Faculty Bibliography

OBJECTIVES:To determine if clinical and ultrasound (US) imaging features help predict management in clinically suspected retained products of conception (RPOC). METHODS:334 patients sonographically evaluated for RPOC were included in this IRB-approved retrospective study. Of the 334 patients, 176 had sonographic diagnosis of RPOC and comprised the final study group. Patients were managed expectantly, medically, or surgically in accordance with clinical judgment of treating physicians. Pelvic sonograms were retrospectively reviewed for endometrial stripe thickness and vascularity was graded on a 0-3 scale based on appearance relative to myometrium (Grade 0: no vascularity, Grade 1: minimal vascularity, Grade 2: moderate vascularity, Grade 3: marked vascularity). Clinical and imaging predictors of management were evaluated in univariate and multivariate analysis. RESULTS:Mean patient age was 29.6 years and mean gestational age was 17.4 weeks. Most (74.4%) women presented with vaginal bleeding. 83 patients (47.2%) were treated conservatively with expectant management, 42 (23.8%) were treated medically, and 51 (29.0%) required surgical intervention. Mean endometrial stripe thickness was 21.3 mm. 47 women (26.7%) had vascularity score of 0; 50 (28.4%) had score 1; 52 (29.6%) had score 2; and 27 (15.3%) had score 3. In univariate analysis, serum hemoglobin (Hb) (p < 0.0001), endometrial stripe thickness on US (p < 0.005), presenting symptoms (p = 0.03), and US vascularity score (p < 0.005) were statistically significant predictors of final management. In multivariate logistic regression, serum Hb (OR 0.69, 95% CI 0.55-0.86, p < 0.0009), endometrial stripe thickness (OR 1.08, 95% CI 1.04-1.12, p < 0.0001), and US vascularity score (OR 1.77, 95% CI 1.16-2.70, p < 0.01) were statistically significant predictors of need for surgery. CONCLUSIONS:Serum Hb, endometrial stripe thickness, and US vascularity score were significant predictors of clinical management, particularly the need for surgical intervention, in women with clinically suspected RPOC.

OBJECT OF STUDY/OBJECTIVE:Retained products of conception (RPOC) displays variable vascularity, ranging from avascular to markedly vascular on color Doppler sonography. We hypothesize that variability in sonographic vascularity may be due to histopathologic variation in the placental tissue. MATERIALS, METHODS, AND PROCEDURES/UNASSIGNED:After institutional review board approval, sonographic images and pathologic specimens were retrospectively reviewed in 26 patients with pathologically proven RPOC. Ultrasound (US) images were scored 0-3 for the degree of vascularity by two radiologists blinded to the diagnosis. Corresponding pathologic specimens were evaluated for vascularization of chorionic villi, degree of inflammation, morphology of maternal arteries, chorionic villous preservation, and percentage of clot, membranes, chorionic villi, and decidua/myometrium. Statistical analysis, including multiple linear regression, was performed. RESULTS:RPOC with histologically avascular chorionic villi or those with markedly reduced vascularization had significantly lower US vascularity scores (p = 0.030) than those with chorionic villi showing normal or decreased vascularization. Sonographically avascular RPOC had a significantly lower percentage villi (p = 0.028) and higher percentage of decidua (p = 0.004) than specimens where US showed any Doppler vascularity. Histologic vascularity of villi (p = 0.049) and non-observation of maternal arteries (p = 0.001) were significant predictors of US vascularity scores in multivariate linear regression analysis, while inflammation of villi (p = 0.053) was a marginally significant predictor. SIGNIFICANCE OF THE CONCLUSIONS/UNASSIGNED:Histologic vascularity of villi appears to contribute to the observed variation in sonographic vascularity. This finding may underlie known differences in clinical outcomes between sonographic vascularity groups.

PURPOSE/OBJECTIVE:To determine the expression of SMAD transcripts in human granulosa cells. METHODS:Luteinized mural granulosa cells were harvested from forty women undergoing oocyte retrieval, and RNAs were isolated. SMAD expression levels were determined by polymerase chain reaction (PCR) and quantitative real-time PCR (q-RTPCR). RESULTS:SMAD1-7 and 9 are expressed in human granulosa cells, with SMAD2, 3 and 4 showing the highest expression levels. Peak estradiol (E2) levels correlated with the number of oocytes retrieved during IVF. Oocyte number showed no correlation with SMAD expression levels or ratios. Fertilization rates also did not correlate with the expression levels of individual SMADs, but did correlate with higher SMAD4:SMAD3 ratios (p = 0.0062) and trended with SMAD4:SMAD2 (p = 0.0698). CONCLUSIONS:SMAD transcripts are differently expressed in human granulosa cells, where they may mediate TGF-beta superfamily signaling during folliculogenesis and ovulation. Further, the relative expression ratios of SMAD2, 3 and 4 may differentially affect fertilization rate.

OBJECTIVE:To describe the safety and efficacy of highly active antiretroviral therapy (HAART) in pregnant women treated in an integrated antiretroviral antenatal clinic (ANC ARV). METHODS:A retrospective analysis was performed on patients attending the ANC ARV from August 2004 through February 2007. RESULTS:Data were collected on 689 treatment-naive pregnant women initiated on HAART. The mean age was 29.2 years. The mean baseline CD4 count was 154 cells per microliter, and mean baseline HIV viral load was 101,561 copies per milliliter. Tuberculosis was the most prevalent presenting opportunistic infection (7.7%). Stavudine, lamivudine, and nevirapine were initiated in 82% of women with the most frequent adverse drug reaction being nevirapine-associated skin rash (3.5%). Mean gestational age at HAART initiation was 27 weeks. Among women with follow-up data, 80% gained 50 or more CD4 cells per microliter and 80.5% achieved viral suppression to <1,000 copies per milliliter. Of 302 mother-infant pairs who completed postnatal follow-up, the HIV transmission rate was 5%. In women who received more than 7 weeks of HAART during pregnancy, transmission was 0.3%. CONCLUSIONS:Within the ANC ARV program, initiating pregnant women on HAART was feasible, safe, and effective. Advanced gestational age at treatment initiation and loss to follow-up emerge as important challenges in this population.