Uterine rupture of cesarean scar related to spontaneous abortion in the first trimester

We report the case of a 31-year-old Japanese female diagnosed by transvaginal ultrasonography to have a spontaneous uterine rupture in the first trimester. Her condition was complicated by diabetes mellitus type 1. Her previous pregnancy had resulted in an emergency cesarean section by transverse incision of the lower uterine segment with single-layer suture at 37(+4) weeks of gestation. Transvaginal ultrasonography displayed both a gestational sac located in the anterior lower uterine segment and a defect in the uterine wall located at the site of the previous cesarean delivery scar. Pelvic magnetic resonance imaging showed that the uterine muscle layer was discontinuous and the gestational sac was almost outside the uterine cavity, accompanied by mild hemorrhaging within the endometrial cavity. The defect in the lower uterine wall was round in shape and was 3 cm in diameter. Since uterine ruptures can occur during all gestational periods, it is important to pay attention to the uterine wall where any cesarean incision was previously made.     

Interstitial ectopic pregnancy: A more confident diagnosis with three-dimensional sonography

ObjectiveTo present a confident tool for the diagnosis of interstitial ectopic pregnancy. 3-Dimensional US helps to reach a more proper diagnosis and enables to arrange therapeutic and surgical strategies.Case reportA 36-year-old, gravida 4 para 2, woman was referred from the local medical department in the suspicion of ectopic pregnancy. Transabdominal ultrasound revealed an empty uterine cavity but an 8-week-old gestational sac located eccentrically on the right side of the uterine fundus. The Three-dimensional sonography (3D US) demonstrated a gestational sac (GS) over the right cornual region separated from the endometrial cavity. Interstitial pregnancy was impressed. Laparoscopic surgery was then arranged. After entering the pelvic cavity, a bulging mass was found over the utero-tubal junction, compatible with interstitial pregnancy. The wedge resection of interstitial ectopic pregnancy and right salpingectomy were undertaken. The patient was discharged within 2 days after the surgery.ConclusionThe conventional sonography still remained the primary tool to diagnose the ectopic pregnancy, but 3D US played an indispensable role in demonstrating the precise location of GS. Interstitial ectopic pregnancy was symptomatically late in gestation and rupture of an interstitial pregnancy causes catastrophic consequence due to massive bleeding, so prompt and accurate diagnosis was definitely life-saving. Appropriate therapy or surgical intervention could be arranged.     

Comparison of magnetic resonance imaging and ultrasonography in the early diagnosis of interstitial pregnancy

OBJECTIVE: To investigate the usefulness of ultrasonography (USG) and magnetic resonance imaging (MRI) in the early diagnosis of interstitial pregnancy. STUDY DESIGN: Four cases of interstitial pregnancy that showed characteristic ultrasonographic and MRI findings were studied. All cases received cornual resection, and the presence of interstitial pregnancy was confirmed by pathologic examination. RESULTS: Three of four cases had a gestational sac in the uterine cornu or a protruding cornual mass and myometrium between the sac and uterine cavity on both USG and MRI. In the remaining case, preoperative diagnosis was inconclusive because no gestational sac was demonstrated by USG or MRI. Color flow mapping was conducted in three cases and revealed prominent peritrophoblastic blood flow. CONCLUSION: The findings suggest that USG combined with color flow mapping is the first choice in the early diagnosis of interstitial pregnancy. MRI, which is an extremely expensive imaging technology, should be used only if transvaginal USG with color flow mapping is inconclusive in ruling out the diagnosis of interstitial pregnancy.     

经阴道彩色多普勒超声诊断剖宫产切口瘢痕妊娠的临床价值

目的探讨经阴道彩色多普勒超声诊断剖宫产切口瘢痕妊娠(CSP)的临床价值。方法收集2012年10月至2014年10月沈阳市妇婴医院收治的64例经阴道超声诊断为剖宫产切口瘢痕妊娠患者的影像及临床资料,分析其超声声像图特征及与临床结局的关系。结果超声诊断为CSP的64例患者中59例(92.2%)经病理证实,5例为难免流产。根据超声声像图特征将59例CSP分为2型:孕囊型(41例)和混合回声型(18例)。孕囊型分为3个亚型:I型妊娠囊边缘位于切口处(24例),Ⅱ型妊娠囊陷入切口内(15例),Ⅲ型妊娠囊向膀胱方向凸出(2例)。I型治疗以宫腔镜为主,Ⅱ型、Ⅲ型及混合回声型治疗以腹腔镜为主。结论经阴道彩色多普勒超声为诊断CSP的有效方法,正确的超声分型及对切口瘢痕厚度的准确测量有助于临床医生选择更加适合患者的个体化治疗方案。     

经阴道超声结合VCI-C平面及3D-Glassbody成像模式在诊断异位妊娠中的应用

目的:探讨容积对比成像技术(VCI-C平面)、三维玻璃体模式(3D-Glassbody)及经阴道彩色多普勒超声诊断异位妊娠(EP)的特征性依据,以提高EP诊断的准确性。方法:对188例疑似早期EP的患者,进行二维经阴道(必要时结合经腹)彩超及VCI-C平面+Glassbody模式,观察包块滋养动脉血流分布及频谱。结果:188例中及时确诊183例。①附件区的妊娠囊内可见胎芽和(或)卵黄囊,17例(9.0%)有胎心搏动。②Donut征(输卵管环),其中98例有Donut征,占52.1%。③附件区内可探及混合性包块,有时伴有少量积液,共60例,占31.9%。④另有8例仅表现为盆腔积液,占4.3%。诊断符合率97.3%。误诊5例,均为宫内妊娠合并卵巢黄体破裂,误诊率为2.7%。结论:经阴道超声结合彩色多普勒(CDFI)/能量多普勒(CDE),能准确迅速地取得EP的诊断证据,VCI-C平面超声成像结合3D-Glassbody成像模式,信息量大,提高了对比分辨率与信噪比,可较二维超声提供更详尽的信息。     

Three-dimensional ultrasonographic diagnosis and hysteroscopic management of a viable cesarean scar ectopic pregnancy

Implantation of conception material within a cesarean section scar is an extremely rare form of ectopic pregnancy with devastating complications, such as uterine rupture and intractable bleeding. Both 2-D and 3-D transvaginal ultrasonographic devices are used adequately for precise diagnosis, but there is still a lack of consensus concerning management strategies. No therapeutic modality is suggested to be entirely efficacious and safe for preserving uterine integrity. We present here a 29-year-old woman with vaginal bleeding and a gestational sac with a viable embryo of 6 weeks of age that was implanted in a cesarean section scar. Serum beta-hCG levels were 16 792 mIU/mL. Following an unsuccessful treatment course of systemic methotrexate, the patient underwent operative hysteroscopy. Minimally invasive hysteroscopic resection of the ectopic gestational mass without major complication appears to be an alternative therapeutic approach with minimal morbidity and preservation of future fertility.     

Primary application of three-dimensional ultrasonography to early diagnosis of ectopic pregnancy

Preliminary evaluation of three-dimensional (3D) imaging for early diagnosis of ectopic pregnancy. Twelve asymptomatic patients before six weeks of amenorrhea and with no feature of intrauterine nor of ectopic pregnancy at traditional bidimensional ultrasonography were considered. Laparoscopy showed ectopic pregnancy in 9 cases. 3D transvaginal ultrasonography preceeding laparoscopy showed small ectopic gestational sac in 4 cases. Moreover the fallopian tube on the side of ectopic pregnancy could be imaged in all cases. This was possible because the fallopian tube was surrounded by a fine hypoechogenic border, an apparently specific feature which had not been reported previously. These preliminary data suggest that 3D ultrasonography is an effective procedure for early diagnosis of ectopic pregnancy in asymptomatic patients before six weeks of amenorrhea.     

Transvaginal color Doppler study of blood flow in ectopic pregnancies.

OBJECTIVE: To compare Doppler indices of blood flow in the uterine and spiral arteries and the corpus luteum (CL), in ectopic and intrauterine pregnancies (IUPs). DESIGN: A prospective study of women with an ectopic or singleton IUP at the corresponding stage of gestation. SETTING: The Gynaecological Ultrasound Clinic, King's College Hospital. PATIENTS: Fifty-two women, 19 with an ectopic pregnancy (EP) and 33 with an IUP. INTERVENTIONS: All women were examined by transvaginal ultrasonography with color Doppler immediately before surgery. MAIN OUTCOME MEASURES: The resistance index from the left and right uterine arteries, the spiral arteries, and the CL. The peak blood velocity (cm/sec) from the uterine arteries. The length of gestation. RESULTS: Fetal heart activity was observed in all cases of IUP at 5 weeks' gestation. Three women had an EP with a live embryo, 5 had an embryo with no heart activity, 5 contained only a yolk sac, and 2 had an empty sac. A hematocele was seen in 3 women, and 1 had tubal thickening. The mean uterine and spiral arterial resistance index decreased with the gestational age of IUPs but remained constant during EPs. Peak blood velocity in the uterine arteries increased with the gestational age of IUPs, and the values were significantly higher than in EPs. A CL was seen in 88% of women with an IUP and in 100% of women with an EP. The resistance index was similar in CL associated with both types of pregnancy, and the values did not change with gestational age. CONCLUSION: These data show that: (1) blood flow impedance in the uterine and spiral arteries, and CL, is similar in IUPs and EPs and (2) peak flow velocity in the uterine arteries reflects a decreased blood supply to EPs.     

Early abdominal pregnancy with an unexpected and misleading location. The ultrasonographic interpretation

Abdominal pregnancy is a rare condition defined as an ectopic pregnancy that implants in the peritoneal cavity and is associated with important morbidity and mortality. We report a case of a 35-year-old woman with an ultrasonographic diagnosis of a left extrauterine pregnancy located proximally in the isthmus or distally in the interstitial region. In the exploratory laparotomy a gestational sac implanted anteriorly on the uterine serosa was found, with no signs of uterine perforation or tubal abortion. The pathologic examination confirmed the diagnosis of an early first trimester abdominal pregnancy. This case illustrates the importance of an early sonography in the diagnosis of an abdominal pregnancy as well as a high index of suspicion.     

Early detection of ectopic pregnancy. Use of a sensitive urine pregnancy test and transvaginal ultrasonography

We performed a prospective study to evaluate the reliability of a rapid monoclonal antibody urine pregnancy test with a sensitivity limit of 20 mIU/mL combined with transvaginal ultrasonography in the early diagnosis of ectopic pregnancy in 116 women with subacute pelvic pain and a stable general condition. The diagnosis of tubal pregnancy was confirmed with laparoscopy in 100 of the 103 women with positive sensitive urine pregnancy tests and no intrauterine gestational sac at transvaginal ultrasonography. Laparoscopy revealed a hemorrhagic corpus luteum in four of the eight subjects with negative monoclonal antibody pregnancy tests and no intrauterine gestational sac, an ovarian cyst in three and a normal pelvis in one. Of the five women with a positive pregnancy test and an intrauterine gestational sac, two had a hemorrhagic corpus luteum, two a normal pelvis and one a tubal pregnancy at laparoscopy. The sensitivity of a monoclonal antibody urine pregnancy test and transvaginal ultrasonography combined for the diagnosis of ectopic pregnancy was 99%, and the specificity was 80%, with positive and negative predictive values of 97% and 92%, respectively.     

A large yolk sac may be important in the early diagnosis of gestational trophoblastic disease: a case report

A large yolk sac in a deformed shape gestational sac was detected by ultrasonography in an 8 week pregnant woman. The disappearance of the yolk sac and the gestational sac, enlargement of the uterine cavity and a heterogeneous appearance similar to early gestational trophoblastic disease were recognized when ultrasonographic examination was performed 2 weeks later. After uterine evacuation, partial hydatidiform mole was diagnosed by histopathological evaluation of the curettage material. In our study, the role of the large yolk sac in predicting trophoblastic disease is discussed.     

Efficiency of transvaginal scanning in obstetric and gynecologic fields

Transvaginal ultrasonography was done on 26 pregnant women ranging from 5 to 27 weeks of gestation and 12 patients with gynecologic diseases. In early gestation, significant correlations were found among gestational age, crown-rump length, diameter of yolk sac and fetal heart rate. The maximal length of the gestational sac did not correlate with any other parameter. Transvaginal image quality was better in 76.2% in obstetric field and in 66.7% in gynecologic field, as compared to findings with conventional abdominal ultrasonography, respectively. Fine structures and individual organs were better evidenced transvaginally. Therefore, transvaginal ultrasound affords pertinent information complementary to that obtained with the transabdominal technique.     

A case of unruptured intrafollicular ovarian pregnancy diagnosed prior to operation

A case of an unruptured intrafollicular ovarian pregnancy of 8 gestational weeks diagnosed by ultrasonography in a virtually asymptomatic patient is reported. A 32 year-old woman with 1 vaginal delivery 8 years ago presented with a history of intermittent spotting after removal of an IUD during her last menstrual period 4 weeks ago. IUD was inserted 6 years prior. The patient was symptom-free and showed no abnormal findings upon vaginal examination. Transvaginal ultrasonography however disclosed a gestational sac with a live embryo within the left ovary. The woman was operated on via laparotomy without delay. The intraoperative finding showed a normally appearing corpus luteum in the intact left ovary without any visible abnormality of the pelvic organs. Having in mind the US finding a resection of the corpus luteum was done revealing the gestational sac within it. The authors describe the following three US signs specific of unruptured intrafollicular ovarian pregnancy: extremely thickened uniformly echogenic wall of the sac, the sac is partially surrounded by ovarian structure, no corpus luteum is detected in either ovary. The essential role of transvaginal ultrasonography in the precise diagnosis of the ectopic pregnancy and its location is emphasized. The absence of specific complaints and findings until rupture of the ovary occurs and the association of ovarian pregnancy and IUD are also confirmed by the case-report.     

彩色多普勒超声诊断胎盘植入的价值

目的：评价彩色多普勒超声诊断胎盘植入的价值。方法：回顾性分析2012年1月-2013年10月在天津市中心妇产科医院超声诊断胎盘低置状态或低置胎盘或前置胎盘的住院患者93例,其中超声检查疑似胎盘植入者24例。经腹部超声及阴道超声着重扫查胎盘的位置及其厚度、胎盘内回声、胎盘附着处子宫肌层厚度及其与子宫肌层的关系、与子宫相邻的膀胱壁情况、胎盘附着处血流情况。结果：24例经彩色多普勒超声检查疑似胎盘植入,经手术病理确诊为胎盘植入20例,其中粘连性胎盘4例,植入性胎盘14例,穿透性胎盘2例。超声误诊5例,漏诊1例。彩色多普勒超声检查的敏感度为95.00%,特异度为93.15%,阳性预测值为79.17%,阴性预测值为98.55%。结论：彩色多普勒超声为产前检查胎盘植入的较好方法。     

Pitfalls in Ultrasound Diagnosis of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP) is a rare kind of ectopic pregnancy implanted in the previous cesarean scar and has an increasing incidence over the past 30 years. As the suspicion is low, the diagnosis may be delayed or misinterpreted in ultrasound, leading to treatment strategies that might end up in uterine rupture or hysterectomy. The objective here is to review the ultrasound findings in CSP with varied presentations. Transabdominal and transvaginal sonography combined with color Doppler is a reliable tool for the diagnosis of CSP. When the gestational sac is seen in lower part of the uterine cavity, differentiation between threatened miscarriage, cervical pregnancy and CSP could be difficult. Not all cases of CSP present with typical ultrasound findings and a high index of suspicion is needed for diagnosis in these cases. An attempted curettage or MTP pill taken in an undiagnosed CSP often alters the typical findings. The possibility of CSP should also be considered in cases presenting with abnormal uterine bleeding and have a prior history of cesarean section. With lack of awareness about this condition, the diagnosis can often be missed either with MRI or in ultrasound. Correct interpretation and timely diagnosis save the mother from life-threatening complications and also preserves future fertility.     

Prospective Evaluation of the Incidence of Uterine Vascular Malformations Developing After Abortion or Delivery

Study ObjectiveTo describe the incidence of uterine vascular malformations (UVMs) including uterine arteriovenous malformations (AVMs) in patients after abortion or delivery and in outpatients.DesignProspective study (Canadian Task Force classification II-3).SettingFukushima Red Cross Hospital.PatientsSix patients with a UVM including 1 with an AVM.InterventionsClinical screening of patients using transvaginal color Doppler ultrasonography between April 2010 and March 2012.Measurements and Main ResultsThe incidence of UVM developing after abortion or delivery or in outpatients was prospectively evaluated using transvaginal color Doppler ultrasonography. From 959 patients, we identified 6 (0.63%) with UVMs, including 1 (0.10%) with a uterine AVM. Specifically, we detected UVMs in 4 of 77 patients (5.2%) after abortion, 1 of 458 patients (0.22%) after delivery, and 1 of 424 outpatients (0.24%). Four patients after abortion and 1 after delivery reported mild symptoms, which were treated conservatively; however, the outpatient had a severe uterine AVM, which was confirmed via 3-dimensional computed tomography angiography.ConclusionThe incidence of UVMs was relatively higher, in particular in the patients after abortion, and was significantly higher than that in postpartum or outpatient groups. Therefore, it is important to consider the possibility of UVMs in any patient with episodes of unexplained uterine bleeding and to perform follow-up analysis using color Doppler ultrasonography. Such an approach will facilitate accurate diagnosis and lead to appropriate clinical management to prevent unnecessary dangerous repeat curettage, which might induce profuse uterine bleeding.     

Diagnosing amnionicity at 6 weeks of pregnancy with transvaginal three-dimensional ultrasonography: case report.

OBJECTIVE: To report a case of monochorionic, diamniotic twin pregnancy diagnosed at 6 weeks of pregnancy with three-dimensional (3D) transvaginal sonography and to discuss the use of this diagnostic method in the evaluation of multifetal pregnancy in the first trimester. DESIGN: Case report. SETTING: University-based IVF program. PATIENT(S): A 30-year-old ovum recipient underwent ultrasonographic evaluation of a first-trimester twin pregnancy. INTERVENTION(S): Two-dimensional (2D) and 3D transvaginal sonography. MAIN OUTCOME MEASURE(S): Accurate diagnosis of chorionicity and amnionicity. RESULT(S): Monoamniotic pregnancy and conjoined twinning could not be ruled out by using 2D transvaginal sonography at 6 weeks, because only one yolk sac (YS) and no membranes could be visualized, and the two embryos were closely positioned within one gestational sac. Applying 3D technique, two YSs and two separate embryos could clearly be observed, establishing the correct diagnosis of a monochorionic, diamniotic pregnancy. CONCLUSION(S): The 3D transvaginal ultrasonography provides a quick and accurate diagnostic modality for the evaluation of a first-trimester multiple gestation.     

Transvaginal ultrasonography in patients at risk for ectopic pregnancy

Transvaginal ultrasonography was performed in 139 patients at risk for ectopic pregnancy. Among these patients, 22 ectopic pregnancies and 117 intrauterine pregnancies were eventually confirmed. Transvaginal ultrasonography definitively identified 18 of 22 (82%) ectopic pregnancies at initial evaluation by either direct visualization of an ectopically placed gestational sac (N = 14) or failure to visualize an intrauterine gestational sac combined with a level of the beta-subunit of human chorionic gonadotropin greater than 1300 mIU/ml (First International Reference Preparation) (N = 4). Transvaginal ultrasonography definitively diagnosed 103 of 117 (88%) intrauterine pregnancies at initial evaluation. Eighteen patients could not be definitively diagnosed by transvaginal ultrasonography at initial evaluation because nonvisualization of a gestational sac and a beta-subunit of human chorionic gonadotropin value less than 1300 mIU/ml. Evaluation of this group with serial measurements of beta-subunit of human chorionic gonadotropin, repeat ultrasonography, or both, revealed ectopic gestation (N = 4), early intrauterine pregnancy (N = 4), and complete abortion (N = 10).     

Transvaginal color Doppler imaging in the assessment of uteroplacental blood flow in the normal first-trimester pregnancy

Characteristic changes of low resistance and high diastolic blood flow velocity were identified by Doppler studies starting in the early phase of the second trimester. These changes were attributed by some authors to trophoblastic invasion of the uterine vasculature converting the uterus into a low-resistance organ. Because of technical limitations previous studies were confined to the uterine artery and its main branches. With the development of color Doppler and transvaginal ultrasonography we can now identify blood flow in various small vessels in the placental bed. This study was performed to assess the ability of color Doppler ultrasonography to evaluate subtrophoblastic blood flow by color identification in the early phase of normal pregnancy from 5 to 9 weeks' gestation. Results show that the characteristic increase in diastolic blood flow is evident as early as 5 weeks' gestation.     

Assessment of uterine circulation in ectopic pregnancy by transvaginal color Doppler

OBJECTIVE: The aim of our study was to determine the effect of abnormal implantation on uterine circulation and to evaluate whether the assessment of uterinal blood flow can provide additional information for the diagnosis of tubal pregnancies. METHODS: Forty-nine patients with ectopic pregnancy were examined by transvaginal color Doppler immediately before surgery. Resistance and pulsatility indices of blood flow in the uterine and tubal arteries were measured. RESULTS: The blood flow parameters of the uterine and tubal arteries did not change with gestational age. There was a significant increase in blood flow on the side with the tubal gestation. Differences between sides were higher in the tubal arteries than in the main uterine arteries and showed no dependence on gestational age. CONCLUSION: The abnormal implantation and tubal trophoblast invasion in ectopic pregnancy (EP) can cause more marked blood flow changes in the adjacent supplying vessels than in the main uterine arteries.