Faculty Bibliography

Our objective was to determine the best method to approach a multifetal pregnancy reduction of a patient with a multiple pregnancy of grand order (12 fetuses). Transvaginal ultrasound-guided reduction was performed in three stages. Successful outcome was achieved. The patient delivered twins at 37 weeks' gestation. The published and unpublished literature is reviewed and discussed in the light of this case. Our conclusion is that a multifetal pregnancy reduction of grand order can be performed in stages to achieve the desired number of fetuses

The purpose of this study was two-fold. The first was to extend the previously developed and published nomograms of the fetal lateral ventricles from 18 weeks back to 14 weeks of gestation using transvaginal sonography, and, second, to test the performance of the nomograms by plotting the measurements of 36 fetuses whose transabdominal and/or qualitative transvaginal scans were suspicious for ventriculomegaly. In all the cases in which postnatal confirmation of the diagnosis was possible, prenatal ultrasound correctly identified the lesion. Although a total of nine nomograms was created, the clinically meaningful measurements were: the height of the occipital horn on the parasagittal plane, and the two ratios derived from the measurements performed on the parasagittal plane. In conclusion, the transvaginally generated nomograms were useful for the correct identification of fetuses with ventriculomegaly

OBJECTIVES: Two major approaches for multifetal pregnancy reduction have been developed over the past several years: transabdominal potassium chloride by injection and pelvic procedures by either transcervical aspiration or transvaginal potassium chloride injection or by an automated spring-loaded puncture device. The purpose of this study was to create the largest database from among the world's largest centers to assess possible differences in efficacy and complication rates by transabdominal or transcervical or multifetal pregnancy reduction. STUDY DESIGN: Data on over 1000 completed pregnancies that underwent multifetal pregnancy reduction by both methods from major centers with among the highest worldwide experience were combined. Transabdominal cases were divided temporally (1986 through 1991 and 1991 through 1993). RESULTS: Transabdominal multifetal pregnancy reduction was successfully performed on 846 patients and transcervical or transvaginal on 238 patients. Transcervical or transvaginal reduction is performed earlier and starts and finishes with fewer embryos. In 12.6% of cases transcervical or transvaginal reduction left a singleton as opposed to 4.4% for transabdominal reduction. Pregnancy losses (up to 24 weeks) were observed in 13.1% of transcervical or transvaginal cases and in 16.2% of transabdominal cases early in the series and 8.8% of late transabdominal cases. Transcervical or transvaginal reduction may be safer very early in gestation and transabdominal safer later in the first trimester. Premature deliveries were comparable, with only about 5% delivered between 25 and 28 weeks. The smaller starting numbers for transcervical and transvaginal reduction may explain a slightly higher term delivery rate. The transabdominal route tends to reduce the fundal embryos and the transcervical and transvaginal the lower ones. The significance of this is not clear. CONCLUSIONS: (1) Multifetal pregnancy reduction by either method is a relatively safe and efficient method for improving outcome in multifetal pregnancies. (2) More than 84% are delivered at > 33 weeks. (3) The experience and preference of the operator are probably the key determinants for an individual patient. (4) An inverse relationship of starting and finishing number to loss rates and gestational age at delivery suggests that there still is a cost of iatrogenic multifetal pregnancies, even if multifetal pregnancy reduction can be successfully performed

OBJECTIVE: Our aim was to determine the chorionic and amniotic types in multifetal pregnancies with transvaginal ultrasonography at > or = 14 weeks' gestation. STUDY DESIGN: Two hundred twelve multifetal pregnancies were scanned transvaginally at or before 14 weeks' gestation. The number of fetuses and the chorionic and amniotic type were determined ultrasonographically. Of the 212 patients, 54 were delivered at our institution, and 43 of these 54 had pathologic evaluation of the placenta. Ultrasonographic and pathologic correlation of the chorionic and amniotic type was assessed in this group. RESULTS: Ultrasonographic evaluation of the 212 pregnancies demonstrated 64 twin, 87 triplet, 41 quadruplet, 18 quintuplet, 1 sextuplet, and 1 septuplet gestation. Nine of the twin pregnancies were monochorionic-diamniotic; two of the triplets were dichorionic-triamniotic, and four of the quadruplets were trichorionic-quadraamniotic. In the 43 patients with both ultrasonographic and pathologic assessment, there were 40 twins, five of which were monochoronic diamniotic type. All three triplets were trichorionic-triamniotic type. In all 43 transvaginal ultrasonography correctly predicted the chorionic and amniotic type as determined by the pathologic findings. CONCLUSIONS: Transvaginal ultrasonography at < or = 14 weeks can easily and accurately determine the chorionic and amniotic type in multifetal pregnancies

We evaluated the feasibility of transvaginal methotrexate injection of viable cervical pregnancies to avoid complications of the 'classic' surgical procedures in use and to preserve future fertility. Five viable cervical pregnancies, at 6 to 8 weeks, were treated. In three patients a spring-loaded automated puncture device and in two a manually operated simple needle guide mated to and guided by a transvaginal ultrasonography probe were used with 21-gauge needles. The puncture and injection treatment was successful and without complications in all five cases presented. This procedure may become a useful alternative to other, more radical or complex surgical approaches

OBJECTIVE: The aim of the study was to modify a previously devised morphologic scoring system with the use of transvaginal ultrasonography in the hope of improving discrimination of benign from malignant ovarian and adnexal masses. STUDY DESIGN: Transvaginal ultrasonographic images of 312 patients for a total of 350 ovarian and adnexal masses were obtained over a 3-year period. The derived morphologic data were analyzed by multiple linear regression analysis to select the best performance of the previously described scoring system by Sassone et al. in 1991. This system was thus modified in several ways including weighted point value assignments, fewer point values per variable studied, the deletion of one variable found not to be significant (wall thickness), and the inclusion of a new variable called shadowing. RESULTS: At surgery, 308 benign masses, 31 malignant masses, and 11 tumors of low malignant potential were found. The mean point value obtained was 1.8 for the benign masses, 3.9 for the tumors of low malignant potential, and 5.6 for the malignant tumors (p < 0.0005). With a cutoff of > or = 3 used as the best discriminator, the sensitivity was 96.8% and the specificity 77%. The positive and negative predictive values were 29.4% and 99.6%, respectively. CONCLUSION: Limitations of the previously devised scoring system included the arbitrary point assignments of each variable, the multiple (4 or 5) point choices for each variable, and the poor positive predictive value. This new scoring system performs well in the differentiation of benign from malignant masses, while assigning scientifically derived, therefore more valid, point values and simplifying the system overall. That the positive predictive value was not improved proves that ultrasonographically, to date we are still hampered by complex and malignant-appearing benign ovarian masses

A transvaginal sonographic (TVS) scoring system using morphologic features has been developed at our institution to maximize discrimination between benign and malignant ovarian and adnexal cysts. Low (4-7) or intermediate (8-9) scores have been found to correlate with benignity, hence TVS-guided or laparoscopically directed needle aspiration of low-scoring lesions may safely be performed. High-scoring lesions (10-14) are often malignant, therefore in situ needle aspiration of such lesions is not recommended. The aim of our study was to correlate the results of TVS characterization of ovarian and adnexal cysts with the aspiration cytologic evaluation. Twenty-three of the 43 cysts studied were aspirated in situ from the patient; 20 were aspirated from resected surgical specimens. Thirty-six benign cysts had TVS scores ranging from 4 to 12, with a median score of 7. All 25 cysts that were benign by TVS and/or histology were also cytologically benign as well as an additional 11 cysts that were not resected (TVS scores: 4 to 9). Seven cytologically and histologically malignant cysts had high TVS scores (TVS scores 10-14; median = 12). The combination of TVS and needle aspiration cytology is valuable, particularly in the diagnosis of cysts having low or intermediate TVS scores and benign cytology. Aspiration of cysts or masses with high TVS scores is not recommended. This combined evaluation may allow a more limited surgical approach, such as operative laparoscopy, or, in some cases, obviate the need for operative treatment altogether

A total of 230 apparently healthy postmenopausal women underwent transvaginal sonography and pelvic examination. The mean ovarian volume was 3.1 cm(3) with a range of 0.4-57.4 cm(3) and fewer than 5% (4.8%) of the subjects had a mean volume exceeding two standard deviations of the sample mean. Transvaginal sonography successfully imaged 64% of reported ovaries overall, although the proportion of ovaries imaged varied by sonographer. The poorer imaging rates found in this study, as compared with some previous investigations using transabdominal sonography, could be due to several factors including the type of sonography, the type of sample, the scanning time, and/or the criteria used to identify an ovary. Transvaginal sonography offers practical advantages over transabdominal sonography, but the potential loss in sensitivity, due to non-visualization of a substantial proportion of ovaries, must be formally assessed before adopting transvaginal sonography more widely as the primary screening modality

OBJECTIVE: Our purpose was to determine the Doppler ultrasonographic characteristics of fetal breathing-related nasal fluid flow velocity in uncomplicated pregnancies. STUDY DESIGN: Fetal nasal flow velocity was studied in 52 uncomplicated pregnancies at gestational ages ranging from 22 to 41 weeks. The evaluation of fetal breathing-related nasal fluid flow velocity was performed with ultrasonography combined with color flow and spectral Doppler analysis. RESULTS: The study revealed that the breath-to-breath interval and duration of the inspiratory phase of the fetal breathing-related nasal flow increased from 22 to 35 weeks and decreased thereafter. The breath-to-breath interval (milliseconds) at 33 to 35 weeks (1203.9 +/- 295.7 SD) was approximately twice what it was in the earliest age group (22 to 25 weeks); subsequently it decreased by approximately 25% in the term group (38 to 41 weeks). A positive correlation existed between the mean breathing-related nasal peak inspiratory flow velocity and advancing gestational age (r = 0.56, p = 0.0008), and between the inspiratory flow velocity acceleration and advancing gestational age (r = 0.53, p = 0.0076). CONCLUSION: Changes in fetal breathing activity during uncomplicated pregnancies can be determined by measurement of fetal breathing-related nasal fluid flow velocity. Our observations in uncomplicated pregnancies may be useful in future studies of these parameters in complicated pregnancies such as those at risk for pulmonary hypoplasia