Ultrasound features help identify patients who can undergo noninvasive management for suspected retained products of conception: a single institutional experience

Objectives To evaluate ultrasound (US) features associated with successful noninvasive management for suspected retained products of conception (RPOC). Methods In this IRB-approved retrospective study, the radiology report database was queried for pelvic US with keywords of postpartum hemorrhage (PPH) and/or RPOC over a 2-year period. Follow-up exams, US exams without clinical follow-up, suboptimal image quality, and > 1 year from delivery or pregnancy termination were excluded. Charts were reviewed for clinical presentation and management. Two radiologists reviewed images for endometrial thickness, endometrial echogenicity, endometrial vascularity, and enhanced myometrial vascularity (EMV), as well as inner myometrial peak systolic velocity (PSV) and resistive index (RI) where available. Features were assessed for associations with management approach, and test characteristics were calculated. Results Initial query yielded 196 exams, and 48 were excluded. A total of 148 patients were included. Mean age was 34.2 years (21–47), and mean time from delivery or pregnancy termination was 40.4 days (0–223). 81 (55%) underwent noninvasive management: 72 (48%) expectant and 9 (6%) medical. 67 (45%) underwent invasive management: 60 (41%) surgical and 7 (5%) uterine artery embolization. There was substantial inter-reader agreement for assessment of EMV (K = 0.78) and endometrial vascularity (K = 0.72). Thin endometrial stripe, avascular endometrium, and absence of EMV were associated with successful noninvasive management (p < 0.05). Thin endometrium (< 10 mm) had specificity (90%), PPV (88%), and likelihood ratio (5.91) in predicting successful noninvasive management. Conclusion Endometrial thickness < 10 mm, avascular endometrium, and absence of EMV are the sonographic features associated with successful noninvasive management for PPH or suspected RPOC.

49 The dynamic changes in uterine morphology and function during the proestrus-diestrus transition in beef cattle

In cattle, early development of the non-attaching embryo depends exclusively on the biochemical properties of the intrauterine milieu. As the embryo transitions from the oviduct to the tip of the uterine horn around 4 days after oestrus, little is known about uterine functions that modulate the milieu composition and potentially determine pregnancy success. The objective was to characterise changes in uterine luminal fluid (ULF) accumulation and absorption, endometrial vascularity, and endometrial thickness in response to progesterone fluctuations during the peri-ovulatory period in beef heifers. Fourteen Bos indicus heifers that presented a prostaglandin F2α (PGF2α) responsive CL received 500µg of PGF2α analogue i.m. (PGF) and were examined daily by rectal B-mode and pulse-wave colour-Doppler ultrasonography until the fifth day after oestrus (oestrus=Day 0). Plasma progesterone (P4) concentrations were measured daily. Uterine luminal fluid score was given based on the accumulation of fluid throughout the entire organ (0, no fluid, to 4). Measurement of the main ovarian structures, endometrial thickness, uterine luminal fluid score, and luminal fluid area of the cranial portion of the uterine horn ipsilateral to the preovulatory follicle and subsequent CL were executed by B-mode ultrasonography and endometrial vascularity by colour Doppler. The fixed effect of day was analysed by ANOVA. There was an effect of day on endometrial vascularity, endometrial thickness, and uterine luminal fluid score (P≤0.01) as well as uterine luminal fluid area (P≤0.05). Endometrial vascularity and endometrial thickness increased after PGF injection to peak on Day −1, whereas uterine fluid score peaked on Day 0. Interestingly, cranial uterine luminal fluid area peaked twice, on Day −1 and Day 5. Vascularity, thickness, and fluid accumulation decreased gradually from Day 0 to Day 5. There was a negative correlation (r=−0.55) between the sum of daily P4 concentrations during proestrus (i.e. from PGF to oestrus) and the greatest ULF score measured (P=0.05). Length of proestrus was correlated negatively (r=−0.69) with the increase in uterine body thickness during proestrus (P=0.03). The sum of daily luminal fluid scores, from PGF injection to Day 5, was double for heifers grouped within the upper third for that variable compared with those grouped within the lower third. In conclusion, peri-ovulatory transformations in uterine morphology and function are dramatic and vary in duration and in intensity among animals. Temporal changes in intraluminal fluid accumulation and absorption at the site of embryo arrival may change its biochemical composition. Potential implications for embryo receptivity and reproductive outcomes deserve further investigation.

Endometrial Thickness and Subendometrial Vascularity in Anovulatory Polycystic Ovarian Syndrome Patients Treated by Metformin

Background PCOS, the commonest endocrinalogical disorder affecting women of age group between 18 and 44 years. PCOS compromises fertility through various pathways as hyperandrogenism, insulin resistance and impedance of the uterine and endometrial blood flow. Metformin improves the blood flow to the endometrium through reducing androgen level and correction of insulin resistance. The commonest parameters used to detect the endometrial receptivity outcome are endometrial vascular indices. Aim of the Work to evaluate the outcome of metformin administration in anovualtory PCO patients and its effect on the endometrium, including its role in ovulation and improvement of pregnancy rates. Patients and Methods this study included 85 patients from Ain Shams University outpatient gynecology and infertility clinic during the period from January 2018 till June 2018. These patients were investigated before treatment with ultrasound on day 14, 21 to evaluate the endometrial receptivity parameters such as endometrial thickness, uterine artery vascularity, endometrial and subendometrial vascularity. The patients received metformin 500mg three times per day for three months. After this duration they were reevaluated by ultrasound at days 14, 21 to detect any improvement. Results metformin therapy resulted in a significant increase of endometrial thickness and had a significant effect on uterine RI and PI. On the endometrial level, the endometrial and subendometrial R.I and P.I were significantly reduced after metformin treatment indicating better blood flow. Conclusion Metformin therapy improves endometrial vascularity, in addition to increasing endometrial thickness and improved impedance observed in uterine artery flow.

Novel relationships between porcine fetal size, sex, and endometrial angiogenesis†

It is hypothesized that growth restriction occurs due to inadequate vascularization of the feto-maternal interface. Evidence exists for sexual dimorphism in placental function although associations between fetal sex and the endometrium remain poorly investigated. This study investigated the relationship between porcine fetal size, sex and endometrial angiogenesis at multiple gestational days (GD). Endometrial samples supplying the lightest and closest to mean litter weight (CTMLW), male and female Large White X Landrace conceptuses or fetuses were obtained at GD18, 30, 45, 60, and 90 (n = 5–9 litters/GD). Immunohistochemistry for CD31 revealed a greater number of blood vessels in endometrium supplying females compared to those supplying males at GD45. Endometrial samples supplying the lightest fetuses had fewer blood vessels (GD60) and uterine glands (GD90) compared to those supplying the CTMLW fetuses. Quantitative PCR revealed decreased CD31 (GD60), HPSE and VEGFA (GD90) expression, alongside increased HIF1A (GD45) expression in endometrial samples supplying the lightest compared to the CTMLW fetuses. At GD30, PTGFR, CD31, and VEGFA mRNA expression was increased in samples supplying female fetuses compared to those supplying male fetuses. Intriguingly, decreased expression of ACP5, CD31, HIF1A, and VEGFA mRNAs was observed at GD60 in endometrial samples supplying female fetuses compared to those supplying their male littermates. Endothelial cell branching assays demonstrated impaired endothelial cell branching in response to conditioned media from endometrial samples supplying the lightest and female fetuses compared with the CTMLW and male fetuses, respectively. This study has highlighted that endometrial tissues supplying the lightest and female fetuses have impaired angiogenesis when compared with the CTMLW and female fetuses respectively. Importantly, the relationship between fetal size, sex and endometrial vascularity is dynamic and dependent upon the GD investigated.