Faculty Bibliography

The worldwide use of the transvaginal scanning route has revolutionized obstetrical and gynecologic imaging. The long, slow, and at times challenging aspects of its acceptance by the obstetrical and gynecologic community are the subject of this article. From its inception to its recent use, the dedicated doctors in the Department of Obstetrics and Gynecology at Rambam Medical Center, Haifa, Israel, were instrumental in conceiving and then collaborating with an Israeli manufacturer in the construction and worldwide use of the transvaginal ultrasound probe, resulting in the now well-known field of transvaginal sonography.

Ultrasound is considered the first-line imaging modality in the evaluation of the fallopian tubes. This chapter reviews both the physiologic and pathologic sonographic findings of the fallopian tubes and how to recognize characteristic entities. Specifically, it describes how to use ultrasound techniques to distinguish between pathologic processes including chronic versus acute pelvic inflammatory disease, as well as infertility, torsion, and malignancy. It also describes how to employ modern ultrasound techniques, such as color Doppler, three-dimensional imaging, and salpingocentesis in clinical practice.

Vascular control is a fundamental step in the surgical management of morbidly adherent placenta (MAP), and this implies a precise knowledge of the vascular supply in the lower part of the genital tract. High degrees of MAP are sometimes characterised by the presence of a rich vascular anastomotic system between the bladder, uterus, and vagina involving the superior, medial, and inferior vaginal and the lower vesical arteries. This brief report shows that prenatal ultrasound assessment of bladder-uterovaginal anastomoses in MAP is feasible.

BACKGROUND: Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10 to 62%. At times, lifesaving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single balloon catheter for treatment of cesarean scar pregnancy after local injection of methotrexate we evaluated the use of a double balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This is a retrospective study. OBJECTIVES: To describe the placement of a cervical ripening double balloon catheter as a novel minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac. MATERIAL AND METHODS: Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum hCG were followed weekly or as needed. RESULTS: Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 - 7 4/7 weeks). Patients' acceptance for the double balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but one patient noted vaginal spotting at the follow-up appointment. Only one patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range 1- 5 days). Median time from treatment to total drop of hCG was 49 days (range 28 - 97 days). CONCLUSION: The double balloon is a successful, minimally invasive and well tolerated single treatment for cervical pregnancy and cesarean scar pregnancy.. This simple treatment method has four main advantages: It effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies and is familiar to obstetricians/gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.

BACKGROUND: Cesarean scar pregnancy is a serious complication of pregnancy, which consists of implantation of the gestational sac in the hysterotomy scar. This condition is increasing in frequency and often poses a diagnostic challenge. Its diagnosis is dependent on visual assessment of the uterus on the longitudinal sagittal ultrasound plane. Misdiagnosing a low intrauterine chorionic sac as a cesarean scar pregnancy, or a true scar pregnancy as an intrauterine pregnancy may lead to adverse outcomes including hysterectomy. OBJECTIVE: The objective of the study is to describe a sonographic method for the differential diagnosis of cesarean scar pregnancy versus intrauterine pregnancy in early gestation. The current study addressed to test the hypothesis that on a first-trimester ultrasound performed between 5 and 10 weeks of gestation, the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus, can be used for early detection of cesarean scar pregnancies. STUDY DESIGN: This is a retrospective review of electronically archived ultrasound images of intrauterine and cesarean scar pregnancies between 5 and 10 weeks of gestation. A total of 242 ultrasound images were analyzed: 185 cases of normal intrauterine pregnancies (including 128 in anteverted uteri, 31 in retroverted uteri and 26 intrauterine pregnancies with history of previous cesarean delivery) and 57 cases of cesarean scar pregnancies diagnosed throughout 2004-2015 in a single institution. The following measurements were made for each case: distance from the external cervical os to the uterine fundus, the midpoint axis of the uterus, the distance from the external cervical os to the center of gestational sacs and the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix. RESULTS: The location of the center of the gestational sac relative to the midpoint axis of the uterus between 5 and 10 weeks of gestation differentiated between intrauterine and cesarean scar pregnancies (mean, 17.8 vs -10.6 mm, respectively, p = 0.0001), indicating that most of the cesarean scar pregnancies are located proximally to the midpoint axis of the uterus whereas most of the normal intrauterine pregnancies are located distally from the midpoint of the uterus. Using location of the center of the gestational sac as a marker of cesarean scar pregnancies between 5 and 10 weeks of gestation yielded the following characteristics of diagnostic accuracy: sensitivity 93.0% and specificity 98.9%. The likelihood ratio of the positive test was 84.5. The likelihood ratio of the negative test was 0.07. CONCLUSIONS: The location of the center of the gestational sac relative to the midpoint axis of the uterus can be used as an easy, method for sonographic differentiation of intrauterine and cesarean scar pregnancies between 5 and 10 weeks of gestation.