoms.ConclusionThis case report highlights the possibility of anembryonic pregnancy occurring in women using the levonorgestrel-releasing subdermal implant (JADELLE®).

Magnetic resonance imaging of first trimester pregnancy: expected intrauterine contents in relation to gestational age.

To determine if and when fetal structures are identifiable during first trimester pregnancy on magnetic resonance imaging (MRI) in women with acute abdominopelvic pain. Sixty-four first trimester MRI examinations performed for evaluation of abdominopelvic pain were reviewed retrospectively. T2-weighted images were assessed independently by three radiologists for the presence of gestational sac, yolk sac, fetal pole, and limb buds. Mean sac diameter and sac volume were determined, and logistic regression analyses were performed. Criterion values for fetal structures and gestational sac size were calculated using receiver operating characteristic analysis. A gestational sac is present in all but two cases. The yolk sac is never identified. A fetal pole is identified at a gestational age (GA), mean sac diameter (MSD), and gestational sac volume (GSV) of greater than 6.4weeks, 1.7cm, and 8.9mL, respectively. Limb buds are identified at a GA, MSD, and GSV of greater than 8.1weeks, 3.4cm, and 27.1mL, respectively. There is a significant correlation between GA and gestational sac size, including the MSD (r 2=0.85, P<0.01) and GSV (r 2=0.86, P<0.01). The gestational sac is readily demonstrated on T2-weighted images, but the yolk sac is not identified on routine MRI. The fetal pole and limb buds are seen on MRI at a similar GA and MSD as with published values using transvaginal sonography.

Discriminant analysis forecasting model of first trimester pregnancy outcomes developed by following 9,963 infertile patients after in vitro fertilization

To investigate a forecasting method developed to predict first trimester pregnancy outcomes using the first routine ultrasound scan for early pregnancy on days 27-29 after ET and to determine whether to perform a repeated scan several days later based on this forecasting method. Prospective analysis. Infertile patients at an assisted reproductive technology center. A total of 9,963 patients with an early singleton pregnancy after invitro fertilization (IVF)-ET. None. Ongoing pregnancy >12weeks of gestation. The classification score of ongoing pregnancy was equal to (1.57 × Maternal age) + (1.01 × Mean sac diameter) + (-0.19 × Crown-rump length) + 25.15 (if cardiac activity is present) + 1.30 (if intrauterine hematomas are present) - 47.35. The classification score of early pregnancy loss was equal to (1.66 × Maternal age) + (0.84 × Mean sac diameter) + (-0.38 × Crown-rump length) + 8.69 (if cardiac activity is present) + 1.60 (if intrauterine hematomas are present) - 34.77. In verification samples, 94.44% of cases were correctly classified using these forecasting models. The discriminant forecasting models are accurate in predicting first trimester pregnancy outcomes based on the first scan for early pregnancy after ET. When the predictive result is ongoing pregnancy, a second scan can be postponed until 11-14weeks if no symptoms of abdominal pain or vaginal bleeding are present. When the predictive results suggest early pregnancy loss, repeated scans are imperative to avoid a misdiagnosis before evacuating the uterus.

Defining safe criteria to diagnose miscarriage: prospective observational multicentre study

Objectives To validate recent guidance changes by establishing the performance of cut-off values for embryo crown-rump length and mean gestational sac diameter to diagnose miscarriage with high levels of certainty....

Comparison of posterior and medial approaches for popliteal artery aneurysms

Long-term results of the posterior approach (PA) for the treatment of popliteal artery aneurysms are lacking in the literature. We reviewed our experience during a 13-year period in patients with popliteal artery aneurysms, comparing those treated through a PA with those operated on through a standard medial approach (MA). Clinical data of all patients treated between February 1998 and October 2011 were retrospectively reviewed and outcomes analyzed. The Kaplan-Meier method was used to estimate survival, and χ(2), Wilcoxon, and log-rank tests were used for analysis. A total of 77 aneurysms were treated in 65 patients (64 men). Mean age was 68 years (range, 48-96 years). Thirty-six aneurysms were asymptomatic (47%). Mean sac diameter was 2.8 ± 1 cm. A PA was used in 43 PAAs (55%) and an MA in 34. The PA and MA patients differed significantly in age (median being older), smoking history (more frequent in PA), and renal insufficiency and cerebrovascular disease (higher for MA). In 42 cases the aneurysm was symptomatic (54.5%) for chronic limb ischemia, with intermittent claudication in 18 patients, acute ischemia in 17, blue toe syndrome in 3, compression on adjacent structures in 3, and rupture with severe acute pain in 1. All PA repairs consisted of aneurysmectomy with an interposition graft with end-to-end anastomoses; among MA repairs, 22 interposition grafts and 12 bypasses were performed. A polytetrafluoroethylene graft was used in 54 cases. Five patients had an early thrombosis (two PA and three MA). No perioperative deaths occurred. Two patients sustained a permanent (PA) and a temporary (MA) peroneal nerve lesion. There were no early amputations. The median in-hospital stay was longer for MA (10 days) than for PA (7 days; P = .02). Median follow-up was 58.8 months (range, 5 days-166 months). Nine patients died during follow-up of unrelated causes. The 5-year primary and secondary patency rates were 59.6% ± 8.6% and 96.5% ± 3.4%, respectively, for PA, and 65.1% ± 11.1% and 79.4% ± 9.7%, respectively, for MA (P = .53 for primary patency rate and P = .22 for secondary patency rate). Limb salvage was 100% at 5 years and 93.3% ± 6.4% at 10 years for PA and 91.1% ± 6.3% at both time points for MA (P = .28). PA and MA both achieved satisfactory results in primary and secondary patency rates, as well as limb salvage, during long-term follow-up. The differences between the two groups were small and not statistically significant. PA was burdened by similar postoperative nerve and wound complications compared with MA. The in-hospital stay after PA was significantly lower.

Impact of new society of radiologists in ultrasound early first-trimester diagnostic criteria for nonviable pregnancy.

New early first-trimester diagnostic criteria for nonviable pregnancy recommended by the Society of Radiologists in Ultrasound via a multispecialty consensus panel extended the diagnostic size criteria of crown-rump length from 5 to 7 mm for embryos without a heartbeat and mean sac diameter from 16 to 25 mm for "empty" sacs. Our study assessed the potential impact of the new criteria on the number of additional follow-up sonograms these changes would engender. A retrospective study of all first-trimester sonograms in women with first trimester bleeding from 1999 to 2008 was conducted. Everyone included in the study had a visible gestational sac in the uterus. There were no pregnancies of unknown location or ectopic pregnancies included in this study cohort. Pregnancy of unknown location was used to describe cases in which there were no signs of pregnancy inside or outside the uterus on transvaginal sonography despite a positive pregnancy test result. A total of 1013 patients met the inclusion criteria. Seven hundred fifty-two patients (74%) had identifiable embryos, and 261 (26%) did not. Of those with an identifiable embryo, 286 (38%) had no detectable embryonic cardiac activity. The breakdown of crown-rump lengths in this group was as follows: 100 measuring less than 5 mm, 36 measuring 5 to 7 mm, and 150 measuring 7 mm or greater. The breakdown of mean sac diameters in those without a visible embryo was as follows: 120 measuring less than 16 mm, 90 measuring 16 to 25 mm, and 51 measuring 25 mm or greater. When diagnosing a failed pregnancy, there can be no room for error. Only 126 of 1013 early pregnancies threatening to abort (12%) fell into the more conservative zones defined by the new compared to the former size criteria (crown-rump length, 5-7 mm; mean sac diameter, 16-25 mm). Therefore, the potential impact of the new guidelines on follow-up sonograms does not appear inordinate.

Miscarriage in contemporary maternal-fetal medicine: targeting clinical dilemmas

Miscarriage in contemporary maternal-fetal medicine: targeting clinical dilemmas

The safety of offie manual vacuum aspiration in treating gestational trophoblastic disease associated with early pregnancy failure

Compare complication rates among women with molar pregnancy undergoing uterine aspiration in the office with those treated in the operating room. We conducted a chart review of patients undergoing manual vacuum aspiration or electric vacuum aspiration with a molar pregnancy from January 1st 2001 to December 31st 2011. Women with molar pregnancies were identified using ICD codes. The medical record was reviewed to confirm the diagnosis which required histopathology. Women were included in the study if they had confirmed molar pregnancy diagnosis and were less than 14 weeks gestation. Procedure location was determined from the operative note and appointment schedule. Charts were reviewed for complications including: need to stop procedure due to pain, conversion to general anesthesia, postabortal syndrome, estimated blood loss greater than 300ccs, blood transfusion, hospital admission, uterine perforation, endometritis, retained products of conception, and visit to the emergency department within 2 weeks. Additionally, the incidence of recurrent gestational neoplastic disease, metastases and need for chemotherapy was recorded. Risk factors for complications including uterine size, gestational age, mean sac diameter by ultrasound, suspicion for mole preoperatively and maximum b-hcg values were also examined. We identified 136 women with histopathology confirmed molar pregnancy of which 49 underwent office MVA. Patients undergoing office based procedures had slightly smaller gestational ages (53.0 vs 63.7 days for OR group, p 0.03). B-hcg values were also lower for office based procedures (56,203 vs. 161,478, p<0.001). Patients undergoing evacuation in the clinic were less likely to have blood loss greater than 300ccs (4.1% vs. 42.5% in the OR group, p <0.001). There were no other significant differences in complication rates. Based on this small series of patients, complication rates were not increased if treated in the office as compared to in the operating room.

External validation of models and simple scoring systems to predict miscarriage in intrauterine pregnancies of uncertain viability

Does a logistic regression model and scoring system to predict viability of an intrauterine pregnancy of uncertain viability (PUV) perform as well in an independent patient group as the original patient group? The model and scoring system showed good performance on external validation confirming their value for the prediction of miscarriage/viability in PUV patients up to 11-14 weeks of gestation. Several individual ultrasound and demographic factors have been described as predictors for miscarriage. A logistic regression model and simple scoring system using basic clinical and ultrasound features, such as maternal age, bleeding score, mean gestational sac diameter (MSD) and presence or absence of yolk sac, have been developed to allow patient-specific prediction of viability of PUV beyond the first trimester. Prospective observational external validation cohort study in two inner city early pregnancy assessment units over a period of 18 months. All consecutive women with a PUV were recruited. Ultrasound (mean sac diameter and presence of yolk sac) and demographic variables (maternal age, bleeding score and gestational age) were noted. The outcome measure was first trimester (11-14 week) viability. Women with unknown first trimester outcome were excluded. Receiver operating characteristic (ROC) curves and calibration plots were constructed. Test performance was compared with the original development data set. A new model and scoring system, which did not include gestational age, was built and evaluated. Of the 575 women who were recruited, first trimester outcome was known for 89.2% (n = 513). The model could only be validated in 400 patients, due to missing values in model variables and outcome. The model predicted viability with an area under the ROC curve (AUC) of 0.845 [95% confidence interval (CI), 0.806-0.884] compared with 0.774 (95% CI, 0.701-0.848) in the original study. The AUC for the scoring system was 0.832 (95% CI, 0.792-0.872) compared with 0.771 (95% CI, 0.698-0.844) from the original study data set. The new model and the scoring system, excluding gestational age, could be evaluated on 503 patients and resulted in an AUC of 0.801 (95% CI, 0.765-0.841) for the model and 0.773 (95% CI, 0.733-0.812) for the scoring system. Approximately 22% of patients could not be validated due to missing variables and for 11% of patients the first trimester outcome was unknown. Both the model and the scoring system showed excellent performance on external validation confirming their generalizability and utility in prediction of viability beyond the first trimester in clinical practice. An advantage of the mathematical models original Mo and new Mn and scoring systems original SSo and new SSn is that they can provide women with an individualized probability of the viability of their pregnancy using only demographic information, symptoms and TVS findings. Furthermore, the risk of miscarriage can be given immediately following examination. T.B. is supported by the Imperial Healthcare NHS Trust NIHR Biomedical Research Centre. This research is supported by Research Council KUL GOA MaNet, iMinds 2012, Belgian Federal Science Policy Office IUAP P719. VVB is a postdoctoral fellow of the Research Foundation - Flanders (FWO). There are no conflicts of interest.