Transvaginal Ultrasound Examination Research Articles

Urinary concentrations of phthalate biomarkers in relation to uterine leiomyomata risk

PDS 62: Chemicals and metals: exposure and biomarkers, Johan Friso Foyer, Floor 1, August 28, 2019, 10:30 AM - 12:00 PM Background/Aim: Animal and epidemiologic studies suggest that phthalates have adverse reproductive effects. However, the association of phthalates with risk of uterine leiomyomata (UL), hormone-dependent neoplasms, is inconsistent. Only cross-sectional and case-control studies have been conducted to date. Methods: We conducted a prospective case-cohort study of urinary phthalate metabolites with UL incidence in the Study of the Environment, Lifestyle, and Fibroids (SELF), a cohort of premenopausal Black women aged 23-35 residing in Detroit, Michigan. Participants underwent transvaginal ultrasound examinations to identify UL at baseline and follow-up (20, 40 and 60 months). The Centers for Disease Control measured eight urinary phthalate metabolites: mono(2-ethylhexyl) phthalate (MEHP), mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), mono(2-ethyl-5-carboxypentyl) phthalate (MECPP), mono-isobutyl phthalate (MiBP), mono-n-butyl phthalate (MBP), monobenzyl phthalate (MBzP), and monoethyl phthalate (MEP) in a random sample selected at baseline and all incident UL cases through 60 months (n=764). We modeled cumulatively-averaged creatinine-adjusted metabolites (i.e., baseline, 20 and 40 month samples). We examined individual metabolites and the total molar sum of di(2-ethylhexyl) phthalate metabolites [ΣDEHP(MEHP+MEHHP+MEOHP+MECPP)]. Cox regression models used cumulatively-averaged quartiles to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI), adjusting for potential confounders. Results: We detected phthalate metabolites in the baseline urine of 91-100% of participants. Metabolites were weakly to highly correlated (Spearman correlations=0.19-0.97). We observed a protective association of MiBP and UL, with an adjusted IRR comparing highest vs. lowest quartiles of 0.71 (95% CI: 0.51-0.97), but found varying associations with other individual metabolites (IRRs ranging from 0.80 to 1.14). Adjusted IRRs (95% CIs) comparing ΣDEHP quartiles 2, 3, and 4 (highest) vs. 1 (lowest) were 0.92 (0.67-1.26), 0.62 (0.44-0.87), and 0.80 (0.58-1.10), respectively. Models using baseline concentrations produced comparable findings. Conclusions: In this prospective cohort of reproductive-aged Black women, individual and ΣDEHP molar sum phthalate metabolites were not strongly associated with UL risk.

EP31.15: Diagnosis of appendicitis by transvaginal ultrasound examination

EP31.15: Diagnosis of appendicitis by transvaginal ultrasound examination

OC24.07: Prevalence of congenital uterine anomalies in asymptomatic premenopausal women at three‐dimensional transvaginal ultrasound examination

OC24.07: Prevalence of congenital uterine anomalies in asymptomatic premenopausal women at three‐dimensional transvaginal ultrasound examination

EP29.07: Hysteroscopic management of Caesarean section scar and interstitial (cornual) pregnancy

There is no consensus about surgical approach in cases of Caesarean section scar (CSSP) and interstitial (cornual) pregnancy (ISP). The optimal management is yet to be defined because it represents a rare form of ectopic pregnancy. With the raising number of Caesarean section deliveries the rate of this type of ectopic pregnancy increases. The raising trend in minimally invasive surgery offers new treatment modalities. We present two cases of ectopic pregnancies successfully managed by minimally invasive surgical technique: hysteroscopic resectoscope removal of retained products of conception (RPOC). Case 1: a 42-year-old Caucasian woman, gravida 2, Caesarean section 2, at 7 weeks gestation was diagnosed with pregnancy in the scar of previous Caesarean section - niche, with 2 hybrid myomas on the anterior wall of uterus measured in diameter 90x76 mm and 41x39 mm. Transvaginal ultrasound (TVUS) examination revealed endogenic type I CSSP. The initial beta human chorionic gonadotropin (b-hCG) was 93.745 IU/L. After one 50 mg dose methotrexate, she underwent hysteroscopic-guided removal (HGR) of embryo, leaving chorionic sac in situ. After 3 months, b-hCG fell to 158 IU/L, and vacuum aspiration of chorionic sac was performed. The intervention was successful, without complication. Case 2: a 29-year-old Caucasian woman, gravida 0, at 9 weeks gestation, with ectopic interstitial pregnancy in left cornu. Initial b-hCG on admission valued 1.666 IU/L. After laparoscopic confirmation of the interstitial pregnancy, the patient underwent HGR of the ISP. We used hysteroscopic resectoscope (HR) as a tool. Successful minimally invasive treatment using HR in both ectopic CSSP and ISP may be applied. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Ultrasound accuracy in prenatal diagnosis of abnormal placentation of posterior placenta previa

ObjectivesTo evaluate the accuracy of ultrasound in prenatal diagnosis of Placenta accrete spectrum disorders in patients with posterior placenta previa, and to assess the impact of prenatal diagnosis in our population. Study DesignWe prospectively enrolled 198 women with posterior placenta previa from 2011 to 2017. We performed transabdominal and transvaginal ultrasound examinations (Grey-scale and colour/power Doppler). The diagnosis of placenta accreta spectrum disorders was based on detection of at least two of the following criteria: loss of retroplacental clear zone, interruption of uterine serosa–bladder wall interface, turbulent placental lacunae with high velocity flow, myometrial thickness <1 mm, increased vascularity of uterine serosa–bladder wall interface, loss of vascular arch parallel to basal plate and/or irregular intraplacental vascularization. Definitive diagnosis was made at delivery with Caesarean section. Furthermore, we compared maternal outcomes in cases diagnosed antenatal versus that one’s diagnosed at delivery. ResultsThere were 20/198 cases of placenta accreta spectrum disorders. The two-criteria system identified 12 cases of placenta accreta, providing a 60.0% of sensitivity, 98.8% of specificity, 85.7% of positive and 95.7% of negative predictive value. Maternal outcomes were better in women with prenatal diagnosis of placenta accreta spectrum disorders, although not statistical significant. ConclusionsOur data showed that grey-scale and Color-Doppler ultrasound evaluation for detecting placenta accreta spectrum disorders on posterior placenta previa have high specificity, positive and negative predictive value, but a low sensitivity. Nevertheless, an antenatal diagnosis of placenta accreta spectrum disorders for posterior placenta previa should be encouraged.

Sonographic Criteria for Uterine Curettage: Suspecting Endometrial Neoplasia.

The aim of the work is to determine the Suspicious sonographic findings associated with endometrial hyperplasia or cancer in premenopausal and perimenopausal women requiring uterine curettage other than endometrial thickness. Transvaginal ultrasonography examinations of premenopausal and perimenopausal women were reported here. These women underwent endometrial biopsy based on abnormal uterine bleeding or discharge and sonographic endometrial abnormalities. Histologically, hyperplasia was found in PCOS patients, endometrial cancer on top of tamoxifen therapy was found in others. The highly related ultrasound criteria are thick irregular endometrium, ill-defined endometrial myometrial junction, myometrial invasion with pseudowidening of the endometrium, turbid intrauterine fluid collection, associated complex adnexal masses, and cystic areas in the endometrium. Endometrial stripe abnormality by transvaginal ultrasonography is considered to be important in the recommendation of endometrial biopsy to exclude cancer along with positive complains in addition to thickness abnormalities.

Ovarian cancer stage, variation in transvaginal ultrasound examination rates and the impact of an urgent referral pathway: A national ecological cohort study.

The aim of this study was to determine whether variation in transvaginal ultrasound examination rates in Danish general practice populations is associated with ovarian cancer outcomes, and to explore the impact of the introduction of a cancer patient pathway for ovarian cancer. We performed a national register-based cohort study of gynecological cancer-free women aged 40years or above, living in Denmark and listed with a specific general practitioner in 2004-2014. Practice populations were divided into quartiles according to the general practitioners' transvaginal ultrasound propensity in the preceding year. Associations between transvaginal ultrasound rates and ovarian cancer outcomes were analyzed using Poisson and logistic regression. We included 2769 general practices with 1739422 listed women, of whom 5325 were diagnosed with ovarian cancer during the study period. Practices varied twofold in transvaginal ultrasound rates before and after the implementation of the cancer patient pathway. Before the cancer patient pathway was introduced, women listed with practices with the highest transvaginal ultrasound rates were diagnosed with earlier stages of ovarian cancer (odds ratio 1.38, 95% confidence interval 1.06 to 1.81) and had a higher proportion of borderline tumors (incidence rate ratio 1.38, 95% confidence interval 1.10 to 1.75) compared with women least exposed to transvaginal ultrasound. After the cancer patient pathway, no significant differences were identified between the groups. Before the cancer patient pathway, women exposed most to transvaginal ultrasound were significantly more likely to be diagnosed with early stage ovarian cancer compared with those least exposed to transvaginal ultrasound. After the cancer patient pathway was implemented, the difference disappeared. This suggests that increased awareness and access to transvaginal ultrasound is useful for diagnosing early-stage ovarian cancer.

New sonographic marker of borderline ovarian tumor: microcystic pattern of papillae and solid components.

To describe and evaluate the utility of a new sonographic microcystic pattern, which is typical of borderline ovarian tumor (BOT) papillary projections, solid component(s) and/or septa, as a new ultrasound marker that is capable of distinguishing BOT from other adnexal masses, and to present/obtain histologic confirmation. In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who had undergone preoperative transvaginal ultrasound (TVS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations, associated with solid component(s), papillary projections and/or septa. From the same cases, histopathologic slides of each BOT were examined for presence of any of these microcystic features which had been identified on TVS. To confirm that the microcystic TVS pattern is unique to BOTs, we also selected randomly from our ultrasound and surgical database 20 cases of epithelial ovarian cancer and 20 cases of benign cystadenoma, for review by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to determine whether the association between microcystic tissue pattern and BOT has been described previously. Included in the final analysis were 62 patients (67 ovaries) with preoperative TVS and surgically confirmed BOT on pathologic examination. The mean patient age at surgery was 39.8 years. The mean BOT size at TVS was 60.7 mm. Of the 67 BOTs, 47 (70.1%) were serous, 15 (22.4%) were mucinous and five (7.5%) were seromucinous. We observed on TVS a microcystic pattern in the papillary projections, solid component(s) and/or septa in 60 (89.6%) of the 67 BOTs, including 46 (97.9%) of the 47 serous BOTs, 11 (73.3%) of the 15 mucinous BOTs and three (60.0%) of the five seromucinous BOTs. On microscopic evaluation, 60 (89.6%) of the 67 samples had characteristic 1-3-mm fluid-filled cysts similar to those seen on TVS. In seven cases there was a discrepancy between sonographic and histologic observation of a microcystic pattern. The 20 cystadenomas were mostly unilocular and/or multilocular and largely avascular. None of them or the 20 epithelial ovarian malignancies displayed microcystic characteristics, either on TVS or at histology. On review of 23 published articles in the English medical literature, containing 163 sonographic images of BOT, we found that, while all images contained it, there was no description of the microcystic tissue pattern. We report herein a novel sonographic marker of BOT, a 'microcystic pattern' of BOT papillary projections, solid component(s) and/or septa. This was seen in the majority of both serous and mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of benign entities and malignancies, the microcystic appearance seems to be unique to BOTs. No similar description has been published previously. Utilization of this new marker should help to identify BOT correctly, discriminating it from ovarian cancer and benign ovarian pathology, and should ensure appropriate clinical and surgical management. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Reference ranges for uterine vein dimensions in non-pregnant women with normal pelvic organs.

To establish reference ranges for uterine vein (UtV) diameters in non-pregnant women with normal pelvic organs. This was a prospective study of all women attending the general gynecological clinic of a university teaching hospital in the UK, between August 2015 and December 2016. All women aged ≥ 18 years underwent a transvaginal ultrasound examination in accordance with the study protocol. In women with normal pelvic organs, the largest trunk of the uterine venous plexus was identified in the transverse plane on each side. The maximum anteroposterior vessel diameter was measured by placing the calipers on the inner walls of the vein, and the mean of three measurements was used as the representative value. Inter- and intraobserver variability was assessed in a subgroup of 30 women. Maximum UtV diameter was compared between right and left UtVs and between pre- and postmenopausal women. Factors associated with UtV diameter were assessed and reference ranges were constructed. Of 1500 women examined, 486 (32%) had normal pelvic organs on ultrasound scan and were included in the final analysis. In all women, the uterine venous trunk was clearly visualized and there was no significant difference between the maximum median left and right UtV diameters (P = 0.37). UtV diameters were generally lower in postmenopausal, compared with premenopausal, women, with the difference being statistically significant for the right UtV and the average of left and right UtVs. There was a gradual increase in UtV diameter with advancing age, with a peak observed in women aged 41-50 years and decreasing values in older age groups. Univariable analysis showed that parity, menopausal status and age were associated significantly with UtV diameters (P < 0.01). On multivariable analysis, only higher parity was significantly associated with increasing venous size in both pre- and postmenopausal women. Reference ranges were constructed separately for nulliparous and parous premenopausal women aged between 18 and 45 years. UtVs can be identified and measured consistently in all women with normal pelvic organs using transvaginal ultrasound. Parity was the main factor influencing the maximum mean UtV diameter, which had to be taken into account when constructing reference ranges. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Diagnosis of Fetal Posterior Fossa Malformations in High-Risk Pregnancies at 12–14 Gestational Weeks by Transvaginal Ultrasound Examination

Objective: To demonstrate sonographic detectable abnormalities of the posterior fossa in fetuses with a crown-rump length of 45–84 mm in high-risk pregnancies. Methods: This was a prospective, observational study including 47 fetuses with known outcome, whose mothers attended our centers for first trimester tests and showed an abnormal first trimester ultrasound scan. In these fetuses, we examined transvaginal acquired three-dimensional volume blocks for abnormalities of the fetal posterior fossa. In these fetuses, the measurements of the cerebellar vermis (VE) and of the anterior membranous area (AMA) were compared with published reference ranges. Results: There were 8 fetuses with a ver­mian length below the 5th centile. In 5 of these fetuses, the AMA was also elongated and in 4 of these fetuses, pathology was confirmed. One case with a normal vermian length and normal AMA had a hypoplastic VE later on in the confirmatory test. Conclusion: Pathology of the posterior fossa can be directly diagnosed by assessing the VE and the AMA at the first trimester scan by examining transvaginal acquired volume blocks.

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

A Novel Intelligent Scan Assistant System for Early Pregnancy Diagnosis by Ultrasound: Clinical Decision Support System Evaluation Study.

BackgroundEarly pregnancy ultrasound scans are usually performed by nonexpert examiners in obstetrics/gynecology (OB/GYN) emergency departments. Establishing the precise diagnosis of pregnancy location is key for appropriate management of early pregnancies, and experts are usually able to locate a pregnancy in the first scan. A decision-support system based on a semantic, expert-validated knowledge base may improve the diagnostic performance of nonexpert examiners for early pregnancy transvaginal ultrasound.ObjectiveThis study aims to evaluate a novel Intelligent Scan Assistant System for early pregnancy ultrasound to diagnose the pregnancy location and determine the image quality.MethodsTwo trainees performed virtual transvaginal ultrasound examinations of early pregnancy cases with and without the system. The ultrasound images and reports were blindly reviewed by two experts using scoring methods. A diagnosis of pregnancy location and ultrasound image quality were compared between scans performed with and without the system.ResultsEach trainee performed a virtual vaginal examination for all 32 cases with and without use of the system. The analysis of the 128 resulting scans showed higher quality of the images (quality score: +23%; P<.001), less images per scan (4.6 vs 6.3 [without the CDSS]; P<.001), and higher confidence in reporting conclusions (trust score: +20%; P<.001) with use of the system. Further, use of the system cost an additional 8 minutes per scan. We observed a correct diagnosis of pregnancy location in 39 (61%) and 52 (81%) of 64 scans in the nonassisted mode and assisted mode, respectively. Additionally, an exact diagnosis (with precise ectopic location) was made in 30 (47%) and 49 (73%) of the 64 scans without and with use of the system, respectively. These differences in diagnostic performance (+20% for correct location diagnosis and +30% for exact diagnosis) were both statistically significant (P=.002 and P<.001, respectively).ConclusionsThe Intelligent Scan Assistant System is based on an expert-validated knowledge base and demonstrates significant improvement in early pregnancy scanning, both in diagnostic performance (pregnancy location and precise diagnosis) and scan quality (selection of images, confidence, and image quality).

Vaginoscopic hysteroscopy in management for women with post-menopausal vaginal bleeding

ObjectivesThe feasibility of vaginoscopic hysteroscopy combined with office endometrial biopsy after ultrasonography for management of post-menopausal vaginal bleeding (PMB). Materials and methodsA prospective observational study of with PMB whom attending the Outpatient Clinic of Kang Ning Hospital during a four months period (1st Feb to 31st May 2018) was included. Vaginoscopic hysteroscopy was performed with endometrial biopsy after the initial clinical pelvic examination and transvaginal ultrasound examination. ResultsA total of 45 consecutive women with PMB was included. The hysteroscopy and endometrial biopsy were successful in 44 out of 45 (98%), a complete view in 82%, adequate tissue was in 91%, only one case was failed both procedures due to pain. The correlation between hysteroscopy and endometrial biopsy by was 100%. The mean operation time was 229 ± 68 s. The most common histological findings was atrophic endometrium 18 (42%). Five endometrial polyps and 2 submucosal leiomyomas were found. One rare case of endometrial carcinosarcoma (2%) was detected. Patients reported less pain for hysteroscopy than endometrial biopsy with rated VAS pain score was 3.5 ± 2.2, with 5 more score in 18%, and for endometrial biopsy 4.2 ± 2 and 33% respectively (p < 0.001). Six cases (13%) experienced vasovagal attacks immediately after the procedure. There is no other complication. ConclusionThe Vaginoscopic hysteroscopy combined endometrial biopsy is safe and feasible for assessment of endometrial pathology with postmenopausal bleeding.

Deep Learning-Based Automatic Endometrium Segmentation and Thickness Measurement for 2D Transvaginal Ultrasound.

Endometrial thickness is closely related to gyneco-logical function and is an important biomarker in transvaginal ultrasound (TVUS) examinations for assessing female reproductive health. Manual measurement is time-consuming and subject to high inter- and intra- observer variability. In this paper, we present a fully automated endometrial thickness measurement method using deep learning. Our pipeline consists of: 1) endometrium segmentation using a VGG-based U-Net, and 2) endometrial thickness estimation using medial axis transformation. We conducted experimental studies on 137 2D TVUS cases (74/63 secretory phase/proliferative phase). On a test set of 27 cases/277 images, the segmentation Dice score is 0.83. For thickness measurement, we achieved mean absolute error of 1.23/1.38 mm and root mean squared error of 1.79/1.85 mm on two different test sets. The results are considered well within the clinically acceptable range of ±2 mm. Furthermore, our phase-stratified analysis shows that the measurement variance from the secretory phase is higher than that from the proliferative phase, largely due to the high variability of the endometrium appearance in the secretory phase. Future work will extend our current algorithm toward different clinical outcomes for a broader spectrum of clinical applications.

How to assess the ureters during pelvic ultrasound.

BACKGROUND: Endometriosis, fibroids and gynecological malignancy can all impact the pelvic ureters. Ureteric involvement is likely to be an important factor in determining the extent and timing of surgery in women with these conditions and assessment of the pelvic ureters is now a recommended component of the imaging work-up for women with endometriosis. The aim of this paper is to provide a step-by-step guide for the identification and assessment of the distal ureters during pelvic ultrasound. We hope that this detailed explanation of the examination technique will help ultrasound examiners to develop this skill and enable them to integrate assessment of the pelvic urinary tract into their routine ultrasound examination. CONTENT: In this paper, we describe a '6 step' detailed approach to ultrasound assessment of the ureters during pelvic ultrasound examination. We discuss tips and common examination findings. CONCLUSION: The pelvic segments of normal ureters can be identified in almost all women on transvaginal ultrasound examination and the method described is useful in detecting urinary tract abnormalities.

Prevalence of polycystic ovary syndrome in a metabolically healthy obese population.

To determine whether polycystic ovary syndrome (PCOS) prevalence is increased among metabolically healthy obese (MHO) women. A national epidemiologic survey in 10 provinces and municipalities of China between October 2007 and September 2011. Women were stratified into four groups according to metabolic health (assessment by Adult Treatment Panel III) and obesity (body mass index [BMI] ≥28): metabolically healthy nonobese (MHNO), metabolically unhealthy nonobese (MUNO), MHO, and metabolically unhealthy obese (MUO). PCOS was diagnosed via Rotterdam Criteria. Participants completed a questionnaire and underwent physical and transvaginal ultrasound examination. BMI, blood pressure, glucose, and lipid profile were measured. The survey included 3551 women. The MHO group had a higher prevalence of PCOS and chronic anovulation versus nonobese groups (all P<0.05). Obesity was a risk factor for PCOS (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.68-3.14, P<0.05). Being metabolically unhealthy was a risk factor for PCOS (OR, 1.32; 95% CI, 1.09-1.60; P<0.05). The MHO group had an increased risk of PCOS relative to the MHNO group (OR, 2.39; 95% CI, 1.42-4.02; P<0.05). MHO women had an increased risk of PCOS and chronic anovulation. Obesity might be an independent risk factor for these two disorders.

Evaluation of Uterosacral Ligament Involvement in Deep Endometriosis by Transvaginal Ultrasonography.

This study was designed to conclude the ultrasonic characteristics of uterosacral ligament (USL) lesions involved by endometriosis and evaluated the value of transvaginal sonography (TVS) in diagnosing USL involvement in deep infiltrating endometriosis (DIE). A total of one hundred and eighteen patients with DIE were included in the study and underwent surgery. All these patients were evaluated by transvaginal ultrasound examination by one trained examiner. The gold standard for diagnosis was surgery and histopathology. 85 patients with USL endometriosis were confirmed by surgical pathology. 84 patients were diagnosed USL endometriosis by TVS and 81 of which were confirmed by the gold standard. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of TVS for diagnosing USL endometriosis were 95.3, 90.9, 96.4, 88.2, and 94.1%, respectively. According to the ultrasound characteristics of USL endometriosis, we summarized four types: Type I. thickened and stiff lesions, Type II. local nodules, Type III. irregular striped lesions, and Type IV. mixed lesions. The conclusion of the study was that TVS was a convenient, accurate and first-line diagnostic technique for USL endometriosis and the USL lesions could be summarized into four types according to the ultrasound morphological changes.

Hysterotomy level at Cesarean section and occurrence of large scar defects: a randomized single-blind trial.

To study the association between the level of Cesarean hysterotomy and the presence of large uterine scar defects 6-9 months after delivery. This was a two-center, randomized, single-blind trial of a surgical procedure with masked assessment of the principal outcome under study. Women without a history of Cesarean section (CS) who underwent emergency CS at cervical dilatation ≥ 5 cm were randomized to high or low incision. Hysterotomy was performed 2 cm above and 2 cm below the plica vesicouterina in the high and low incision groups, respectively. Women were examined using saline contrast sonohysterography to assess the appearance of the hysterotomy scar 6-9 months after delivery. The main outcome was presence of a large scar defect, defined as the remaining myometrial thickness over the defect being ≤ 2.5 mm. Secondary outcomes were perinatal outcome, operative complications within 8 weeks after delivery and long-term outcome in a subsequent pregnancy. Of 122 patients enrolled in the trial, 114 were assessed by ultrasound examination, of whom 55 were randomized to high and 59 to low CS incision. Large scar defects were seen in four (7%) women in the high-incision group and in 24 (41%) in the low-incision group (P < 0.001; odds ratio, 8.7 (95% CI, 2.8-27.4)). There were no differences in operative complications and perinatal outcomes between the two groups. The median follow-up time was 4 years and 7 months, during which 56 (49%) women had a subsequent pregnancy. No significant differences were observed in the rate of complications in subsequent pregnancy and delivery between women who had low and those who had high incision at the index CS. Low Cesarean hysterotomy level in women in advanced labor is associated with higher incidence of large scar defects detected by transvaginal ultrasound examination 6-9 months after delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound and Histopathologic Correlation of Ovarian Cystadenofibromas: Diagnostic Value of the "Shadow Sign".

Cystadenofibromas (CAFs) are rare benign ovarian tumors without a widely accepted ultrasound (US) pattern. They are usually described by as thin-walled, unilocular or multilocular, and at times septated cysts with scant blood flow and no solid components. We describe a unique US feature, the "shadow sign," seen in prospectively diagnosed benign CAFs. We also provide the histopathologic basis for this typical US appearance. Ultrasound (US) examinations were performed in our obstetric and gynecologic US unit. Pathologic examinations were performed by a dedicated gynecologic pathology team. The US and pathology department's database was searched for the diagnosis of a CAF between 2010 and 2017. We identified 20 patients who underwent transvaginal US examinations with a sole US diagnosis of a CAF, and the tumors were surgically removed. The common US feature across the 20 cases was the presence of hyperechoic avascular shadowing nodules. The correlating histologic features were unilocular or multilocular cysts with a smooth internal wall surface lined by a simple epithelium and occasional robust polypoid fibrous stroma. This US marker helps in differentiating CAFs from borderline ovarian tumors, which do not show this US feature. We hope that recognizing the suggested shadow sign as an additional descriptor of CAFs will lead to minimizing their unnecessary removal and eliminating additional and unnecessary imaging by computed tomography and magnetic resonance imaging.

Mini-invasive transvaginal repair of isthmocele: a video case report

To describe our technique for transvaginal treatment of isthmocele. Surgical video article. Local Institutional Review Board approval for the video reproduction was obtained. A scientific institute. A 26-year-old patient complaining of abnormal uterine bleeding and pelvic pain was referred to our gynecological clinic for secondary infertility. At transvaginal ultrasound examination, a cesarean scar defect of 22 × 11mm was identified, with a residual myometrial thickness over the defect of 2mm. Isthmocele excision and myometrial repair was performed transvaginal, under regional anesthesia. Before surgery, a hysteroscopy was performed to identify the dehiscence of the cesarean scar on the anterior wall of the uterus and to confirm the presence of the isthmocele and its distance from the external os. Then an incision was made at the anterior cervicovaginal junction and the bladder was dissected away until the anterior peritoneal reflection was identified. Hysteroscopic guidance by transillumination was used to identify the exact position and the limits of the isthmocele. The fibrotic tissue was then removed, and the myometrial defect was closed with interrupted sutures by using 2-0 Vicryl, engulfing the myometrial fibers that would tend to slide laterally. The vaginal mucosa was then sutured with interrupted Vicryl 2-0 sutures. At the end of the procedure, a hysteroscopy was performed to visualize the correction of the defect and to prove the continuity of the cervical canal with the uterine cavity. Repair of isthmocele and relief of symptoms. The postoperative course was uneventful, and the patient was discharged the day after surgery. At 1-month follow-up pelvic ultrasound showed complete anatomic repair of the uterine defect. The patient was asymptomatic with no more postmenstrual bleeding. She is satisfied with the treatment and is still trying for pregnancy. Symptomatic isthmocele can be treated surgically via a hysteroscopic, laparoscopic, or vaginal approach, depending on the clinical findings and the skill set and comfort level of the surgeon. Unfortunately, there is no consensus about the ideal surgical approach. The hysteroscopic approach has been demonstrated to be effective for the treatment of abnormal uterine bleeding; however, it does not strengthen the uterine wall and it has a risk of bladder injury. The laparoscopic approach provides good anatomic results, but it requires general anesthesia and may be associated with bladder injury. The transvaginal approach appears to be a feasible, effective, and safe modality to repair the uterine defect and to restore the original thickness of the myometrium. It is a minimally invasive, scarless, and low-cost procedure. It ensures quick recovery and a relatively pain-free postoperative course with early return to normal function.