Faculty Bibliography

There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.

Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.

OBJECTIVES/OBJECTIVE:Cystadenofibromas (CAFs) are rare benign ovarian tumors without a widely accepted ultrasound (US) pattern. They are usually described by as thin-walled, unilocular or multilocular, and at times septated cysts with scant blood flow and no solid components. We describe a unique US feature, the "shadow sign," seen in prospectively diagnosed benign CAFs. We also provide the histopathologic basis for this typical US appearance. METHODS:Ultrasound (US) examinations were performed in our obstetric and gynecologic US unit. Pathologic examinations were performed by a dedicated gynecologic pathology team. The US and pathology department's database was searched for the diagnosis of a CAF between 2010 and 2017. RESULTS:We identified 20 patients who underwent transvaginal US examinations with a sole US diagnosis of a CAF, and the tumors were surgically removed. The common US feature across the 20 cases was the presence of hyperechoic avascular shadowing nodules. The correlating histologic features were unilocular or multilocular cysts with a smooth internal wall surface lined by a simple epithelium and occasional robust polypoid fibrous stroma. CONCLUSIONS:This US marker helps in differentiating CAFs from borderline ovarian tumors, which do not show this US feature. We hope that recognizing the suggested shadow sign as an additional descriptor of CAFs will lead to minimizing their unnecessary removal and eliminating additional and unnecessary imaging by computed tomography and magnetic resonance imaging.

OBJECTIVE:Accurate diagnosis of borderline ovarian tumors (BOTs) is important to ensure timely and appropriate management, especially in women desiring to preserve fertility. Transvaginal ultrasound (TVUS) is considered the best modality to diagnose adnexal tumors. Sonographic features of BOTs described in the literature include septa, solid components, mural nodules (papillae) and blood vessels within these structures. However, there is no single signature that differentiates BOTs from other adnexal masses. We have identified a microcystic pattern on ultrasound of BOTs. The objective of our study was to evaluate the utility of a new sonographic pattern to describe a novel, yet typical, microcystic pattern of papillary projections, solid components and/or septa as a new ultrasound marker of BOTs and present their histologic confirmation. MATERIAL AND METHODS/METHODS:In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who underwent pre-operative transvaginal ultrasound (TVUS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations associated with solid components, papillary projections, and/or septa. Case-matched histopathologic slides of each BOT were examined for the presence of the above-described microcystic features identified on TVUS. To confirm that the microcystic TVUS pattern is unique to BOTs, we randomly selected 20 cases of epithelial cancer and 20 cases of benign cystadenomas from our ultrasound and surgical database. These were also reviewed by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to learn if the above described microcystic tissue pattern was previously described. RESULTS:Sixty-seven cases with pre-operative ultrasound that had surgically confirmed BOT on pathologic examination were included in the final analysis. Median age at surgery was 39.8 years. Average size of the BOTs was 60.7mm. Of the 67 BOTs, 47 (70.14%) were serous, 15 (22.38%) were mucinous, and 5 (7.46%) were seromucinous. Sixty (89.7%) of 67 BOTs demonstrated the microcystic pattern in the papillary projections, solid components and/or septa. On ultrasound imaging, 46 of the 47 (97.9%) serous type BOTs had a microcystic pattern compared to 11 of the 15 (73.3%) mucinous and 3 of the 5 (60.0%) seromucinous BOTs. On microscopic evaluation, 60 (89.7%) of 67 samples had characteristic 1-3-mm fluid-filled cysts like those seen on transvaginal ultrasound. Only 7 cases revealed discrepancies between the sonographic and histologic identification of a microcystic pattern. The cystadenomas (we submitted 4 of the 20 pairs we studied for comparison for this article) were mostly unilocular and/or multilocular and largely avascular. None of the 20 cystadenomas or 20 epithelial ovarian malignancies case-matched to histology displayed microcystic characteristics on ultrasound. On review of 23 published articles in the English medical literature containing 163 sonographic pictures of BOT, no description of the microcystic tissue pattern was found. CONCLUSION/CONCLUSIONS:In conclusion, we report a novel sonographic marker of BOTs termed "microcystic pattern" of their papillary projections, solid components and/or septa. This was seen in the majority of both the serous and the mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of both benign entities and malignancies, the microcystic appearance appears to be unique to BOTs. No such or similar description was previously provided. We feel utilization of this new marker will help to correctly identify BOTs, discriminating them from ovarian cancers and benign ovarian pathologies, and ensure their appropriate clinical and surgical management.

In this opinion article, we provide compelling arguments of why early screening for pregnancies following previous cesarean delivery would be beneficial. First, we provide an overview of the perils of undiagnosed or misdiagnosed cesarean scar pregnancies (CSP), mostly with bleeding, but also with other complications, that may lead to multiple surgeries, uterine artery embolization, loss of fertility and in rare cases of documented deaths. There is well-documented histopathological connection between CSP and the placental adherence spectrum (PAS) suggesting that CSP is a precursor to PAS. We argue that the ultrasound markers to recognize CSP are present in the 1^st trimester and that they may go on and become 2^nd and 3^rd trimester cases of PAS. We stress that early 5-7 weeks ultrasound screening for CSP is strongly indicated (if not mandated) and can be easily implemented alongside several other proven 1^st trimester screening tests.

OBJECTIVES/OBJECTIVE:To develop a prenatal ultrasound staging system for placenta accreta spectrum (PAS) disorders in women with placenta previa and to evaluate its association with surgical outcome, placental invasion and the clinical staging system for PAS disorders proposed by the International Federation of Gynecology and Obstetrics (FIGO). METHODS:This was a secondary retrospective analysis of prospectively collected data from women with placenta previa. We classified women according to the following staging system for PAS disorders, based upon the presence of ultrasound signs of PAS in women with placenta previa: PAS0, placenta previa with no ultrasound signs of invasion or with placental lacunae but no evidence of abnormal uterus-bladder interface; PAS1, presence of at least two of placental lacunae, loss of the clear zone or bladder wall interruption; PAS2, PAS1 plus uterovescical hypervascularity; PAS3, PAS1 or PAS2 plus evidence of increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region. We explored whether this ultrasound staging system correlates with surgical outcome (estimated blood loss (EBL, mL), units of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets (PLT) transfused, operation time (min), surgical complications defined as the occurrence of any damage to the bladder, ureters or bowel, length of hospital stay (days) and admission to intensive care unit (ICU)) and depth of placental invasion. The correlation between the present ultrasound staging system and the clinical grading system proposed by FIGO was assessed. Prenatal and surgical management were not based on the proposed prenatal ultrasound staging system. Linear and multiple regression models were used. RESULTS:Two-hundred and fifty-nine women were included in the analysis. Mean EBL was 516 ± 151 mL in women with PAS0, 609 ± 146 mL in those with PAS1, 950 ± 190 mL in those with PAS2 and 1323 ± 533 mL in those with PAS3, and increased significantly with increasing severity of PAS ultrasound stage. Mean units of PRBC transfused were 0.05 ± 0.21 in PAS0, 0.10 ± 0.45 in PAS1, 1.19 ± 1.11 in PAS2 and 4.48 ± 2.06 in PAS3, and increased significantly with PAS stage. Similarly, there was a progressive increase in the mean units of FFP transfused from PAS1 to PAS3 (0.0 ± 0.0 in PAS1, 0.25 ± 1.0 in PAS2 and 3.63 ± 2.67 in PAS3). Women presenting with PAS3 on ultrasound had significantly more units of PLT transfused (2.37 ± 2.40) compared with those with PAS0 (0.03 ± 0.18), PAS1 (0.0 ± 0.0) or PAS2 (0.0 ± 0.0). Mean operation time was longer in women with PAS3 (184 ± 32 min) compared with those with PAS1 (153 ± 38 min) or PAS2 (161 ± 28 min). Similarly, women with PAS3 had longer hospital stay (7.4 ± 2.1 days) compared with those with PAS0 (3.4 ± 0.6 days), PAS1 (6.4 ± 1.3 days) or PAS2 (5.9 ± 0.8 days). On linear regression analysis, after adjusting for all potential confounders, higher PAS stage was associated independently with a significant increase in EBL (314 (95% CI, 230-399) mL per one-stage increase; P < 0.001), units of PRBC transfused (1.74 (95% CI, 1.33-2.15) per one-stage increase; P < 0.001), units of FFP transfused (1.19 (95% CI, 0.61-1.77) per one-stage increase; P < 0.001), units of PLT transfused (1.03 (95% CI, 0.59-1.47) per one-stage increase; P < 0.001), operation time (38.8 (95% CI, 31.6-46.1) min per one-stage increase; P < 0.001) and length of hospital stay (0.83 (95% CI, 0.46-1.27) days per one-stage increase; P < 0.001). On logistic regression analysis, increased severity of PAS was associated independently with surgical complications (odds ratio, 3.14 (95% CI, 1.36-7.25); P = 0.007), while only PAS3 was associated with admission to the ICU (P < 0.001). All women with PAS0 on ultrasound were classified as having Grade-1 PAS disorder according to the FIGO grading system. Conversely, of the women presenting with PAS1 on ultrasound, 64.1% (95% CI, 48.4-77.3%) were classified as having Grade-3, while 35.9% (95% CI, 22.7-51.6%) were classified as having Grade-4 PAS disorder, according to the FIGO grading system. All women with PAS2 were categorized as having Grade-5 and all those with PAS3 as having Grade-6 PAS disorder according to the FIGO system. CONCLUSION/CONCLUSIONS:Ultrasound staging of PAS disorders is feasible and correlates with surgical outcome, depth of invasion and the FIGO clinical grading system. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

The efficacy of treating cesarean scar pregnancies and cervical pregnancies with the Cook® cervical ripening balloon catheter, in a multicenter office-based setting is reported. Thirty-eight women were treated. Insertion of the catheter was performed under real-time ultrasound guidance. Patients received adjuvant systemic methotrexate, prophylactic oral antibiotics, and oral pain medication. Serum human chorionic gonadotropin and ultrasound scans were followed serially until resolution. Thirty-seven patients were successfully treated, requiring no further procedures. We found that the Cook cervical ripening balloon technique is a simple, effective, outpatient, minimally invasive treatment with few complications noted in this expanded series.

OBJECTIVES: To assess whether cesarean delivery changes the natural position of the uterus. METHODS: In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery. RESULTS: We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans +/- SD was 18 +/- 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P < .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8 degrees +/- 45.7 degrees ) versus vaginal delivery (145.8 degrees +/- 43.7 degrees ; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4 degrees +/- 51.2 degrees ) versus vaginal delivery (152.8 degrees +/- 47.7 degrees ; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6 degrees versus 7.0 degrees ; P = .027). CONCLUSIONS: Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.

Vein of Galen Malformation (VGM) constitutes a spectrum of arterio-venous malformations resulting in excess blood flow to the cerebral veins (1,2). Arteriovenous shunting caused by this malformation increases cardiac preload. Prenatal diagnosis is commonly made during the third trimester, with signs of cardiac failure (3,4). This report describes the challenges of prenatal diagnosis of VGM which presented as intracranial hemorrhage in the second trimester, prior to the onset of cardiac volume overload.

OBJECTIVE:To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). METHODS:An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis. RESULTS:A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case. CONCLUSIONS:CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome.