The Utility of Routine Ultrasound in the Diagnosis and Management of Adolescents with Abnormal Uterine Bleeding

Study Objective

Despite the fact that most cases of abnormal uterine bleeding (AUB) in adolescence are due to an immature hypothalamic-pituitary-ovarian (HPO) axis, the current approach to investigating adolescents who present with AUB often includes pelvic ultrasound to exclude rare structural causes. The aim of this study was to determine whether an ultrasound ordered for the investigation of AUB in adolescents detects any significant anatomic pathology or alters diagnosis and management.

Diagnostic ultrasound and the intrauterine pessary

The aim of the authors is an analysis of the results in application of ultrasound technique in patients with intrauterine device (IUD). Using the ultrasound criteria for a correct and incorrect position of IUD, the criteria for an elevated risk for expulsion and contraindications for IUD application, the authors have used ultrasound technique for diagnosis in 65 patients with IUD. The causes for the "wrong" diagnosis were discussed: imperfection of the apparatuses, non-observance of the conditions for ultrasound examinations and lack of experience. Practical conclusions and recommendations for an increase of the effectively of this seemingly easy method for diagnosis and follow-up of the IUD were made.     

Suspicious axillary lymph nodes in patients with unremarkable imaging of the breast

Objective

The aim of this study was to evaluate the pathological findings and the method of tissue harvesting in those patients who have both suspicious axillary lymph nodes and normal imaging of the breast.

Study design

From January 2005 to June 2008 all female patients who underwent opportunistic screening mammography and ultrasound examination of the breast and the axilla, and who were found to have suspicious axillary lymph nodes seen on ultrasound examination, were retrospectively analysed. Tissue harvesting was done by fine needle aspiration, core needle biopsy, or open biopsy.

Results

Out of approximately 7500 screened patients, 51 were found to have suspicious axillary lymph nodes on ultrasound with unremarkable breast ultrasound and mammography. Histopathology and/or cytology of these lymph nodes showed 33 benign and 18 malignant results. Of the malignant results only 1 case was an occult invasive lobular breast carcinoma detected afterwards on breast magnetic resonance imaging. Eleven cases were non-Hodgkin lymphomas, 4 were malignant melanomas, and 2 were metastases from the lower genital tract. Diffuse cortical thickening and complete loss of echo texture were the only features on ultrasound predicting malignancy. Palpation and mean size of the evaluated lymph nodes had no predictive value for malignancy. In the 33 cases of non-malignant pathology 9 patients showed patterns of specific infectious disease, including 4 patients with tuberculosis.

Conclusion

Suspicious lymph nodes of the axilla seen on ultrasound rarely indicate occult breast cancer but show a variety of other malignancies and generalised infectious disease requiring further treatment. Fine needle aspiration and/or core needle biopsy are both sufficient methods for clarification in the majority of cases.     

3D vocal power Doppler sonography for the estimation of tumor volume and vascularization in stage IB1 cervical cancer

Purpose

To evaluate the tumor’s volume and intratumoral vascularization with 3D vocal power Doppler ultrasound in patients with stage 1B1 cervical cancer.

Methods

This was a prospective study on patients with cervical cancer and stage 1B1 disease, which took place between 2012 and 2015. All women had an initial 2D ultrasound examination for the estimation of the tumor volume. Following this, 3D volumes of the cervix were acquired and were further analyzed using the Virtual Organ Computer Aided Analysis (VOCAL) program. In the selected volume, the vascular pattern (linear or complex vascularization) was also examined. The ultrasonographic findings were compared to the histological ones following surgery.

Results

Twenty-seven patients were included. The average cervical tumor volume measured by the 2D ultrasound and 3D VOCAL-PD were 3.14 and 3.08 cm³, respectively. Both 2D and 3D VOCAL-PD overestimated the tumor staging. Further analysis showed a statistically significant superiority of 2D ultrasound over 3D VOCAL-PD for tumors equal or smaller than 2.5 cm³ with linear vascularity (p?<?0.001), while for tumors of larger volume with complex vascularization, a statistically significant superiority of 3D VOCAL-PD was confirmed (p?<?0.001).

Conclusions

3-D VOCAL-PD is extremely accurate and superior to 2D ultrasound for the estimation of tumor volume and vascularization when it is more than 2.5 cm³ and has a complex vascularization in patients with stage 1B1 cervical cancer.

     

Intratumor flowmetry in endometrial carcinoma. Correlation with the tumor stage

BACKGROUND: To assess the value of intra-tumoral (endometrial) flow as detected by color Doppler ultrasound in relationship with negative prognostic factors in patients with endometrial carcinoma. METHODS: Fifty-three patients with a previous histological diagnosis of endometrial carcinoma were included in the study. Transvaginal ultrasound with pulsed color Doppler was performed in order to record resistance indexes and vascular density (defined as "high" if > or = 3 vascular spaces were detectable for any given area). All cases were classified according to FIGO after surgery and histology. Prognostic bad factors were considered: FIGO stage (> I), tumor grade (> 1), myometrial invasion (> 50%) involvement of vascular spaces and lymph node metastasis. RESULTS: Both resistance indexes and vascular density in the endometrium related well to more prognostic signs. No relationship was found for lymph node metastasis, probably justified by the small number of positive nodes (2/27). DISCUSSION: Color Doppler ultrasound seems to be a promising technique in pre-surgical staging of endometrial carcinoma. Detection of vascular spaces rather than low resistance indexes is, in personal experience, more significantly related to advanced disease. It is hypothesized that long term follow-up of these patients can show a predictive value of Doppler ultrasound on the outcome of the disease.     

beta-Subunit of human chorionic gonadotropin, ultrasound, and ectopic pregnancy: a prospective study

This prospective study shows that the beta-subunit of human chorionic gonadotropin (beta-hCG) "screen" and ultrasound provide for nearly 100% clinical accuracy in diagnosing ectopic pregnancy in suspected cases. During the 14 months from February, 1981, to April, 1982, 81 consecutive patients believed to have ectopic pregnancies were screened. Fifty-six had a negative beta-hCG screen, thus ruling out early pregnancy complications. No false negative results were found. Twenty-seven patients had a positive screen, and 16 of these had an ectopic pregnancy. Twenty of the 27 patients with a positive beta-hCG screen underwent pelvic ultrasound examination. All of those with a positive beta-hCG screen and no intrauterine pregnancy on ultrasound had ectopic pregnancies. With the use of these clinical aids, morbidity and tubal damage are reduced because delay in operating upon those with ectopic pregnancy is avoided. Unnecessary operation is avoided in those patients who do not have an ectopic pregnancy.     

Transvaginal ultrasound and sonohysterography for assessment of postpartum residual trophoblastic tissue

Objective

To compare the accuracy of transvaginal ultrasound and sonohysterography (SHG) in diagnosing residual trophoblastic tissue in postpartum women and to assess the adverse effects and complications of the SHG procedure.

Methods

A prospective study of patients with postpartum bleeding enrolled for clinical symptoms and signs of residual trophoblastic tissue. All women underwent transvaginal ultrasound and SHG. Uterine cavity curettage was performed in all women and the material collected was sent for pathologic examination.

Results

Among 84 patients, transvaginal ultrasound revealed residual trophoblastic tissue in 60 women, whereas SHG detected residual trophoblastic tissue in 48 and blood clots in 12. Pathologic examination confirmed trophoblastic tissue in 48 patients and blood clots in 12. Fifteen (17.9%) patients experienced adverse effects after SHG. Thirteen (15.5%) experienced postprocedural fever that resolved with antibiotics. Two women (2.4%) had severe complications of infection: 1 required surgery for peritonitis, which revealed salpingitis and a pelvic abscess; 1 experienced fever and mild abdominal pain that resolved with antibiotics after 10 days of hospitalization.

Conclusions

Although SHG showed greater accuracy than transvaginal ultrasound in detecting residual trophoblastic tissue, a high proportion of patients experienced adverse effects.     

Risk of endometrial cancer in asymptomatic postmenopausal patients with thickened endometrium: data from the FAME-Endo study: an observational register study

Purpose

To evaluate the risk for endometrial cancer (EC) in a large series of asymptomatic patients with thickened endometrium at ultrasound examination based on previously published data of a theoretical cohort.

Methods

In a prospective register study, a total of 1024 women with thickened endometrium in ultrasound examination undergoing histological diagnosis by dilation, hysteroscopy and curettage were evaluated. 124 patients were excluded due to current medication with tamoxifen and/or presence of HNPCC leaving 900 patients for further analysis.

Results

Mean [standard deviation (SD)] age of patients was 65.6 (8.6) years. Mean (SD) endometrial thickness was 11.9 (5.8) mm. 32 and 6 cases of EC and complex endometrial hyperplasia with atypia were found, respectively. In the univariate analysis, a statistically significant association between endometrial thickness, current use of antihypertensive medication, number of deliveries, and the presence of endometrial fluid in preoperative vaginal ultrasound (p?<?0.05) with EC was found. A multivariate logistic regression model incorporating these parameters showed a statistically significant independent association of endometrial thickness, number of deliveries, and the presence of endometrial fluid in preoperative vaginal ultrasound (p?<?0.05), but not current use of antihypertensive medication, with EC. Using a cut-off of the endometrial thickness of?>?11 mm, the risk for “EC alone” and “EC and complex endometrial hyperplasia with atypia combined” was found to be 6.7% and 7.9%, respectively.

Conclusions

Our data compare favorably to a theoretical cohort suggesting a clinically reasonable cut-off of?>?11 mm endometrial thickness to discriminate between “normal” and “pathological”. The data regarding “risk for endometrial cancer” can be used for counseling affected women.

     

The value of the cervical score in monitoring ovulation induction for in vitro fertilization: A prospective double-blind study

The present study was designed to determine the accuracy of the cervical score for the timing of human chorionic gonadotropin (hCG) administration in in vitro fertilization patients compared to the timing of hCG administration based upon estradiol and ultrasound measurement. Forty-two patients undergoing ovulation induction with human menopausal gonadotropin (hMG)/hCG for in vitro fertilization were studied. A total of 192 cervical scores was obtained together with plasma estradiol levels and pelvic sonography. hCG was given based on estradiol and ultrasound results without knowing the cervical score. An independent decision to give hCG was made based on the cervical score only following a mean of 2.5 days of a cervical score of 9–12 without the examiner's knowledge of estradiol and ultrasound results. This decision was theoretic and was not condidered for the actual timing of hCG. In 16 (38%) of the cases this decision coincided with that based on estradiol and ultrasound. In 24 (57%) of the cases there was a 1-day gap. A direct correlation was found among the cervical score, the plasma estradiol concentration, and the mean diameter of the two leading follicles (P<0.001). The overall distribution of the cervical score grouped according to estradiol levels (<200, 201–400, and >401 pg/ml) was significantly different (P<0.001). The proportion of mature cervical scores (score of 11–12) in the three different estradiol groups was 15.6, 34.5, and 68.0%, respectively. In conclusion, independent decisions to give hCG based on cervical score or estradiol and ultrasound were coincident ±1 day in 95% of the cases. These results suggest that the cervical score can be a useful adjunct for monitoring follicle maturation in in vitro fertilization patients when estradiol and/or sonography are not available. The ultimate success of in vitro fertilization cycles monitored solely by cervical score remains to be determined.On leave from the Department of Obstetrics and Gynecology, The Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.On leave from Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan     

Combined pelvic sonography and serum beta hCG, versus laparoscopy for the diagnosis of stable patient suspected of ectopic pregnancy

The role of sonography in stable patients suspected of ectopic pregnancy is to establish the diagnosis using positive, suggestive or negative signs. Establishing whether or not intrauterine gestation is present is crucial, as is the detection of any extrauterine abnormality. Sonography may be normal in ectopic pregnancy or when it is not abnormal findings are frequently nonspecific. Therefore, the sonographic results must be correlated and integrated with the clinical history and findings as well as with other diagnostic procedures. The combination of ultrasound scanning with beta hCG was found highly contributory to the determination of the existence of an ectopic pregnancy. Understanding the objectives and limitations of each diagnostic test involved is essential for logical and optimal sequences of diagnostic procedures to be employed in patient management. During a twenty-month period, 138 patients were examined due to clinical suspicion of "sub-acute" ectopic pregnancy. Sixty-one patients were managed according to a non-invasive protocol composed of: a) ultrasound scanning alone and b) ultrasound scanning combined with serum beta subunit hCG. Ultrasonograms for ectopic pregnancy diagnosis were coded: positive (fluid in cul-de-sac or extrauterine sac); suggestive empty uterus, adnexal mass and pseudo-gestational sac) and negative (intrauterine gestational sac and normal pelvis). Surgical procedure was carried out immediately on nine patients with positive signs; all of them had ectopics. Suggestive signs were found in twenty-two patients. beta subunit hCG was determined prior to interventive procedure; ectopic pregnancy was revealed in eighteen of them. Among thirty patients with negative signs, only two patients (7% of this sub-group or 3.5% of the general group) had ectopics.(ABSTRACT TRUNCATED AT 250 WORDS)     

Karyotyping for isolated neural tube defects. A report of two cases

BACKGROUND: Neural tube defects occur in approximately 1 in every 1,000 live births. In the United States, chromosomal abnormalities have been noted in 2-10% of fetuses with neural tube defects; however, there is no consensus on whether to offer karyotype analysis to patients with isolated neural tube defects found on ultrasound. CASE: We reviewed the prenatal diagnosis database for the University of Washington between 1985 and 1997. We report on two fetuses who, on ultrasound, were found to have "isolated" neural tube defects. Karyotype analysis revealed trisomy 18 in both fetuses. The pregnancies were subsequently terminated, and autopsy revealed subtle syndromic findings that were not identified on ultrasound. CONCLUSION: Fetuses with isolated neural tube defects also appear to have a high risk of chromosomal abnormalities, so patients should be offered fetal karyotyping to define recurrence risks for future pregnancies.     

Renal ultrasound to detect hydronephrosis: a need for routine imaging after radical hysterectomy?

Background

Hydronephrosis can be a side effect of radical hysterectomy for cervical cancer. The incidence of clinically relevant hydronephrosis has not been studied in a large sample and the benefit of early detection of hydronephrosis is not clear.

Objective

To assess the incidence of hydronephrosis, following radical hysterectomy and evaluate the usefulness of routine renal ultrasound (RH).

Methods

Retrospective study, January 1998 and December 2008. Cervical cancer patients (FIGO stage IBI-IIA), treated with radical hysterectomy and pelvic lymph node dissection with or without adjuvant radiotherapy, without surgical lesion of the ureter, followed-up 6 months in the Academic Medical Center Amsterdam. Routine renal ultrasound was performed four weeks after RH, and in some on indication before or after the routine ultrasound. We documented which interventions for hydronephrosis were performed and evaluated the profile of patients at risk for hydronephrosis.

Results

281 patients were included: 252 (90%) underwent routine renal ultrasound and 29 (10%) underwent imaging on indication before routine ultrasound. The overall incidence of hydronephrosis was 12%. In symptomatic patients, the incidence was 21% and 9% in asymptomatic women undergoing routine ultrasound. Four patients were invasively treated for hydronephrosis (1% of the total group) after imaging for clinical suspicion of hydronephrosis. Patients with hydronephrosis were significantly more often treated with radiotherapy than patients without (43% versus 25% (p = 0.03).

Conclusion

There is no place for routine renal ultrasound following radical hysterectomy. Patients should be instructed about the symptoms that may be related to hydronephrosis, to allow for renal ultrasound on indication.     

Intravaginal echography at the beginning of pregnancy]

Endocavity ultrasound during the first three months of pregnancy provides greater detail in a number of obstetrical fields. In most cases, endocavitary ultrasound is not simply a way of "gaining time" in comparison with conventional transabdominal ultrasound (time saved estimated to be one week). In some cases it is also offers a definite "extra". Two areas of interest are focussed on particularly by the authors: 1) the fetal appendages (vitelline sac, membranes, extra-embryonic coelom, trophoblast) which may be detected or revealed in greater detail by endovaginal ultrasound, make it possible to get a picture of the embryology of the fetus and of the prognosis of the pregnancy. The combination of color coded Doppler corroborates this new approach to the fetus; 2) the developments of this "sono-embryology" makes it possible to identify certain fetal malformations at a very early stage (neuro-medullary, parietal malformations...). However, interpreting the morphology of the fetus examined during the first three months must remain prudent and is no substitute for the morphological ultrasound scan carried out at about four and one half months of pregnancy.     

The role of transvaginal ultrasound in the management of abnormal uterine bleeding

Abnormal uterine bleeding is a common symptom. Modern management should be based on a one-stop approach to which transvaginal ultrasound is ideally suited as a primary diagnostic tool. In premenopausal women focal pathology, such as fibroids and polyps, as well as extra uterine pathology, can be accurately diagnosed. In postmenopausal women endometrial cancer can be excluded. In the majority of women diagnostic hysteroscopy can thus be avoided, and patients with focal pathology detected with transvaginal ultrasound can be triaged for operative intervention. Outpatient endometrial biopsy should still be used to exclude endometrial pathology. This one-stop ultrasound-based clinical approach provides a rapid, accurate diagnosis, with the minimum of investigations and invasive procedures. In this way multiple outpatient visits and unnecessary inpatient admissions can be avoided.     

Surgical treatment of deep venous insufficiency of the lower limb

The substitute "valve" operation, using Technique II with a Silastic (polymeric silicone) tendon designed to produce a valve-like mechanism in the popliteal vein, was performed upon 162 lower limbs (145 patients) which had deep venous insufficiency. Results achieved by this procedure were assessed clinically by Doppler ultrasound and venous pressure measurements, and partially by phlebography. Clinical improvement in 154 of 162 limbs was associated with a reduction of ambulatory venous pressure, prolongation of refilling time, interruption of popliteal reflux by Doppler, and phlebographic evidence of a functioning substitute "valve" postoperatively.     

Comparative study on the role of diagnostic hysteroscopy in evaluation of the uterine cavity prior to in vitro fertilization in a developing country

Introduction

Diagnostic hysteroscopy is a vital tool and a gold standard to evaluate the uterine cavity. The aim of this study was to estimate the prevalence of unsuspected intrauterine abnormalities.

Materials and methods

This cross-sectional study was done involving 870 asymptomatic, infertile women enrolled for IVF, who underwent a transvaginal ultrasound followed by office hysteroscopy. The presence of uterine cavity abnormalities was recorded.

Results

Transvaginal sonography revealed abnormal findings in 113 patients (12.9 %). Hysteroscopy confirmed the ultrasound findings in 76 (67.3 %) women with no obvious findings seen on hysteroscopy in 37 (32.7 %). Among the 757 women, who had a normal pelvic scan, abnormal findings were observed in 108 (14.2 %) on hysteroscopy, while the remaining 649 (85.7 %) patients had normal findings on hysteroscopy. Thus, a total of 184 (21.1 %) patients had confirmed abnormalities that required to be treated before performing IVF/ICSI.

Conclusions

The present study highlights the relatively higher prevalence of intrauterine abnormalities in our patient population. Diagnosing and treating these abnormalities are imperative to improve the success of IVF treatment. Therefore, a routine diagnostic hysteroscopy in these patients becomes mandatory before proceeding with expensive procedures such as assisted reproduction.     

Contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women

Objective

To determine the contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women.

Study design

One thousand and ninety-four women with adnexal mass were included. Patients were divided into three groups according to clinical complaints: asymptomatic (group A), patients with symptoms non-suspicious of ovarian cancer (group B) and patients with symptoms suspicious of ovarian cancer (group C). All patients underwent transvaginal power Doppler ultrasound prior to surgery. Any mass in which the echo architecture at B-mode ultrasound was not highly suggestive of benign histology was categorized as questionable. In these cases power Doppler was performed as the second step. Definitive histological diagnosis was used as the standard reference. Sensitivity, specificity, positive likelihood ratio (+LR) and negative likelihood ratio (−LR) were calculated for B-mode diagnosis and B-mode plus Doppler in each group.

Results

In group A, B-mode was significantly more sensitive (98.1%) than Doppler ultrasound (91.3%) (p < 0.01). In group B Doppler ultrasound (97.0%) was more specific than B-mode ultrasound (92.2%) (p < 0.001). In group C Doppler ultrasound (84.0%) was more specific than B-mode ultrasound (68.0%) (p < 0.001). Positive LR was significantly higher after Doppler evaluation in all groups (30.5 vs 12.8 in group A, 33.2 vs 12.8 in group B and 6.0 vs 3.1 in group C).

Conclusions

The diagnostic performance of B-mode and power Doppler ultrasound is different depending on patients’ complaints.     

Fetal heart monitoring and ultrasound in the management of placental abruption

Three cases of placental abruption with the "pseudosinusoidal" fetal heart rate (FHR) pattern, a periodic late deceleration related to frequent uterine contractions are reported. This 'pseudosinusoidal' pattern is clearly not a true sinusoidal pattern. The fetal monitoring patterns of these patients are presented and discussed along with the use of ultrasound in the management of this condition. All infants were delivered by cesarean section with low Apgar scores at birth, but they soon recovered completely.     

The correlation of pelvic ultrasound and laparoscopy in the diagnosis and management of gynecologic disorders.

Cases were reviewed in which both laparoscopy and ultrasound were performed for diagnostic purposes at the Ben Taub General Hospital, Houston, Texas, from January 1976 through May 1977. Thirty patients were found to have undergone both procedures. The most common reason (13 cases) was the presence of an adnexal mass. The findings from both techniques agreed in 20 cases, for a positive correlation of 66.7%. Different diagnoses were found in 10 cases, for a negative correlation of 33.3%. The major cause of the discrepancy was the presence of pelvic adhesive disease, not diagnosed by ultrasound but observed via laparoscopy. When the ultrasound findings were reported as "normal," all were confirmed at laparoscopy. Eight laparotomies were performed, and in each case the laparoscopic findings were confirmed.     

Bronchoalveolar lavage for the treatment of neonatal pulmonary atelectasis under lung ultrasound monitoring

Objective: Pulmonary atelectasis (PA) is a common clinical complication among newborns, and it is one of the most common causes of neonatal dyspnea, a condition with no specific effective treatment. This study examined the effectiveness and security of bronchoalveolar lavage (BL) regarding the treatment of neonatal PA under ultrasound monitoring.

Methods: A total of 57 patients diagnosed with PA via lung ultrasound (LUS) were included in this study. All patients received BL via a tracheal intubation injection of lavage fluid. The LUS was conducted immediately after each lavage to understand the conditions of lung re-expansion. Irrigation was repeated two to three times as one course of treatment. BL was provided as one to two courses of treatment daily for several days according to atelectasis and lung recruitment status.

Results: Of the 57 patients, BL was very effective in 44 cases (77.2%), marginally effective in nine cases (15.8%) and ineffective in four cases (7.0%), showing a total effective rate of 93.0%. The four ineffective cases showed a long disease duration and severe pulmonary consolidation.

Conclusions: BL showed significant effectiveness for the treatment of neonatal PA under ultrasound monitoring. This treatment is easy to operate, and no adverse side effects were observed. Thus, BL should be considered for clinical application.