Three-Dimensional Ultrasonographic Assessments of Fetal Development

Objective: To visualize fetal surface anatomic structures in advancing gestation by use of three-dimensional ultrasonography with a specially developed abdominal three-dimensional transducer.Methods: One hundred six normal fetuses from 9 to 40 weeks’ gestation were studied with a specially developed abdominal three-dimensional transducer (3.5 MHz). This imaging system can provide conventional two-dimensional ultrasonography images and also can generate within seconds high-quality three-dimensional images in the surface and transparent modes with no need for an external workstation. We determined percentage of surface anatomic structures visualized at each trimester using two-dimensional and three-dimensional ultrasonography.Results: The number and the clarity of surface anatomic structures increased from the first to the third trimester of pregnancy. The image quality was less distinct in the first trimester because of the small fetal size. The ability to view the fetal face, hands, and feet was better with three-dimensional ultrasonography than with two-dimensional ultrasonography in the first trimester (P < .05), whereas fetal genitals were viewed better with two-dimensional ultrasonography than with three-dimensional ultrasonography in the second and third trimesters (P < .05).Conclusion: Three-dimensional ultrasonography provides a new means of visualizing surface anatomic structures of the fetus in utero. Our results suggest that three-dimensional ultrasonography has the potential to be a supplement to two-dimensional ultrasonography and should be useful in evaluating fetal abnormalities in high-risk pregnancies.     

Timing of ultrasound in pregnancy—How often? At what intervals?

The second trimester fetal anatomic survey has continued to evolve over the past 27 years. This review will summarize the changes in the anatomic survey that have occurred and provide recommendations that serve to improve compliance with the components of the survey. In order to provide clarity and direction, the goals and limitations of the second trimester fetal anatomic survey should be defined. The visualization rate of specific fetal anatomic structures can be increased by specifying acceptable, alternative views. A single follow-up examination within 2–4 weeks of a fetal anatomic survey or before 22 weeks' gestation should be offered when specific components of the fetal anatomic survey cannot be visualized. The fetal anomalies that the anatomic survey seeks to identify should be defined along with an acceptable detection rate.     

Third trimester ultrasound accuracy and delivery outcome in obese and morbid obese pregnant women

Objective: Several studies have highlighted the negative impact of maternal obesity on ultrasound accuracy for fetal weight estimation (EFW). However, the evidence is conflicting. We aimed in our study to find if the ultrasound accuracy for EFW would differ or decrease in obese and morbid obesity classes. We also studied the mode of delivery within the same cohort.

Methods: It is a retrospective study of obese patients with recorded BMI ≥30?kg/m², class I and II (BMI: 30–39.9?kg/m²) compared with extreme obese class III (BMI ≥40?kg/m²), who gave birth after 28-week gestation of viable singleton, who had an ultrasound within 7 d of delivery with reported normal amniotic fluid and no major fetal anomaly; the EFW was consistently measured through Hadlock regression formula in the period of 2014–2015 inclusive. Differences between the EFW and actual birth weight (ABW) were assessed by percentage error, accuracy in predictions within ±10% of error and the Pearson correlation coefficient were used to correlate EFW with the ABW. The study’s secondary outcome was to study the mode of delivery and the rate of cesarean section in obese and morbid obese patients.

Results: Total 106 cases fulfilled our criteria. Class I and II as the first group (n?=?53). Class III as the second group (n?=?53). Maternal and birth characteristics were similar. The Pearson correlation coefficient equal 1 in both groups. The overall mean absolute difference (MAD) in grams of the whole obese cohort was 242?±?213. The MAD was 242?±?202 and 242?±?226?g for the first and second group, respectively (p?=?1.0). The overall mean absolute percentage error (MAPE) in this obese cohort was 8%. The MAPE for the first and second group, respectively were 8 and 7% (p?=?0.4). The overall rate of cesarean delivery was 60% (64/106) with no differences between the obese and morbid obese BMI classes. Sixty-six percentage (42/64) of these cesarean cases was for repeat cesarean section.

Conclusion: Despite what has been previously reported about the negative impact of maternal obesity on EFW accuracy, we could not demonstrate this relationship in our obese cohort (MAPE <10%). In addition, we could not illustrate a significant difference in ultrasound accuracy across various obesity classes. However, we found a significantly increased rate of delivery by repeated cesarean section in this obese cohort.     

Association between first trimester vaginal bleeding and uterine artery Doppler measured at second and third trimesters of pregnancy

Abstract

Objective: To evaluate the prevalence of first trimester vaginal bleeding among patients with abnormal second and third trimester uterine artery Doppler.

Methods: A prospective study of patients with a uterine artery Doppler measurement between 27 and 42 weeks’ gestation was undertaken. A comparison was made between two groups: patients with and without first trimester vaginal bleeding. Abnormal uterine artery Doppler was defined as PI >95th% or the presence of a diastolic notch.

Results: Of the 277 patients that were included in the study, 65 (23%) had first trimester vaginal bleeding. No differences were noted in uterine artery Doppler waveforms among patients with and without first trimester vaginal bleeding.

Among patients with first trimester vaginal bleeding, 9 (14%) had a bilateral uterine artery notch and 56 (86%) did not, compared with 51 (24%) and 161 (76%), in the control group, respectively. Patients with first trimester vaginal bleeding, and a bilateral uterine artery notch had significantly higher rates of small for gestational age neonates, low-Apgar scores (<7) at one minute and cesarean deliveries compared to patients with first trimester vaginal bleeding who did not have bilateral uterine artery notch.

Conclusion: First trimester vaginal bleeding was not associated with a higher incidence of abnormal uterine artery waveforms or with placental related conditions. However, adverse perinatal outcomes were found when first trimester vaginal bleeding was associated with second and third trimester bilateral uterine artery notchs.     

Second trimester growth velocities: assessment of fetal growth potential in SGA singletons

Objective: To evaluate the validity of second trimester growth velocities as measures of fetal growth potential in Small-for-Gestational-Age (SGA) singletons.

Methods: Second trimester growth velocities for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur diaphysis length (FDL) were determined by linear regression analysis or direct measurement in 53 SGA singletons with normal growth outcomes (SGA N Group) and 73 with growth restriction (SGA GR) based on a composite fetal growth pathology score (FGPS1). The latter were subdivided into six groups based on their growth restriction pattern (Patterns group). Similar data were available for 118 singletons with normal neonatal growth outcomes (NNGO group). Coefficients of determination (R²) and growth velocities for each anatomical parameter were compared between Patterns subgroups and the SGA N, SGA GR and NNGO groups.

Results: Median R² values in the six Patterns subgroups ranged from 98.2% (Pattern 2, FDL) to 99.9% (Pattern 5, AC). Within each anatomical parameter set, no significant differences were found (Kruskal–Wallis). Patterns subgroup data were pooled to form the SGA GR group for each anatomical parameter. Mean values for the three main groups ranged from 98.4% (SGA N, FDL) to 99.6% (SGA N, HC). No significant differences between groups (ANOVA) were found for any anatomical parameter (ANOVA). Only 1.7–3.8% had R² values <95th%. No significant differences in median second trimester growth velocities among different Patterns subgroups were found for any anatomical parameter. In the SGA N and SGA GR groups, mean BPD and HC values did not differ but were significantly smaller than the NNGO group values. No differences in mean FDL values were seen. With AC, all three means were significantly different, having the following order: NNGO?>?SGA N?>?SGA GR. Of all 504?second trimester growth rates, 92.5% were within their respective 95% reference ranges.

Conclusion: Growth in the second trimester is linear in fetuses at risk for growth restriction. Except for FDL, growth velocities were lower than those for fetuses with NNGO. Only AC had mean velocities that differed between the SGA N and the SGA GR groups. Since most velocities (92.5%) were within normal reference ranges, they are reasonable measures of growth potential in fetuses at risk for growth restriction.     

First and second trimester screening for large for gestational age infants

Abstract

Objectives: To find the best early predictor model for fetal growth and large for gestational age (LGA) infants considering clinical, ultrasonographic and biochemical variables.

Method: In 2097 singleton pregnancies at first trimester, we evaluated maternal characteristics, PAPP-A and ß-HCG proteins, fetal nuchal translucency thickness and uterine artery pulsatility index (UtA-PI). At second trimester fetal ultrasound biometry and UtA-PI were then measured. The relationships between birth weight and LGA and maternal characteristics, first and second trimester variables, and all variables combined, were studied. The performance of screening was determined by receiver operating characteristic curves analysis.

Results: Stepwise regression analysis showed that in the prediction of birthweight percentile there were significant contributions from all maternal factors, PAPP-A and Ut-A PI in the first trimester, and fetal biometric variables in the second trimester. Maternal charateristics combined with PAPP-A, β-hCG, fetal NT and uterine artery PI identified 30.2 % LGA (FPR 10%). The combined model reached a sensitivity of 41.2% (FPR 10%) and 56.2% (FPR 20%).

Conclusions: Sensitivity of the screening for LGA improves significantly after addition of second trimester ultrasound measurements to first trimester variables and maternal characteristics.     

The association between second trimester estimated fetal weight and small for gestational age at birth

Objective: To analyze diagnostic accuracy of second trimester ultrasound fetal growth parameters as predictors of small for gestational age (SGA) birth weight.

Methods: We reviewed the fetal biometry from 714 consecutive patients with second trimester ultrasounds. The estimated fetal weight (EFW) and abdominal circumference (AC) percentiles were tested as predictors of SGA at birth (<10‰).

Results: 87 (12.2%) patients had an SGA baby. Patients with a second trimester EFW?≤25‰ were significantly more likely to have SGA at birth (24.2% versus 10.3%, p?<?0.001). Similar results were seen for women with second trimester AC?≤25‰ (likelihood of SGA 21.9% versus 11.2%, p?=?0.013). A second trimester EFW?≤25‰ was a better predictor of SGA at birth than a second trimester EFW?≤?10‰ (Positive likelihood ratio 2.30 versus 2.09). In the second trimester, only 9 (1.3%) patients had an EFW 0–10‰, only 43 (6%) patients had an EFW 11–20‰, and only 46 (6.4%) patients had an EFW 91–99‰. Each other EFW centile had more than 10% of the patients.

Conclusions: The incidence of second trimester EFW or AC?≤10‰ is less common than expected from standard tables. An EFW?≤25‰ and an AC?≤25‰ should be considered the second trimester marker for risk of SGA at birth. However, due to the low likelihood ratio of, it is not clear if second trimester ultrasound should be used as a predictor of SGA at birth.     

Effect of second trimester and third trimester weight gain on immediate outcomes in neonates born to mothers with gestational diabetes: a retrospective observational study from India

Abstract

Aim: To evaluate the effect of second trimester and third trimester rate of weight gain on immediate outcomes in neonates born to mothers with Gestational Diabetes Mellitus (GDM).

Method and material: This retrospective observational study enrolled 593 eligible mothers. The records of all pregnant women booked before 24?weeks and screened for diabetes were eligible if they were diagnosed with Gestational Diabetes Mellitus (GDM) anytime during pregnancy. All the necessary maternal and neonatal details were collected from hospital database. The rate of weight gain was calculated at 18–24?weeks, 28–30?weeks, and that before delivery. The enrolled women were categorized into: poor weight gain, normal weight gain, and increased weight.

Results and discussion: The mean birth weight, length, and head circumference of neonates were significantly lower in women who had poor rate of weight gain in comparison with normal weight gain group. The mean prepregnancy BMI was significantly high in women with increased rate of weight gain when compared to normal weight gain women in second and third trimester. Regression analysis done to evaluate the independent effect of weight gain on C section and neonatal complications, showed that the independent predictors for cesarean section were previous cesarean section or 12.5 (95% CI 6.7–23) and conception by assisted reproductive technologies or 1.75 (95% CI 1.01–4.3), and the neonatal complications were influenced by birth weight or 1.5 (95% CI 1.1–2.2) and weight gain during second trimester or 1.26 (95% CI 1–1.6).

Conclusion: In women with GDM, reduced weight gain during pregnancy is associated with small for gestational age neonates. Caesarean section is predicted by previous C-section, and mode of conception whereas neonatal complications were predicted by birth weight and maternal weight gain during second trimester.     

First trimester diagnosis of split hand/foot by transvaginal ultrasound

OBJECTIVE/METHOD: First trimester high-frequency transvaginal ultrasonographic examination was performed in a 26-year-old gravida 2, para 1, diagnosed with tetramelic split hands and feet. The couple was informed about the probable 50% recurrence risk of this anomaly. RESULTS: At 12 weeks' gestation, high-frequency transvaginal ultrasound examination revealed a fetus with biometry consistent with gestational age. Both hands appeared to have a single digit at the ulnar side. On the site of the metacarpal bones, only three bones could be visualized. Both feet showed two digits, with a typical 'split-foot' appearance. Nuchal translucency thickness measured 1.0 mm. No additional abnormalities could be found. The child was born in good condition with the described split hand/foot malformation (SHFM). CONCLUSION: This case report demonstrates prenatal sonographic diagnosis of SHFM in a first trimester fetus. In first trimester there can be several technical advantages and it shortens the period of uncertainty of the parents. Secondly it provides the option of early surgical termination of the pregnancy instead of induction of labour.     

Dynamic changes in maternal decidual leukocyte populations from first to second trimester gestation

IntroductionDecidual leukocytes are critical to the development of the fetomaternal interface, regulating tolerance to the semi-allogeneic fetus and vascular transformation of the uterine spiral arteries. Despite the continuation of these processes beyond the first trimester of pregnancy, the second trimester has largely been unstudied, with investigation focusing on early gestation and term tissues. We sought to characterize changes in decidual leukocyte populations from first to second trimester.MethodsMulticolor flow cytometry was performed on isolated decidual leukocytes from elective terminations of pregnancy between 6 and 20 weeks of gestation for study of first (6–12 weeks) and second trimesters (13–20 weeks). Specific subpopulations were identified by comparison to isotype and fluorescent-minus-one (FMO) controls.ResultsDecidual natural killer cells (CD56⁺CD16⁻CD3⁻) did not change in number, although a population of dNK with decreased CD56 brightness was observed in second trimester decidua. CD14⁺HLA-DR⁺ macrophage numbers declined from first to second trimester (p = 0.031), yet a CD163⁺CD206⁺ subset designating alternatively activated M2-like macrophages increased during the same period (p = 0.015). Intermediate CD205⁺ dendritic cells demonstrated significant decline (p = 0.022), but immature CD209⁺ and mature CD83⁺ dendritic cells did not differ between trimesters. Total CD3⁺ and CD3⁺CD4⁺ T lymphocytes increased (p = 0.0079, p = 0.0028); CD3⁺CD8⁺ T cells trended towards increase but did not differ significantly.ConclusionSeveral changes in leukocyte subsets are observed in the second trimester that promote a tolerogenic and angiogenic decidual microenvironment through mid-gestation.     

Maternal obesity is not associated with increased crown-rump length in first-trimester ultrasounds of singleton gestations

Objective: To evaluate whether or not obesity affects fetal growth in the first trimester of pregnancy.

Study design: A retrospective cohort study of obese versus non-obese women in our ultrasound database was performed to compare crown-rump length (CRL), a surrogate of fetal growth, at the first-trimester genetic screening.

Results: A total of 50 obese and 50 non-obese women were included. CRL for both groups was performed at an average of 12wk5d?±?3 d. A linear regression analysis demonstrated that there was no difference between the cohorts in respect to CRL in the first trimester (p?=?.482). However, the estimated fetal weight at second-trimester anatomy ultrasound and the neonatal birth weight were increased in obese women (p?Conclusion: Maternal obesity does not significantly alter the fetal CRL. However, maternal obesity appears to be associated with increased fetal growth as early as the second trimester.     

Intrauterine ultrasonographic assessments of embryonic development

OBJECTIVE: Our purpose was to describe embryonal anatomic structures by use of intrauterine ultrasonography with a 20 MHz flexible catheter-based, high-resolution, real-time miniature transducer.STUDY DESIGN: Thirty-four women about to undergo therapeutic abortion from 7 to 9.9 weeks' gestation were studied with specially developed catheter-based, high-resolution, real-time miniature (2.4 mm outer diameter) ultrasonography transducer (20 MHz). A percentage of anatomic structures visualized at each gestational age is presented.RESULTS: The number and the clarity of structures increased from 7 to 8 weeks of gestation; however, the image quality was degraded because of the increasing fetal size at 9 weeks. At 8 weeks secondary brain vesicles, spine, midgut herniation, liver, upper and lower limb buds, and sacral tail were visualized in all fetuses. The four-chamber view was first identified at 8 weeks, as were fingers or toes. The stomach was first noted at 9 weeks. The umbilical cord cyst was visualized in 8% of embryos at 7 weeks' gestation and in 29% of embryos at 8 weeks. One cystic hygroma was diagnosed at 8 weeks 5 days.CONCLUSION: Intrauterine ultrasonography provides information on the visualization of anatomic structures of the embryo. In this limited series one embryonic malformation was demontrated, and thus there is a potential for its use in the detection of malformations. These results suggest that intrauterine ultrasonography has the potential to be a supplement to transvaginal ultrasonography during the first trimester in high-risk pregnancies.     

Sequential use of Foley catheter with misoprostol for second trimester pregnancy termination in women with and without caesarean scars: a prospective cohort study

Purpose: The aim of this study is to evaluate the effectiveness and safety of misoprostol and Foley catheter in second trimester termination in women with and without caesarean section (CS) scars.

Materials and methods: Women with an indication for pregnancy termination between 14 and 22 completed weeks of gestation were included to the study. Enrolled women were allocated into three groups: (1) women with no history of CS, (2) women with one CS and (3) women with ≥2 CS. Study consisted 337 patients (233 group 1, 88 group 2 and 16 group 3). Misoprostol and Foley catheter were used sequentially. The primary outcome was the induction to abortion interval. Secondary outcomes were the successful vaginal abortion rate, the percentage of abortions in 24?h and the rates of surgical removal of the placenta, Foley catheter use and major maternal complications (transfusions, thromboembolic events, uterine rupture and death).

Results: Demographic characteristics were comparable. All study outcomes were statistically similar among groups. There was no major maternal complication among all patients.

Conclusions: Sequential use of misoprostol and Foley catheter is safe and effective in second trimester pregnancy termination for patients with and without CS scars.     

First trimester cervical length is associated with mid-trimester loss

Objective: To study the value of the cervical length (CL) measurement at 11–14 weeks in predicting second trimester miscarriage occurring at 16–24 weeks.

Methods: Prospective study in routine obstetric population using transvaginal ultrasound examination to measure the length of the endocervical canal at 11–14 weeks.

Results: The study group consisted of 2836 singleton pregnancies. Eleven (0.0038%) women miscarried between 16 and 24 weeks whereas 2825 delivered after 34 weeks. CL was significantly shorter (Mann–Whitney U test, p?=?0.001), in women that had a second trimester miscarriage in comparison to those who delivered after 34 weeks (median CL 28?mm versus 32?mm, respectively). First trimester CL was predictive of a late miscarriage (OR?=?0.7093304, R^2?=?0.1211, AUC?=?0.7838, p?<?0.001). The detection rate was 63.64% for 20% screen positive rate.

Conclusions: First trimester endocervix is significantly shorter in women destined to miscarry between 16 and 24 weeks. In low risk singleton pregnancies, first trimester CL can be useful in predicting second trimester miscarriage.     

Relationship between first trimester aneuploidy screening test serum analytes and placenta accreta

Objective: The aim of this study is to determine whether there is a relationship between first trimester serum pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotropin (fβhCG) MoM values and placenta accreta in women who had placenta previa.

Study design: A total of 88 patients with placenta previa who had first trimester aneuploidy screening test results were enrolled in the study. Nineteen of these patients were also diagnosed with placenta accreta. As probable markers of excessive placental invasion, serum PAPP-A and fβhCG MoM values were compared in two groups with and without placenta accreta.

Results: Patients with placenta accreta had higher statistically significant serum PAPP-A (1.20 versus 0.865, respectively, p?=?0.045) and fβhCG MoM (1.42 versus 0.93, respectively, p?=?0.042) values than patients without accreta.

Conclusions: Higher first trimester serum PAPP-A and fβhCG MoM values seem to be associated with placenta accreta in women with placenta previa. Further studies are needed to use these promising additional tools for early detection of placenta accreta.     

Second trimester medical abortion in a woman with prior classical caesarean section and a uterine leiomyoma – A case report

Abstract

Background Medical abortion in women with the scar of a classical caesarean section (CS) and a large uterine leiomyoma is rarely attempted; it carries the risk of uterine rupture and haemorrhage.

Case A 34-year-old multiparous woman with prior classical CS and a 14 × 10 × 9 cm leiomyoma arising from the uterine isthmus had an induced abortion at 14 weeks’ gestation. Mechanical cervical priming with Dilapan^®-S followed by vaginal misoprostol administration resulted in the uncomplicated expulsion of the uterine contents.

Conclusions An early second trimester medical abortion with misoprostol was successfully performed in a woman with prior classical CS and a large uterine leiomyoma.     

Prediction of outcome in twin pregnancy with first and early second trimester ultrasound

Abstract

Objective: To establish if first or second trimester biometry is a useful adjunct in the prediction of adverse perinatal outcome in twin pregnancy.

Methods: A consecutive cohort of 1028 twin pregnancies was enrolled for the Evaluation of Sonographic Predictors of Restricted growth in Twins (ESPRiT) study, a prospective study conducted at eight academic centers. Outcome data was recorded for 1001 twin pairs that completed the study. Ultrasound biometry was available for 960 pregnancies. Biometric data obtained between 11 and 22 weeks were evaluated as predictors of a composite of adverse perinatal outcome (mortality, hypoxic ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, respiratory distress, or sepsis), preterm delivery (PTD) and birthweight discordance greater than 18% (18% BW). Outcomes were adjusted for chorionicity and gestational age using Cox Proportional Hazards regression.

Results: Differences in crown-rump length (CRL) were not predictive of adverse perinatal outcome. Between 14 and 22 weeks, a difference in abdominal circumference (AC) of more than 10% was the most useful predictor of adverse outcome, PTD and 18% or more BW discordance in all twins. Overall the strongest correlation was observed for intertwin differences in biometry between 18 and 22 weeks.

Conclusion: Biometry in the early second trimester can successfully identify twin pregnancies at increased risk. Intertwin AC difference of greater than 10% between 14 and 22 weeks gestation was the best individual predictor of perinatal risk in all twins. Sonographic biometry in the early second trimester should therefore be utilized to establish perinatal risk, thus allowing prenatal care to be improved.     

Adenomyosis and adverse perinatal outcomes: increased risk of second trimester miscarriage,preeclampsia, and placental malposition

Objective: To evaluate the potential impact of adenomyosis on the pregnancy outcomes by retrospectively investigating adenomyosis-complicated pregnancy cases.

Methods: We performed a retrospective case–control study. Forty-nine singleton pregnancy cases complicated with adenomyosis were included in this study. The controls (n?=?245) were singleton pregnant women without adenomyosis and were frequency matched to adenomyosis cases by age, parity, and the need for assisted reproductive technology for this conception. The incidence of obstetrical complications and delivery and neonatal outcomes were examined.

Results: Patients in the adenomyosis group were significantly more likely to have a second trimester miscarriage (12.2% versus 1.2%, odds ratio (OR): 11.2, 95% confidence interval (95% CI): 2.2–71.2), preeclampsia (18.3% versus 1.2%, OR: 21.0, 95% CI: 4.8–124.5), placental malposition (14.2% versus 3.2%, OR: 4.9, 95% CI: 1.4–16.3), and preterm delivery (24.4% versus 9.3%, OR: 3.1, 95% CI: 1.2–7.2), compared with the control group.

Conclusion: Adenomyosis was associated not only with an increased incidence of preterm delivery, as previously reported, but also with an increased risk of second trimester miscarriage, preeclampsia, and placental malposition, which could lead to poor perinatal outcomes.     

Uterine artery Doppler ultrasound in second pregnancy with previous elective cesarean section*

Objectives: To assess the effects of previous cesarean delivery (CD) and placental location on second trimester uterine artery Doppler indices in subsequent pregnancy and to assess the predictive values of abnormal Doppler findings for adverse pregnancy outcomes in women with previous CD.

Study design: This prospective cohort study evaluated 400 gravida two pregnant women (200 with previous none medically indicated CD and 200 with previous normal vaginal deliveries (NVD)) who were referred for second trimester fetal anatomic survey. Uterine artery Doppler studies were performed in all participants who were then followed until delivery.

Results: Compared with women having prior NVD, women with prior CD had significantly higher rates of abnormal uterine artery pulsatility index (PI) (p?p?=?.01). Among women with previous CD, all the measured adverse pregnancy outcomes occurred significantly more often in women with abnormal uterine artery Doppler indices (p?Conclusions: CD seems to be associated with increased risks of impaired placental function and circulation and adverse pregnancy outcomes in the subsequent pregnancy, particularly in women with anteriorly located placenta near the previous uterine scar.     

Myoma Imaging by Gynecologic Surgeons Training in Intraoperative Ultrasound Technique

Study ObjectiveTo compare preoperative transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) with intraoperative ultrasound (IOUS) in surgeons first learning to use this technique.DesignA prospective study of IOUS accuracy for mapping the size and location of myomas compared with TVUS or MRI (Canadian Task Force classification II-2).SettingFive University of California academic centers (Davis, Irvine, Los Angeles, San Diego, and San Francisco).PatientsTwenty-six premenopausal women seeking uterine-sparing surgical treatment of myomas. Eligible participants could have no more than 6 myomas ≥2 cm and <10 cm and a uterine size no larger than 16 weeks by pelvic examination.InterventionsMeasurement of myomas by IOUS followed by radiofrequency ablation (RFA) of fibroids.Measurements and Main ResultsEligible participants had to have imaging with TVUS or MRI within the last year to assess myoma characteristics. During the RFA operation, surgeons who had undergone a 1-day training on RFA and IOUS measured all myomas visualized with IOUS. Surgeons measured more myomas than were reported on MRI (12 on MRI and 16 on IOUS) or TVUS (41 on TVUS and 62 on IOUS) in all positions (anterior, posterior, lateral, and fundal). In particular, they identified more myomas <2 cm (4 on MRI, 9 on IOUS, 1 on TVUS, and 19 on IOUS). They located 2.3 times as many myomas in the anterior position as TVUS. For the myomas ≥2 cm identified by IOUS and MRI or IOUS and TVUS, there was no statistically significant difference in the mean myoma number or the mean myoma diameter measurements.ConclusionSurgeons first learning to use IOUS detect the same number of myomas ≥2 cm as identified by TVUS and MRI and find a greater number of myomas <2 cm on IOUS compared with radiologist-reported TVUS.