Faculty Bibliography

The orientation of the sonographer performing a transvaginal scan is currently based on a concept of anatomical planes, which is customary in transabdominal sonography. We challenge this concept and propose a different approach altogether based on focusing on target organs rather than anatomic planes. The problem of orientation in transvaginal sonography stems from the following: (1) There is a very short distance between the relatively high-frequency transvaginal transducer-probe and the scanned area; a close-up image is generated encompassing a single organ or only part of it. (2) The scanning angle is initially perpendicular to that of abdominal sonography. (3) Transvaginal sonography is an endocavitary dynamic scanning technique. According to the experience in our department (30,000 examinations during the past 4 years) and in two other medical centers, best results from the transvaginal ultrasonographic examination are achieved when the operator searches for every specific organ as the main target, without resorting to pelvic 'planes.' The guidelines for targeted organ scanning and the associated change in orientation are reported together with the limitations. Targeted organ scanning without resorting to 'planes' helps the operator to resolve the problem of orientation during the transvaginal ultrasonographic examination, and to simplify the procedure to a great extent

Endometrial sampling is the mainstay of management of the postmenopausal patient with uterine bleeding. Thirty women with postmenopausal bleeding were studied prospectively. Before endometrial sampling, a vaginal probe ultrasonographic examination was performed. Eleven patients demonstrated a thin 'pencil line' endometrial echo in which the maximum anteroposterior thickness on the long axis view was less than or equal to 5 mm. All eleven patients had minimal tissue obtained on biopsy and a pathology report of 'tissue insufficient for diagnosis.' Seventeen patients had an echogenic endometrium greater than or equal to 6 mm. Pathology reports of their samples revealed tissue insufficient for diagnosis (two cases), proliferative endometrium (six), secretory endometrium (three), hyperplastic endometrium (three), polyp (two), and endometrial cancer (one case). Two additional patients had no endometrial echo visualized because of associated myomas. These findings suggest (1) that the absence of significant endometrial tissue (echo less than or equal to 5 mm) on vaginal ultrasonography in cases with postmenopausal bleeding is uniformly associated with tissue insufficient for diagnosis, and (2) when endometrial thickness is greater than or equal to 6 mm the histologic diagnosis should be determined in the pathology laboratory

Often ovarian cancer does not present clinically until the advanced stages. In the past, the presence of any cystic adnexal enlargement in postmenopausal women was an indication for surgical exploration. The ultrasound scans of 42 postmenopausal women with simple adnexal cysts were reviewed. We included only patients who were available for follow-up and who had cysts that were less than or equal to 5 cm in maximum diameter, unilocular (ie, without septations or solid components), and without ascites. Of these patients, 26 underwent prompt surgical exploration. All exhibited benign histopathology. In 16 patients, serial sonographic surveillance was performed every 3-6 months. Two of these patients had exploratory laparotomy at 6 and 9 months of observation; the first operation, for increasing size and septation, demonstrated a cystadenofibroma, and the second, for increasing pain, demonstrated a degenerating myoma. The remaining 14 patients were followed from 10-73 months without any change in size or character of the cyst. Small (less than 5 cm), unilocular postmenopausal cysts had a low incidence of malignant disease (0%) in this series of 28 surgical specimens. Therefore, serial ultrasound follow-up without surgical intervention may play a role in the clinical management of such patients

There are many situations in which the earliest possible detection of an intrauterine pregnancy would enhance clinical management. Current radioimmunoassays for hCG can detect pregnancy as early as eight to 12 days post-conception. The ability to document an intrauterine pregnancy with ultrasound has lagged behind by two to three weeks. New high-frequency endovaginal transducers offer the promise of narrowing this gap. This study was undertaken prospectively on 235 patients all amenorrheic for seven weeks or less and requesting either pregnancy testing or termination. All had endovaginal ultrasound scans. We obtained hCG levels when no sac was seen or when the sac was less than 1.0 cm (initial experience revealed that all sacs over 1.0 cm were associated with hCG levels over 6000 mIU/mL) (International Reference Preparation). Ultrasound findings were correlated with pathology specimens and/or hCG levels where appropriate. Results indicated that normal pregnancies can be imaged when: 1) The sac is greater than 0.4 cm; 2) hCG is greater than 1025 mIU/mL (International Reference Preparation); and 3) the uterus is normal with a homogeneous echo pattern. This was not true in three of our cases with diffuse myomatous changes or a coexisting intrauterine device

To facilitate accurate and standard methods of reporting pathologic uterine corpus enlargement, we constructed a nomogram using the gravid uterine corpus volumes from five to 20 weeks' gestation in 186 patients. The volume was calculated by measuring the maximum length and anteroposterior and transverse diameters of the uterine corpus, and using the formula for the volume of a prolate ellipsoid: V = 0.52 X (L X AP X T). Clinicians can use the nomogram for better understanding in assessing uterine volume

In this study, we attempted to develop a surveillance protocol for elective first-trimester termination to see whether unsuspected ectopic pregnancy could be detected earlier, and to identify those patients with unsuspected second-trimester pregnancies that could be terminated more safely in the hospital. Two hundred fifty consecutive patients requesting elective termination were studied prospectively. All were 12 weeks or less by last menstrual period, had positive urinary pregnancy tests, and had no history of vaginal bleeding. All patients had ultrasound screening before curettage. Immediately after curettage, a 'modified' gross pathologic examination (3X magnification) was also performed on unstained curettage material. The sonographic, operative, and pathologic findings were all correlated. Such screening identified four patients with unruptured ectopic pregnancies, who were operated on the same day as the curettage. In addition, four patients, who were actually in the second trimester but had inaccurate dates, were identified and referred to hospital for appropriate methods of termination. We conclude that such surveillance may reduce morbidity in elective terminations and more rapidly identify unsuspected ectopic pregnancies

Phosphorus-31 nuclear magnetic resonance spectroscopy (31P NMR) was used to assess the temporal changes of high-energy phosphate metabolites in the region of acute myocardial ischemia of open-chest cats. Eight anesthetized cats were studied following ligation of the left anterior descending coronary artery. Creatine phosphate showed a 79 +/- 16% (mean +/- SD) reduction by 4 min after the onset of ischemia. Prominent qualitative reductions of the spectral peak of creatine phosphate occurred by 40 s after ischemia. Adenosine triphosphate measured under the beta spectral peak (beta-ATP) decreased 37 +/- 9% by 20-25 min after ligation of the left anterior descending coronary artery. These reductions developed more slowly and were of smaller magnitude than those of creatine phosphate. Intracellular pH decreased from 7.39 +/- 0.07 to 7.13 +/- 0.09 units by 40 s after ischemia. By 30 min, pH decreased to 6.07 +/- 0.40 units. The study shows, therefore, the temporal changes of high-energy phosphate metabolites during ischemia in localized regions of the myocardium of open-chest animals