Transvaginal Ultrasound Scan Research Articles

P-746 Clinical, laboratory and ultrasonographic risk factors for uterine artery arteriosclerosis: insights for uterus transplantation

Abstract Study question What is the uterine artery arteriosclerosis prevalence in women undergoing total hysterectomy for benign diseases? Summary answer Uterine artery arteriosclerosis shows a prevalence of 70% in women undergoing total hysterectomy for benign diseases. What is known already Arteriosclerosis is defined as a chronic inflammatory disease involving arteries triggered by endothelial dysfunction. The presence of uterine artery arteriosclerosis might identify uteri to be excluded for uterus transplantation. Just one article assessed frequency of UAA in women scheduled for hysterectomy. The Authors observed UAA lesions, from intimal thickness to complex plaque, in all patients; but these data have not been validated in other study populations. Study design, size, duration This is a single center, observational, prospective, cohort study, carried out in a tertiary academic center from December 2020 to May 2021. Forty-two consecutive symptomatic patients refuse/ contraindications/intolerance to medical therapy and scheduled for total hysterectomy were enrolled in the study. Exclusion criteria were virgo patients and patients with specimen removal requiring morcellation. Women underwent preoperative assessment of medical history, gynecological examination, transvaginal ultrasound scan and serum tests. Participants/materials, setting, methods Two-cm length segments of ascending branch of uterine arteries specimens were harvested at a level of the internal cervical os, then divided, fixed in formalin and then embedded in paraffin. Serial sections were obtained with a thickness of 4 micron. Clinical data and serum tests were collected during preoperative evaluation for each patient. Transvaginal ultrasound was performed. We evaluated PI, RI and PSV as markers of vascular stenosis. Main results and the role of chance Forty women were included in the analyses. UAA prevalence was 70%. Among clinical and laboratory factors, means ± SD of body mass index (p = 0.04), total cholesterol (p = 0.03), and triglycerides (p = 0.049) were significantly higher in patients with UAA compared to patients without UAA. On the contrary, HDL mean ± SD (p = 0.02) was significantly lower in patients with UAA than those without UAA. Regarding ultrasonographic factors, uterine arteries with UAA showed higher PSV values compared to vessels without UAA (p = 0.04). Limitations, reasons for caution A potential limitation of the present study is the small sample size and the enrollment of women affected by uterine diseases requiring surgery. However, we considered unethical to provide histological data in a cohort of patients with regular uterus, thus not requiring hysterectomy. Wider implications of the findings To our knowledge, our study may be the first to evaluate the correlation between both clinical, laboratory and ultrasonographic factors and the presence of UAA. Our findings might direct future studies aiming to improve UTx outcomes. Trial registration number Not applicable

O-058 Obstetric outcomes of twin gestation after In-Vitro Fertilization and Embryo Transfer (IVT-ET) treatment in patients who underwent hysteroscopic septoplasty for subseptate uterus

Abstract Study question Is there an associated increased risk of preterm birth (PTB) in patients who underwent hysteroscopic septoplasty for subseptate uterus (SSU) with twin gestation through IVF-ET? Summary answer This study suggests an increased risk of PTB in patients, who underwent hysteroscopic septoplasty for SSU, and subsequently conceived twins after IVF-ET treatment. What is known already In general, the incidence of PTB is higher after IVF-ET treatment. In addition, Müllerian uterine anomalies, such as unicornuate uterus, are considered risk factors for PTB, even with singleton pregnancy. Furthermore, historical data suggest that some patients with uterine anomaly may have cervical incompetence. Twin gestation is associated with PTB in approximately 50% of cases. It is assumed that the obstetric outcome of twin gestation after successful septoplasty should be no different from those with normal uterine cavity. The impact of previous septoplasty for SSU on the obstetric outcomes of twin gestation after IVF-ET treatment has not been adequately studied. Study design, size, duration This retrospective cohort study included 377 fertility patients who received treatment between 2006-2019. The study group included 162 patients who underwent hysteroscopic septoplasty for SSU and subsequently conceived dichorionic-diamniotic (DI-DI) twins after IVF-ET treatment (Group 1). The control group included 215 patients who had normal endometrial cavity on hysteroscopy (#109) or Transvaginal 3D ultrasound scan with saline sonohysterogram (#106) and subsequently conceived DI-DI twins after IVF-ET treatment (Group 2). Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with an academic hospital. Demographic, clinical, and obstetric outcome data were collected for both groups and compared using appropriate statistical methods. PTB, severe PTB, extreme PTB, and peri-viable birth were defined as < 37 weeks, <32 weeks, <28 weeks and between 20 weeks-25 weeks 6 days gestation respectively. Main results and the role of chance There was no significant difference in mean age, BMI and infertility duration or in the incidence of smoking, primary infertility, tubal factors and unexplained infertility between the two groups. There was significantly lower mean baseline FSH levels (p < 0.01), lower incidence of male infertility (p < 0.001) and higher incidence of ovulatory disorders (p < 0.001) and endometriosis (p < 0.05) in Group 1 compared to Group 2. As expected, there was past history of lower parity rate (p < 0.01) and higher miscarriage rate (p < 0.001) in Group 1 compared to Group 2 prior to septum division. There was significantly higher incidence of PTB (72.8% vs 56.3%, p < 0.01), severe PTB (20.3% vs 8.2%, p < 0.01), extreme PTB (8.3% vs 3.9%, p < 0.05), and peri-viable birth (6.3% vs 1.9%, p < 0.05) in Group 1 compared to Group 2. There was no significant difference in cesarean section rate (82.8% vs 87.5%, p = 0.349) between Group1 and Group 2 respectively. There was significantly lower gestational age at birth in weeks (34.0 + 4.0 vs 35.6 + 3.0, p < 0.001), birth weight of the first newborn (2180.5 + 717.9 vs 2436.4 + 606.6, p < 0.001), and the second newborn (2235.2 + 674.2 vs 2398.0 + 537.9, p < 0.05) in grams in Group 1 compared to Group 2. Limitations, reasons for caution Our study has limitations being retrospective in nature. Data on cervical length measurements via ultrasound, if performed, was not available. However, recall bias was prevented by retrieving data from that submitted to the Society of Assisted Reproductive Technology. Additionally, procedural variation was reduced as this was a single-center study. Wider implications of the findings Our study suggests that twin gestation after IVF-ET in patients who underwent successful hysteroscopic septoplasty for SSU may increase the likelihood of PTB. Such patients may require increased surveillance with ultrasound cervical length and signs for preterm labor. Future research should focus on measures to reduce PTB in such patients. Trial registration number Not Applicable

P-302 How adenomyosis changes throughout pregnancy

Abstract Study question How do the ultrasound characteristics of adenomyosis modify during pregnancy? Summary answer Signs of adenomyosis are visible in pregnancy and progressively disappear through gestation; adenomyosis was associated with an increased risk of miscarriage in the 1st trimester. What is known already Women with uterine adenomyosis may be asymptomatic (35%) or report menorrhagia (50%), dysmenorrhea (30%) and metrorrhagia (20%). Several authors recently linked this condition to subfertility since many women with “unexplained infertility” were found to have adenomyosis. Being relatively inexpensive and accurate, ultrasound is now considered the imaging modality of choice for diagnosing adenomyosis. Although the increasing interest towards the adenomyosis there are no data on the identification of sign of adenomyosis among pregnant women and evaluating their changes throughout the pregnancy. Study design, size, duration This is a retrospective exploratory cohort study conducted between 2016 and 2020 including 254 women of which 66 were diagnosed as having focal or diffuse adenomyosis (according to the MUSA classification) before conception or during the 1st trimester of pregnancy. The remaining 188 women were used as controls. Participants/materials, setting, methods Women were included if they had at least one pre-conceptional transvaginal ultrasound scan documenting adenomyosis, at least one scan per trimester and known maternal and neonatal outcomes. Diagnosis of adenomyosis was based on the MUSA classification and the recent consensus classification system for adenomyosis. We evaluated if the signs of adenomyosis were visible later in pregnancy and post-partum. Obstetric and neonatal outcomes were compared between women with or without these signs. Main results and the role of chance The globular aspect of the uterus was reported in 79% women with adenomyosis in the 1st trimester: it progressively disappeared, being present in only 38% and 2% women in the 2nd and 3rd trimester respectively and again visible in the post-partum in 65% women. Asymmetrical thickening (30%) and cysts (23%) were reported in the 1st trimester and disappeared during pregnancy. Adenomyosis was associated with miscarriage (OR 5.9 95%CI 2.4-14.9, p < 0.001) also when considering only normal conception (OR 5.1 95%CI 1.8-14.2, p = 0.002) or when correcting for maternal age (aOR 5.9, CI95% 2.3-15.2, p < 0.001). Gestational age at delivery was lower in women with adenomyosis (p = 0.004); Caesarean Sections (CS) rate was higher than in controls (OR 2.5, CI95% 1.3-4.8, p = 0.007) and this was confirmed (OR 2.4 CI95% 1.1-5, p = 0.02) also excluding women with previous CS. Limitations, reasons for caution These findings are from a monocentric retrospective study including only patients with known obstetric outcomes diagnosed with adenomyosis. Analysis was not stratified according to the mode of conception because of the small sample size, possibly introducing a bias in pregnancy outcomes. Wider implications of the findings Despite their progressive disappearance, signs of adenomyosis can be clinically relevant since associated with an increased risk of miscarriage in the first trimester also when considering only women with normal conception. Adenomyosis per se might have an influence on endometrial molecular expression resulting in impaired implantation and early development. Trial registration number not applicable

Influence of Utero-cervical Angle and Cervical Length on Labor Induction

Background: Successful labor induction is clearly related to the state of the cervix. The utero-cervical angle and cervical length represent novel ultrasonographic markers. Aim: To assess the relationship between utero-cervical angle and cervical length and satisfactory response to labor induction. Methods: Prospective cohort study was conducted in Al-Elwyia Maternity Teaching Hospital for a period of six months; 100 cases were enrolled in the study, and a pre-labor induction measurement of utero-cervical angle and cervical length using transvaginal ultrasound scanning was followed up till the end of labor to estimate the rate of success of induction of labor. Results: 65 patients had successful induction of labor and 35 failed to do so. No differences were found in demographic data and previous obstetric history. Short cervical length and wide utero-cervical angle were found in successful induction of labor. A significant negative correlation was found between utero-cervical angle and labor duration. At the cutoff point of 97.5 degrees of utero-cervical angle, the sensitivity was 83.12%, specificity was 71.4%, positive predictive value was 84.38%, negative predictive value was 69.45% and the accuracy was 88%. At a cutoff point of less than 29.5 mm of cervical length, the sensitivity was 92.3%, specificity was 80%, positive predictive value was 89.55%, negative predictive value was 84.84% and the accuracy was 88%. Conclusion: Utero-cervical angle and cervical length may be independent predictors of successful induction of labor.

Hysteroscopic and ultrasound evaluation of a novel degradable polymer film for the prevention of intrauterine adhesion formation after hysteroscopic surgery

ObjectiveTo collect information on the application and behavior of a novel degradable polymeric film (DPF) developed to prevent intra-uterine adhesions (IUAs) after hysteroscopic surgery. Study designA prospective observational study conducted in a university hospital in Naples, Italy. Women undergoing hysteroscopic myomectomy, metroplasty or adhesiolysis, were eligible for the study. Women had their uterine cavity assessed by transvaginal ultrasound scan before their hysteroscopic surgery, which was followed by the DPF insertion. Ultrasonographic and hysteroscopic assessments were undertaken immediately after insertion then at 2 h, 2–5 days, and 6 weeks postoperative. The main outcome of interest was to assess the behavior of the DPF, from insertion to degradation, by ultrasound and hysteroscopy. Other outcomes included ease of DPF insertion, any patient reported adverse events and the presence of IUAs at 6 weeks. Measurements and main resultsA total of 15 patients were enrolled into the study. The DPF insertion was reported to be very easy in almost all the cases and was visualized immediately and 2 h after insertion in all patients. At the 2–5 day follow-up 5 and 2 of the 15 participants still had the entire or partially hydrolyzed film respectively. By 6 weeks there was no evidence of the DPF in all women. No adverse events were reported at the time of insertion or follow-up. None of the study participants had IUAs at the 6-week assessment. ConclusionsAccording to this pilot study, the solid degradable polymer film, Womed Leaf, is a promising, easy to apply and well tolerated novel option for the prevention of intrauterine adhesion formation after hysteroscopic surgery.

124 Is there any impact of age on psychological well-being when facing early pregnancy problems?

Background: Threatened miscarriage is one of the most common early pregnancy complication. About 20% of women may end up with miscarriage. Women may face a significant social and psychological morbidity. Objective: This study investigated if age of pregnant women would affect their psychological well-being on facing the early pregnancy problems. Method: All Chinese women attending the early pregnancy assessment clinic for early pregnancy problem of abdominal pain and vaginal bleeding were recruited. Exclusion criteria included women requested for termination of pregnancy or referred for suspected ectopic pregnancy. Informed consent was obtained. Demographic data, pain and bleeding severity were collected. They were invited to fill in questionnaire before the consultation, including the Chinese versions of 12-item General Health Questionnaire (GHQ-12), Beck Depression Inventory (BDI), Spielberger’s State Anxiety Inventory (STAI), and Fatigue Scale (FS). After that, gynecological examination and transvaginal ultrasound scan were performed by qualified gynecologists. Diagnosis of first trimester miscarriage, unknown viability and viable pregnancy was made. Women would be further follow-up in 1–2 weeks if the first diagnosis was unknown viability to determine the viability.Comparison was made between women who were aged ≤ 20 years (Group A) and aged ≥ 21 years old (Group B). Results: In all, 18 women were aged ≤ 20 years. Significantly more women aged ≤ 20 years were nulliparous and smoker. More of them also reported bleeding symptoms. Overall, the mean scores of GHQ12, BDI, STAI and FS questionnaires were 4.0 ± 3.1 (range 0–12), 9.2 ± 6.9 (range 0–55), 54.3 ± 10.7 (range 21–80), 2.4 ± 0.5 (1–4) respectively. There was no significant difference in all the GHQ-12, BDI, STAI and FS scores. Conclusion: There was no significant difference on psychological well-being between women aged ≤ 20 years or ≥ 21 years when facing the early pregnancy problems. Table 1 Table 1Demographics and scores of different questionnaires on psychological well-being. AllN = 1271 Group A (n = 18) Group B (n = 1253) P-value Nulliparity 750 (59.0%) 15 (83.3%) 735 (58.7%) 0.035 Smoking 177 (13.9%) 8 (44.4%) 169 (13.5%) 0.002 Presence of bleeding 1002 (78.8%) 8 (44.4%) 994 (79.3%) <0.001 Presence of abdominal pain 866 (68.1%) 14 (77.8%) 852 (68.0%) 0.38 GHQ-12 4.0 ± 3.1 4.1 ± 2.7 4.0 ± 3.2 0.92 BDI 9.2 ± 6.9 10.9 ± 9.2 9.2 ± 6.9 0.28 STAI 54.3 ± 10.7 52.8 ± 9.2 54.3 ± 10.7 0.56 FS 2.4 ± 0.5 2.3 ± 0.5 2.4 ± 0.5 0.39 Outcome of pregnancy - Viable pregnancy 1111 (87.4%) 17 (94.4%) 1094 (87.3%) 0.72 -Miscarriage 160 (12.6%) 1 (5.6%) 159 (12.7%) Open table in a new tab

Characterization of Uterine Peristaltic Waves by Ultrasound Strain Analysis.

Uterine peristalsis (UP) is a wavelike uterine motion that plays an important role in the generation of intrauterine streams for menstrual emptying and to support embryo implantation. Our understanding of uterine mechanical behavior is hampered by a lack of quantitative analysis. Here, we propose a spatiotemporal analysis of UP by ultrasound speckle tracking and dedicated strain analysis. We aim at characterizing UP propagating around the endometrial cavity through the anterior and posterior walls of the uterus. To this end, velocity and coordination features are proposed in this study. We investigated a total of 11 healthy volunteers during their natural menstrual cycle and 81 patients undergoing in vitro fertilization (IVF) treatment. They all received multiple 4-min 2-D transvaginal ultrasound scans. Significant differences in propagation velocity were found among different phases of the menstrual cycle, which are in line with the expected uterine behavior. A significant difference in coordination was found between the group of women with successful (pregnancy at 11 weeks) and unsuccessful IVF. This result suggests that the ability to generate coordinated UP represents an important factor for IVF success. The proposed UP quantification may represent a valuable clinical tool for improved understanding of UP and improved decision-making in the context of IVF procedures.

Postmenopausal lady with virilization: Diagnosis of a rare steroid cell tumor of the ovary

64 year old postmenopausal lady presented with features of virilization over last 5 years. Her Total Testosterone level was 22.2 nmol/l (0.52- 2.47 nmol/l) which is very high to be attributed to normal aging. Her past medical history was unremarkable except adequately controlled diabetes mellitus. Her DHEAS level was normal and did not have other hormonal abnormalities. Her transvaginal ultrasound scan showed a left ovarian tumor of 3 X 3 cm in size. She underwent a CECT abdomen and pelvis which also confirmed the left ovarian tumor without any malignant features or metastasis.

To Determine the Association between Endometrial Polyp and Metabolic Syndrome

Background: Endometrial polyps are common among females especially in postmenopausal women. They have different type of prognosis and could lead to other related comorbidities. Metabolic syndrome is one of those conditions. Aim: To determine the association between endometrial polyp and metabolic syndrome. Study design: Case control study. Place and duration of study: Department of Obstetrics and Gynecology, Unit-IV, Sir Ganga Ram Hospital, Lahore from12-04-2016 to 13-10-2016. Methodology: One hundred women presenting in the obstetric and gynecological outdoor of Sir Ganga Ram Hospital, Lahore who meet the inclusion criteria of age between 18 to 60 years and with confirmation of endometrial polyps enrolled in this study. Detailed history and written informed consent was obtained from each patient. Two groups of patients were assimilated as follows. Cases: Those with endometrial polyp (as per operational definition), Controls: Healthy women without endometrial polyp (endometrial thickness≤5mm on transvaginal ultrasound scan). Patient’s workup was done on outdoor basis and demographic details along with presence/absence of metabolic syndrome were recorded in the attached proforma. All patients were examined by a single resident and all labs were acquired from a single (Hospital) laboratory to eliminate bias. Results: The mean age of the study participants was 33.57±6.65 years. The women who presented are maximum of having second parity 42(42%) and parity 3, 23(23%). There was significant difference for the metabolic syndrome in the cases and control as there were 33(62%) cases who have metabolic syndrome and 20(37%) control were having this disease.(odds ratio &gt;1). Conclusion: There is significant association of endometrial polyps with metabolic syndrome. Keywords: Metabolic syndrome, endometrial polyps, Lipid profile.

The impact of maternal smoking on embryonic morphological development: the Rotterdam Periconception Cohort.

STUDY QUESTIONIs periconceptional maternal smoking associated with embryonic morphological development in ongoing pregnancies?SUMMARY ANSWERSmoking during the periconceptional period is associated with a delayed embryonic morphological development which is not fully recuperated beyond the first trimester of pregnancy.WHAT IS KNOWN ALREADYSmoking during pregnancy decreases prenatal growth, increasing the risk of preterm birth, small for gestational age (GA) and childhood obesity.STUDY DESIGN, SIZE, DURATIONBetween 2010 and 2018, 689 women with ongoing singleton pregnancies were periconceptionally enrolled in a prospective cohort study with follow-up until 1 year after delivery.PARTICIPANTS/MATERIALS, SETTING, METHODSBetween 7 + 0 and 10 + 3 weeks, GA serial three-dimensional transvaginal ultrasound scans were performed. Embryonic morphological development as assessed by the Carnegie developmental stages was evaluated using Virtual Reality techniques. In the absence of fetal morphology classification methods beyond the embryonic period, fetal ultrasound measurements at around 20 weeks’ GA, and birth weight were used to assess fetal growth. Linear mixed models were used to evaluate the association between smoking and the Carnegie stages. Regarding first-trimester morphological development, we additionally stratified our findings for mode of conception. Multiple linear regression models were used to study the association between smoking, fetal growth and birth weight. To investigate to which extent delayed embryonic morphological development mediated the effect of smoking, contemporary mediation analysis was used. Adjustments were made for potential confounders and other covariates.MAIN RESULTS AND THE ROLE OF CHANCEA total of 689 singleton ongoing pregnancies were included and 1210 Carnegie stages were determined. Maternal periconceptional smoking represented by the number of cigarettes/day was associated with a slight non-significant delay of the Carnegie stages (βcigarettes/day = −0.058, 95% CI −0.122; 0.007, P = 0.080). Smoking of ≥10 cigarettes/day showed the strongest association (β≥10 cigarettes/day = −0.352, 95% CI −0.648; −0.057, P = 0.019), as reflected by a 0.9-day delay in reaching the final Carnegie stage. Stratification for mode of conception showed a stronger negative association between the number of cigarettes/day in the IVF/ICSI group (βcigarettes/day = −0.126, 95% CI −0.200; −0.051, P = 0.001) compared to naturally conceived pregnancies (βcigarettes/day = 0.009, 95% CI −0.093; 0.111, P = 0.867). In the IVF/ICSI group, periconceptional smoking of ≥10 cigarettes/day was associated with in a 1.6 day delay in reaching the final Carnegie stage (β≥10 cigarettes/day = −0.510, 95% CI −0.834; −0.186, P = 0.002). In the second trimester, periconceptional smoking was associated with a smaller femur length (βcigarettes/day = −0.077, 95% CI −0.147; −0.008, P = 0.029) and a larger head circumference (β1–9 cigarettes/day = 0.290, 95% CI 0.065; 0.514, P = 0.012). Smoking was associated with a lower birth weight, with a dose-response effect (βcigarettes/day = −0.150, 95% CI −0.233; −0.068, P < 0.001). Furthermore, using the unadjusted model, 40–60% of the association between smoking and fetal ultrasound parameters and 6.3% of the association between smoking and birth weight can be explained by a delayed embryonic morphology.LIMITATIONS, REASONS FOR CAUTIONThe study population was recruited from a tertiary referral center. Smoking habits were explored using self-reported questionnaires and checked for consistency by trained researchers.WIDER IMPLICATIONS OF THE FINDINGSThis study shows that the association of periconceptional maternal smoking and human morphological development can already be detected early in the first trimester of pregnancy using embryonic morphology as outcome. One of the key messages of this study is that the delay, or dysregulation, in embryonic morphology is associated with allometric growth reflected by smaller fetal measurements at 20 weeks gestation and lower weight at birth. The delay in embryonic morphology, measured in early pregnancy, cannot be recuperated during the pregnancy. The results of this study emphasize the importance of smoking intervention programs prior to conception. More research is warranted to assess the association between periconceptional smoking cessation and embryonic development.STUDY FUNDING/COMPETING INTEREST(S)The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. The authors declare no conflicts of interest.TRIAL REGISTRATION NUMBERN/A.

Effectiveness of Ultrasound Screening for a Placenta Accreta Spectrum Using Standard Ultrasound Criteria in a Secondary Care Setting

Objectives: Ultrasound detection of a placenta accreta spectrum (PAS) among women at risk is a key goal to reduce obstetric morbidity, but there is scarce information on its performance in real clinical settings. We report the effectiveness of a standardized ultrasound protocol to detect PAS in women with placenta previa (PP) in a secondary-level hospital. Methods: A retrospective analysis, including a cohort of 126 women with persistent PP among 27,975 pregnancies between 2008 and 2020, was performed. All 126 women underwent standardized transabdominal and transvaginal ultrasound scan that assessed 5 criteria: (1) loss of hypoechoic retroplacental zone and/or myometrial thinning <1 mm; (2) lacunar images with a flow of >15 cm/s; (3) thick and bulging placenta; (4) thinning or interruption of the uterine-bladder serous interface; and (5) placental or uterovesical hypervascularity. The presence of at least one criterion was considered a high risk for PAS. Diagnosis of PAS was confirmed during the caesarean section and by histopathological analysis. Results: Among 126 women with PP, 11 (8.7%) cases of PAS were diagnosed, of which 10 were detected prenatally by ultrasound scan. This resulted in a sensitivity of 90.9%, a specificity of 98.3%, a positive predictive value of 83.3%, and a negative predictive value of 99.1%. Histopathological assessment showed 6 placenta increta (54.5%), 4 percreta (36.4%), and 1 accreta (9.1%). All 10 cases of invasive placenta presented more than 3 ultrasound criteria. Conclusions: Standardized ultrasound screening protocol in women at risk due to PP in the third trimester was highly effective in detecting PAS in a secondary-level hospital setting.

Validation of Self-Report of Uterine Fibroid Diagnosis Using Trans-Vaginal Ultrasound Scan

Validation of Self-Report of Uterine Fibroid Diagnosis Using Trans-Vaginal Ultrasound Scan

Heterotopic pregnancy in natural conception – A case report

Introduction: Heterotopic pregnancy is the coexistence of living or dead intrauterine pregnancy, single or multiple, and extra-uterine pregnancy located in the oviduct, ovary, uterine cornua, cervix or peritoneal cavity. Heterotopic gestation, although common with assisted reproductive techniques, is very rare in natural conception. A high index of suspicion can help in timely diagnosis and appropriate intervention.Case report: A 37- year-old primigravida lady with spontaneous pregnancy presented with amenorrhoea of 5 weeks, sudden and increasing lower abdominal pains of 5 days, dizziness of 2 days and vaginal bleeding of 4hours. Transabdominal and Transvaginal ultrasound scan was performed and revealed a non-viable intrauterine gestation at 6 weeks and 3 days, associated with a heterogenous complex right adnexal mass. Laparotomy was done, it revealed a ruptured right fallopian tube with remnant products of conception and hemoperitoneum; and right salpingectomy was done. The specimen was sent for histopathology. The patient tolerated the procedure well, though was resuscitated with normal saline and blood transfusion; she was taken to the recovery room in stable condition. The histopathological report confirmed the diagnosis of ectopic pregnancy.Conclusion: Despite the rarity of heterotopic pregnancy it should be suspected in patients with hemoperitoneum and an adnexal mass, even in the absence of risk factors, and should be included in the differential diagnosis of acute abdomen in the first trimester. The patient should be thoroughly investigated using abdominal and transvaginal ultrasound to exclude this rare diagnosis and allow on-time proper management.

Relevance of hysterosalpingogram (HSG) in infertility assessment at the rivers state university teaching hospital, Port Harcourt

Background: The aim of this study was to determine the relevance of Hysterosalpingogram (HSG) in current infertility management and to highlight the shortcomings of Hysterosalpingography At the Rivers State University Teaching Hospital (RSUTH), Nigeria and sub-Saharan Africa. Methods: This was a retrospective, cross-sectional study of 200 Hysterosalpingogram results of patients that were being managed for infertility from 1st January 2020 to 31st December 2021 at the Rivers State University Teaching Hospital, Port Harcourt. The HSG was done at the Radiological Department of the hospital. Data was collected from the patient case notes and from the Radiological department of RSUTH. Data were analyzed using SPSS version 25. Quantitative data were represented as mean &plusmn; SD while qualitative ones were described as frequency and percentage. Results: A total of 200 Hysterosalpingogram results of patients were analyzed. Their mean &plusmn;SD age was 33.5&plusmn;5 years. The indication for HSG was infertility for all of them. Infertility duration was greater than one year for all of them. Sixty-two (31%) had primary infertility while 138 (69%) had secondary infertility. One hundred and three (51.5%) of the patients had significant previous gynecological and obstetric history that predisposed them to tubal factor infertility. HSG findings were bilateral tubal patency in 79 cases (39.5%), Hydrosalpinx/peritubal adhesions in 11(5.5%), unilateral tubal occlusion in 14 (7%), Bilateral tubal occlusion in 35(17.5%), and intra uterine adhesion in 50 (25%). Thus, HSG investigation was able to detect the likely cause of infertility in (60.5%) of the participants. Conclusion: HSG is still the most common first-line diagnostic test to evaluate the uterine cavity and tubal pathology in infertility patients. Laparoscopy, Hysteroscopy, Transvaginal ultrasound scan, and Magnetic resonance imaging are more reliable methods of detecting tubal pathology or uterine cavity anomalies in infertility evaluation. These are not easily available in low -and -middle-income countries, especially sub-Saharan Africa and Nigeria in particular because of cost. HSG is relatively cheap and uncomplicated, which has contributed to it acquiring a primary role in assessing abnormal findings in fallopian tubes and uterine cavity.

Diagnostic value of shear wave velocity in polycystic ovarian syndrome.

Aim: In polycystic ovarian syndrome, the ovaries become stiffer due to chronic anovulation. We aimed to compare tissue elasticity in terms of shear wave velocities measured using acoustic radiation force impulse imaging technique between the ovaries of polycystic ovarian syndrome women and non-polycystic ovarian syndrome women. Material and methods: The study was designed as a retrospective data analysis of women who underwent transvaginal ultrasound and acoustic radiation force impulse imaging in a university hospital between July 2014 and March 2015, for various reasons. There were 32 polycystic ovarian syndrome patients and 32 patients without a diagnosis of polycystic ovarian syndrome. Age, body mass index, fasting glucose levels, cycle day 3 follicle stimulating hormone, luteinizing hormone, thyroid stimulating hormone, prolactin, antimullerian hormone levels, and menstrual patterns with clinical hyperandrogenism were evaluated. On the menstrual cycle days 2–4, by performing a transvaginal ultrasound scan, the ovarian volumes and antral follicle counts in both ovaries were recorded for each woman. The ultrasound system was converted into the elastography mode, and acoustic radiation force impulse imaging was performed. Shear wave velocity (m/sec) was measured at least 5 times for each ovary, and the mean value was calculated for each polycystic ovarian syndrome and non-polycystic ovarian syndrome woman. Results: Age, body mass index, fasting glucose levels, cycle day 3 follicle stimulating hormone, luteinizing hormone, thyroid stimulating hormone, and prolactin levels were similar between the groups (p >0,05). Antimullerian hormone levels, antral follicle counts, and mean ovarian volumes were statistically different between the groups (p <0,05). Mean shear wave velocity values for both ovaries were 2.12 ± 0.82 (0.78–4.9) m/sec in the polycystic ovarian syndrome group, and 1.18 ± 0.41 (0.77–2.0) m/sec in the non-polycystic ovarian syndrome group, which was statistically significantly different (p = 0.016). Conclusion: In our study, we found significantly higher shear wave velocity levels in polycystic ovarian syndrome women than non-polycystic ovarian syndrome women, which indicates an impact of the condition on shear wave velocity. The increased acoustic frequencies cause a decreased response in time to transition, and motion becomes out of phase; in other words, scattered waves are faster in stiffer ovaries. Our results are thus compatible with the pathophysiology of the disease. Shear wave velocity is a beneficial tool for evaluating ovarian elasticity in polycystic ovarian syndrome patients in whom the levels are found to be significantly higher than non-polycystic ovarian syndrome women. In light of these findings, shear wave velocity is expected to be slower than polycystic ovarian syndrome levels in ovulatory women.

Corpus luteum number and the maternal renin-angiotensin-aldosterone system as determinants of utero-placental (vascular) development: the Rotterdam Periconceptional Cohort

BackgroundPregnancies with > 1 corpus luteum (CL) display a hyperdynamic circulation and an increased risk of small-for-gestational age deliveries. Among the factors released by the CL is prorenin, the inactive precursor of renin. Since the renin-angiotensin-aldosterone system (RAAS) is involved in early hemodynamic pregnancy adaptation, we linked both CL number and first-trimester concentrations of prorenin (as an indicator of RAAS activity) and the aldosterone/renin ratio (as an indicator of angiotensin-independent aldosterone effectiveness) to non-invasive markers of utero-placental (vascular) development, measured longitudinally from the first trimester onwards.MethodsA total of 201 women, who conceived naturally or after in-vitro fertilization treatment (with 0 (n = 8), 1 (n = 143), or > 1 (n = 51) CL), were selected from the Rotterdam Periconceptional Cohort. Maternal RAAS components were determined at 11 weeks gestation. Placental volume and utero-placental vascular volume were measured from transvaginal 3D ultrasound scans at 7, 9 and 11 weeks gestation, pulsatility and resistance indices of the uterine arteries were assessed by pulsed wave Doppler ultrasounds at 7, 9, 11, 13, 22 and 32 weeks gestation. At birth placental weight was obtained using standardized procedures.ResultsPregnancies without a CL show lower uterine artery indices throughout gestation than 1 CL and > 1 CL pregnancies, while parameters of placental development are comparable among the CL groups. After adjustment for patient- and treatment-related factors, first-trimester prorenin concentrations are positively associated with uterine artery pulsatility and resistance indices (β 0.06, 95% CI 0.01;0.12, p = 0.04 and β 0.10, 95% CI 0.01;0.20, p = 0.04, respectively), while high prorenin concentrations are negatively associated with first-trimester utero-placental vascular volume (β -0.23, 95% CI -0.44;-0.02, p = 0.04) and placental weight (β -93.8, 95%CI -160.3;-27.4, p = 0.006). In contrast, the aldosterone/renin ratio is positively associated with first-trimester placental volume (β 0.12, 95% CI 0.01;0.24, p = 0.04).ConclusionsThe absence of a CL, resulting in low prorenin concentrations, associates with low uterine artery pulsatility and resistance, while high prorenin concentrations associate with a low utero-placental vascular volume and weight. These data support a scenario in which excess prorenin, by upregulating angiotensin II, increases uterine resistance, thereby preventing normal placental (vascular) development, and increasing the risk of small-for-gestational age deliveries. Simultaneously, high aldosterone concentrations, by ensuring volume expansion, exert the opposite.

Gynecological and Obstetrical Outcomes after Laparoscopic Repair of a Cesarean Scar Defect in a Series of 15 Women

<h3>Study Objective</h3> To evaluate gynecological and obstetrical outcomes, as well as remaining myometrial thickness, after laparoscopic repair of a cesarean scar. <h3>Design</h3> Observational study and retrospective evaluation of the remaining myometrium before and after repair. <h3>Setting</h3> Obstetrics and Gynecology Department in a University hospital. <h3>Patients or Participants</h3> A series of 15 symptomatic women with cesarean scar defects and remaining myometrial thickness of less than 3 mm, according to transvaginal ultrasound scan imaging. <h3>Interventions</h3> Laparoscopic repair of the cesarean scar defect. <h3>Measurements and Main Results</h3> Increase in myometrial thickness at the site of cesarean section, gynecological and obstetrical outcomes. The mean thickness of the myometrium increased significantly from 2mm before surgery to 7mm after surgery. Six months after surgery, all but two patients were free of symptoms. The persistence of intermenstrual bleeding in of one of them required a posterior hysteroscopic correction. Among the 7 women with infertility, 3 (42%) became pregnant and delivered healthy babies by cesarean section at 38–39 weeks of gestation. Two of these pregnancies were obtained spontaneously and the other one was an in vitro fertilization. <h3>Conclusion</h3> In symptomatic women with residual myometrial thickness of less than 3mm who wish to conceive, laparoscopic repair could be considered an appropriate approach.

THE EFFECT OF LAPAROSCOPIC SURGERY UNDER GENERAL ANESTHESIA ON PREGNANCY OUTCOMES IN PATIENTS WITH HETEROTOPIC PREGNANCY FOLLOWING IVF-ET

To evaluate the effects of laparoscopic surgery under general anesthesia on pregnancy outcomes of patients with heterotopic pregnancy (HP) following in vitro fertilization-embryo transfer (IVF-ET). This retrospective study reviewed 24 patients with HP following IVF-ET between January 2018 and August 2020. The patients had been divided into two groups according to whether fetal heart activities were detected by ultrasound preoperatively in intrauterine pregnancy (IUP) at diagnosis. General characteristics, clinical characteristics, pregnancy outcomes were compared between the group with heart activity in IUP (18cases) and the group without heart activity in IUP (6 cases). The general and clinical characteristics were comparable except previous ectopic pregnancy history and fetal status in IUP after surgery between two groups. The rate of previous ectopic pregnancy in group with heart activity in IUP was 33.3% versus 0 in group without heart activity in IUP (p=0.04). Postoperative transvaginal ultrasound (TVS) scans had confirmed that four cases were not able to continue intrauterine pregnancies: 1 patient (16.7%) with heart activity in IUP versus 3 patients (50.0%) without heart activity in IUP, the difference was statistically significant (P=0.02). Among the 20 patients who were able to continue intrauterine pregnancy after surgery, the live birth rate, miscarriage rate, premature birth rate, term birth rate, cesarean section rate, male rate, low birth weight infant rate of the group with heart activity in IUP were 88.2%, 11.8%, 17.6%, 70.6%, 93.3%, 53.3%, 20.0%, which were 66.7%, 33.3%, 0, 66.7%, 100%, 100%, 0 in the group without heart activity in IUP respectively, there were no significant differences between the two groups (P>0.05). Among the neonates, one premature neonate was diagnosed with Pilot type sequence sign at birth, and the rest neonates had no birth defects. Laparoscopic surgery under general anesthesia in early pregnancy was safe for HP patients. Early diagnosis and timely surgical treatment may lead to favorable pregnancy outcomes, especially for the patients with heart activity in IUP.

P–727 Prevalence of ultrasound-detected gynaecological pathology in a One-Stop fertility clinic

Abstract Study question What is the prevalence of abnormal findings on transvaginal ultrasound scan (TVS) in a population of women presenting with subfertility to a One-Stop fertility clinic? Summary answer Two thirds of women in our population had ultrasound-detected pathology. The five commonest pathologies were uterine fibroids, polycystic ovaries, endometriosis, adenomyosis and benign ovarian cysts. What is known already Gynaecological pathology is common in women presenting with subfertility. However, their prevalence varies depending on the age, geography, background health of the population and study design. Few prevalence studies performed in the general female population show definitive associations with subfertility. As imaging techniques become increasingly sophisticated and patient demographics evolve over time, the prevalence of gynaecological pathology is anticipated to change. Understanding their prevalence in a subfertile population would shed light on the burden of disease, providing information about prevention strategies and service priorities. There are no published studies on the prevalence of ultrasound-detected gynaecological pathology in the subfertile population. Study design, size, duration This was a retrospective cross-sectional study of 1558 women presenting to a One-Stop fertility clinic of a university teaching hospital between January 2012 and December 2020. Participants/materials, setting, methods Women who attend the clinic routinely have their demographic data and a detailed clinical history taken prior to a transvaginal ultrasound scan. A clinical examiner trained in transvaginal ultrasonography performs the ultrasound examination in a standardized fashion. Ultrasound features and diagnoses are systematically recorded in an electronic database. We obtained demographic data and details of gynaecological diagnoses from the electronic database. We analysed the data using descriptive statistics and reported our results as proportions. Main results and the role of chance The median age of women at the time of scan was 35 years (range 21–46 years). The mean Body Mass Index was 24.8 kg/m2 (range 16.9–50.4 kg/ m2). The median duration of subfertility was 24 months (range 3–168 months). 472/1558 (30.3%, 95% CI 28.0–32.6) women had normal pelvic scans. The most frequent pathology seen in our population was uterine fibroids (410/1558, 26.3%; CI 24.1–28.6); 10.5% of these fibroids distorted the uterine cavity. Polycystic ovaries were the next most common pathology (363/1558, 23.3%; CI 21.2–25.4), followed by endometriosis (177/1558, 11.4%; CI 9.8–13.0), adenomyosis (160/1558, 10.3%; CI 8.8–11.9) and benign ovarian cysts (122/1558, 7.8%; CI 6.6–9.3). The other abnormalities seen on scan included congenital uterine anomalies (81/1558, 5.2%; CI 4.2–6.4), endometrial polyps (69/1558, 4.4%; CI 3.5–5.6), pelvic adhesions (44/1558, 2.8%; CI 2.1–3.8) and intrauterine adhesions (13/1558, 0.8%; CI 0.5–1.4). Of the 1086 women with abnormal scans, 832 (76.6%, CI 74.0–79.1) had one pathology detected on TVS and 254 (23.4%, CI 20.9–26.0) had more than one pathology detected. Limitations, reasons for caution A limitation of our study was the lack of histological confirmation of the ultrasound findings. Due to our smaller sample size, our prevalence could potentially be overestimated. Wider implications of the findings: The relevance of each pathology to chances of conception requires further examination to avoid under- or overtreating women in their fertility journey. Our findings may provide a background for future correlation studies. Furthermore, a scan quality assessment may be considered if the detection rate is substantially different in similar populations. Trial registration number Not applicable

Automated prediction of endometriosis using deep learning

Endometriosis is the anomalous progress of cells at the outer part of the uterus. Generally, this endometrial tissue stripes the uterine cavity. The existence of endometriosis is identified through procedures known as Transvaginal Ultra Sound Scan (TVUS), Magnetic Resonance Imaging (MRI), Laparoscopic procedures, and Histopathological slides. Minimal Invasive Surgery (MIS) Laparo-scopic images are recorded in a small camera. To assist the surgeon in identifying their presence of endometriosis, image quality (characteristics) was enhanced for more visual clarity. Deep learning has the ability in recognising the images for classification. The Convolutional Neural Networks (CNNs) perform classification of images on large datasets. The proposed system evaluates the performance by a novel approach that implements the transfer learning model on a well-known architecture called ResNet50. The proposed system train the model on ResNet50 architecture and yielded a training accuracy of 91%, validation accuracy of 90%, precision of 83%, and recall of 82%, which can be applied for larger datasets with better performance. The presented system yields higher Area Under Curve (AUC) of about 0.78. The proposed method yields better performance using ResNet50 compared to other transfer learning techniques.