Effectiveness of ultrasound screening for placenta accreta spectrum using standard ultrasound criteria in a secondary care setting

Objectives: Ultrasound detection of placenta accreta spectrum (PAS) among women at risk is a key goal to reduce obstetric morbidity, but there is scarce information of its performance in real clinical settings. We report the effectiveness of a standardized ultrasound protocol to detect PAS in women with placenta previa in a secondary-level hospital. Methods: A retrospective analysis, including a cohort of 126 women with persistent placenta previa among 27,975 pregnancies between 2008 and 2020. All 126 women underwent standardized transabdominal and transvaginal ultrasound assessing 5 criteria: 1) loss of hypoechoic retroplacental zone and/or myometrial thinning <1 mm; 2) lacunar images with flow >15 cm/sec; 3) thick and bulging placenta; 4) thinning or interruption of the uterine-bladder serous interface; and 5) placental or uterovesical hypervascularity. The presence of at least one criterion was considered a high-risk for PAS. Diagnosis of PAS was confirmed during caesarean section and by histopathological analysis. Results: Among 126 women with placenta previa, 11 (8.7%) cases of PAS were diagnosed, of which 10 were detected prenatally by ultrasound. This resulted in a sensitivity of 90,9%, a specificity of 98,3%, a positive predictive value (PPV) of 83,3%, and negative predictive value (NPV) of 99,1%. Histopathological assessment showed six placenta increta (54.5%), four percreta (36.4%) and one accreta (9.1%). All 10 cases of invasive placenta presented more than three ultrasound criteria. Conclusions: Standardized ultrasound screening protocol in women at risk due to placenta previa in the third trimester was highly effective in detecting PAS in a secondary-level hospital setting.

Heterotopic Pregnancy after In Vitro Fertilisation and Embryo Transfer Post-unilateral Salpingectomy: A Case Report and Literature Review

Heterotopic pregnancy (HP) is the simultaneous occurrence of intrauterine and ectopic pregnancies (EP). The incidence of HPs occurring spontaneously ranges from 1 in 10,000 to 1 in 30,000. However, this incidence is reported to be 1 in 100 pregnancies following artificial reproductive techniques. HP is a potentially life-threatening condition that is frequently misdiagnosed, as most diagnoses for HPs are delayed, and are only made after rupture of the EP. A high index of suspicion is, therefore, required for an accurate and timely diagnosis in order to reduce maternal morbidity and mortality, which currently stands at 1 in 200,000 live births. The most common risk factors include pelvic inflammatory disease, previous EP, assisted reproduction techniques, and ovarian hyperstimulation syndrome. Transvaginal ultrasound is the gold standard for diagnosis. As detection of an intrauterine pregnancy often leads to the mistaken exclusion of a concomitant EP, a careful transvaginal scanning of the uterus and appendages should be performed in all females of reproductive age with a positive pregnancy test and red flags in anamnesis, and/or with clinical symptoms. Routine transvaginal ultrasound at Day 27 after embryo transfer could facilitate the diagnosis of HP; however, symptoms onset before or after Day 27 are clues to early diagnosis. MRI can be very helpful in diagnosing atypical cases.

Iatrogenic operative hysteroscopic intravascular absorption syndrome: a recurring possibility!

Background Operative hysteroscopic intravascular absorption syndrome (OHIA) is the constellation of signs and symptoms due to fluid overload during hysteroscopic procedures. It can present with hyponatremia, deranged coagulation, pulmonary, and cerebral edema which are life-threatening issues. To our knowledge, this is the first reported case of recurrent OHIA syndrome which was managed uneventfully. Case presentation A 26-year-old American Society of Anesthesiologist (ASA) patient presented with primary infertility and prolonged, heavy menstruation. The abdominal and transvaginal ultrasound (USG) revealed a large posterior intramural fibroid of size 6.1 cm × 4.2 cm with submucosal intracavitary extension. She was planned for two-step laparoscopic and hysteroscopic evaluation and resection of the myoma under general anesthesia. Severe OHIA syndrome occurred with 1.5% glycine in phase 1 resection and recurred with 0.9% sodium chloride in phase 2 resection of intrauterine myoma at two different surgical settings. The uniqueness of this case is recurrence of OHIA syndrome in the same patient despite the use of normal saline (NS) due to lack of precautionary measures for fluid management. Conclusions Normal saline as an irrigating medium may not eliminate the risk of OHIA. Lack of adequate fluid management strategies can be detrimental especially in cases of hysteroscopic myoma resections. Following a standard protocol for vigilant monitoring under general anesthesia is the key in successful management.

Ultrasonographic Visualization of the Ovaries to Detect Ovarian Cancer According to Age, Menopausal Status and Body Type

Because the effects of age, menopausal status, weight and body mass index (BMI) on ovarian detectability by transvaginal ultrasound (TVS) have not been established, we determined their contributions to TVS visualization of the ovaries. A total of 29,877 women that had both ovaries visualized on their first exam were followed over 202,639 prospective TVS exams. All images were reviewed by a physician. While visualization of both ovaries decreased with age, one or both ovaries could be visualized in two of every three women over 80 years of age. Around 93% of pre-menopausal women and ~69% of post-menopausal women had both ovaries visualized. Both ovaries were visualized in ~72% of women weighing over 300 lbs. and in ~70% of women with a BMI over 40. Conclusions: Age had the greatest influence on the visualization of the ovaries. The ovaries can be visualized well past the menopause. Body habitus was not limiting to TVS ovarian imaging, and TVS should be considered capable of imaging one or both ovaries in two of every three women over 80 years of age. Thus, older and obese patients remain good candidates for TVS exams.

Identification of Pelvic Congestion Syndrome Using Transvaginal Ultrasonography. A Useful Tool

The gold standard for the diagnosis of pelvic congestion syndrome (PCS) is venography (VG), although transvaginal ultrasound (TVU) might be a noninvasive, nonionizing alternative. Our aim is to determine whether TVU is an accurate and comparable diagnostic tool for PCS. An observational prospective study including 67 patients was carried out. A TVU was performed on patients, measuring pelvic venous vessels parameters. Subsequentially, a VG was performed, and results were compared for the test calibration of TVU. Out of the 67 patients included, only 51 completed the study and were distributed in two groups according to VG results: 39 patients belonging to the PCS group and 12 to the normal group. PCS patients had a larger venous plexus diameter (15.1 mm vs. 12 mm; p = 0.009) and higher rates of crossing veins in the myometrium (74.35% vs. 33.3%; p = 0.009), reverse or altered flow during Valsalva (58.9% vs. 25%; p = 0.04), and largest pelvic vein ≥ 8 mm (92.3% vs. 25%). The sensitivity and specificity of TVU were 92.3% (95% CI: 78.03–97.99%) and 75% (95% CI: 42.84–93.31%), respectively. In conclusion, transvaginal ultrasonography, with the described methodology, appears to be a promising tool for the diagnosis of PCS, with acceptable sensitivity and specificity.

Deep Learning-Based Analysis of Efficiency and Surgical Timing for Patients with Cervical Insufficiency Using Transvaginal Ultrasound Images

Objective. This work aims to analyze the surgical timing and clinical efficacy of transvaginal cervical ring ligation based on the ultrasound image focus detection of patients with cervical insufficiency (CIC) under the ultrasound image theme generation model. Methods. 134 CIC patients who came to the hospital for ultrasound imaging diagnosis were collected. Observation group was treated with cervical cerclage (CC) and the pregnancy outcome was followed up. Control group was treated conservatively. Results. For patients in the control group, average gestational age was 21.12 ± 2.18 weeks, average cervical length (CL) was 15.54 ± 0.42 mm, and average uterine opening width was 3.06 ± 0.63 mm. In the observation group, average gestational age was 24.45 ± 4.12 weeks, average CL was 17.32 ± 4.09 mm, and average uterine opening width was 0.21 mm. There were significant differences between the two groups ( P < 0.05 ). There were also significant differences in the degree of uterine orifice dilation between the two groups ( P < 0.05 ). Pregnancy outcomes of the two groups were compared, and χ2 and P < 0.05 indicated significant differences. Conclusion. Convolution neural network (CNN) and long short-term memory model (LSTM) algorithm were used to classify patients' ultrasound images, which could effectively improve diagnosis and treatment efficiency. Surgical success rate, clinical outcomes, neonatal survival rate, and clinical effect of observation group were better than those of control group. Cervical ligation was best performed before 17 weeks of pregnancy in CIC.

Extreme Learning Machine Denoising Algorithm-Based Transvaginal Three-dimensional Ultrasound Imaging on the Diagnosis Efficiency of Intrauterine Adhesions

The study was intended to eliminate the noise in three-dimensional transvaginal ultrasound (3D-TVS) images and improve the diagnostic accuracy in intrauterine adhesion (IUA). The extreme learning machine (ELM) algorithm was introduced first for statement. One hundred and thirty cases of suspected IUA patients were taken as the research subjects. The denoising effects of ELM algorithm were evaluated in terms of mean square errors (MSE), peak signal-to-noise ratio (PSNR), and running time, and its diagnostic efficiency of IUA was identified from precise, specificity, and sensitivity. Furthermore, the support vector machine (SVM) algorithm was introduced for comparison. It was found that the MSE and PSNR of the ELM algorithm were 0.0021 and 64.5, respectively, and its average operation time was 11.22 ± 0.89s, that the MSE values of SVM algorithm and ELM algorithm were 0.0045 and 0.0021 and the PSNR values were 52.3 and 64.5, respectively, and that the average running time of SVM algorithm was 16.35 ± 1.33s, and the average running time of ELM algorithm was 11.22 ± 0.89s, superior to the SVM algorithm in denoising effects. Moreover, the ELM algorithm showed excellent diagnostic efficiency for patients with various degrees of IUA. In conclusion, ELM can effectively eliminate noise in 3D-TVS images and demonstrates excellent diagnostic efficiency on IUA, which is worthy of clinical application.

Ovarian Hilus Cell Hyperplasia and Sertoli-Leydig Cell Tumor in a Patient with Postmenopausal Virilization: a Rare Case Report

Objective; We present a case report regarding a 71-year-old woman with postmenopausal virilization caused by ovarian hilus cell hyperplasia and Sertoli-Leydig cell tumor who was suffered from hair loss, clitoromegaly and hirsutism. Case Report; The patient’s plasma testosterone levels were high. In the MRI examination, a nodular formation of 20x26mm in size was observed in the right ovary. At the transvaginal ultrasound, a cystic mass of 28x28mm was seen in the right ovary. Then we performed a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. The final pathology showed a poorly differentiated Sertoli Leydig cell tumor at the right ovary and hilus cell hyperplasia at the left ovary. Sertoli-Leydig cell tumors, which are relatively less common, are extremely rare to be seen in the postmenopausal period. Conclusion; What distinguishes this case from others is that Sertoli-Leydig cell tumor and hilus cell hyperplasia may cause virilization symptoms together, in addition to its prevalence in advanced age.

Clear Cell Carcinoma of the Endometrium in a Patient Presenting with Postmenopausal Bleeding but Negative Endometrial Biopsy

Endometrial carcinoma is the most common gynecological malignancy in the USA with approximately 66,570 cases and 12,940 deaths in 2020. Clear cell carcinoma (CCC) of the endometrium is an estrogen-independent type II endometrial cancer which accounts for &#x3c;5% of endometrial cancer. When diagnosed roughly, 45% of patients have extrauterine metastases. Current American College of Obstetrics and Gynecology guidelines recommend transvaginal ultrasound for postmenopausal bleeding and a biopsy for those with endometrial thickness &#x3e;5 mm. However, we present a case of a postmenopausal woman with a history of fibroid where endometrial biopsy has failed to make diagnosis twice. Hence, further testing should be performed in patients with unexplained postmenopausal bleeding including vaginal hysterectomy with lymph node dissection.