Association between ultrasonographic parameters of Cesarean scar defect and outcome of early termination of pregnancy.

OBJECTIVE: To determine whether Cesarean scar defect (CSD) parameters assessed by transvaginal sonography (TVS) might affect the outcome of early termination of pregnancy (TOP) with mifepristone-misoprostol. METHODS: This was a retrospective review of 183 women with previous Cesarean delivery who received oral mifepristone and misoprostol for TOP. A successful TOP was defined by the absence of an intrauterine gestational sac, with no need for surgical intervention. CSD was diagnosed by TVS in the presence of a hypoechogenic indentation within the myometrium of the lower uterine segment at the site of a previous Cesarean incision. Women were analyzed in three subgroups according to size of defect (ratio of residual myometrial thickness over the defect to adjacent myometrial thickness < 30%, 30%-70% and > 70%). RESULTS: Of the 183 women, 43 (23.5%) had failure of TOP. Fifty-nine (32.2%) had CSD detectable at TVS, and these women had a higher failure rate of TOP than did those without CSD (38.9% vs 16.1%; P = 0.001). CSD was associated significantly with failure of TOP (odds ratio, 3.32 (95% CI, 1.64-6.75)). The TOP failure rates in relation to defect size in the myometrial thickness ratio < 30%, 30%-70% and > 70% subgroups were 57.1%, 25.0% and 18.2%, respectively. There was a linear trend in failure rate across these ratios (Cochran-Armitage trend test; P = 0.015). CONCLUSIONS: Women with CSD are at increased risk of failed TOP. Women with a defect in which the residual myometrial thickness was < 30% of the adjacent myometrial thickness tended to have a greater chance of failed TOP. CSD detected at TVS is of clinical relevance in counseling women with a history of Cesarean delivery who are considering TOP. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of changes in utero-ovarian arterial impedance during the peri-implantation period by Doppler sonography in women undergoing assisted reproduction.

OBJECTIVE: To investigate changes in utero-ovarian blood flow during the peri-implantation period and their significance in successful embryo implantation. METHODS: A prospective longitudinal study was conducted in 317 women undergoing in-vitro fertilization-embryo transfer (IVF-ET) treatment. All of them had at least one good-quality embryo for transfer on the second or third day after oocyte retrieval. Measurement of endometrial thickness and color flow imaging with pulsed waveform analysis of uterine and ovarian arteries were performed before ET and 5-6 days after ET. RESULTS: There were no significant differences in the age of patients, duration of infertility or number of embryos transferred between women who became pregnant (n = 91) and those who did not (n = 226). There was no difference in mean endometrial thickness between the two groups before ET, while a thicker endometrium was found in women who had conceived compared with those who had not 5-6 days after ET (P = 0.02). Mean uterine arterial resistance index (RI) and pulsatility index (PI) values were significantly lower in the pregnant than in the non-pregnant group before ET (P = 0.04 and P = 0.003, respectively), but no significant differences were found between the two groups 5-6 days after ET. In contrast, the mean ovarian arterial RI and PI values were similar between the two groups before ET, yet the pregnant group showed significantly lower RI and PI values compared with the non-pregnant group 5-6 days after ET (P = 0.002 and P = 0.01, respectively). A significantly higher peak systolic velocity (PSV) of intraovarian vessels was also noted in the pregnant group 5-6 days after ET. CONCLUSION: Different utero-ovarian blood flow changes during the peri-implantation period occur in conception and non-conception cycles in women following IVF. Doppler assessment of uterine arterial resistance can help to determine a time interval within the menstrual cycle that is of optimal endometrial status for embryo implantation in assisted conception programs. Delay in achieving adequate uterine perfusion during the temporal window of embryo implantation may have an impact on endometrial receptivity.

Herniated blastomere following chemically assisted hatching may result in monozygotic twins.

OBJECTIVE: To explore a possible mechanism of the increasing incidence of monozygotic twins following assisted hatching of human embryos. DESIGN: Case report. SETTING: Clinical research center in a medical school teaching hospital. PATIENT: A 37-year-old infertile woman with repeated IVF failures. INTERVENTION(S): Assisted hatching of the day 3 embryos using acidic Tyrode's solution. MAIN OUTCOME MEASURE(S): The morphology of the zona-drilled embryos and the pregnancy outcome. RESULT(S): After assisted hatching, a herniated blastomere through an oversized opening in the zona pellucida was found in one embryo. The transfer of two zona-drilled embryos resulted in a triplet pregnancy. CONCLUSION(S): Large openings in the zona pellucida following chemically assisted hatching may cause premature hatching of the blastomeres and may be implicated in the occurrence of monozygotic twins.

Reexpansion pulmonary edema occurring after thoracoscopic drainage of a pleural effusion.

Video assisted thoracoscopic drainage and tale pleurodesis was used to treat a recurrent pleural effusion in a 60 year-old woman undergoing major gynecologic surgery. She developed reexpansion pulmonary edema immediately following surgery. Several important risk factors that were present in this patient are discussed. In addition to almost, complete collapse of the underlying lung for several weeks, thoracoscopy resulted in manipulations and rapid re-inflation of the underlying lung, which further increased the risk to the patient.