HDLive ultrasound images of ovarian dermoid cysts: diagnostic accuracy.

OBJECTIVE: To demonstrate that the use of 3D/4D HDLive increases the image quality in the diagnosis of benign cystic ovarian teratomas. MATERIALS AND METHODS: 3D/HDLive ultrasound (US) was used in 31 cases of suspected ovarian cystic teratoma using vaginal 2D US. The following pathognomonic images of mature cystic teratomas were considered for diagnosis: 1) a cystic, unilocular lesion with a densely echogenic tubercle (Rokitansky nodule); 2) a diffuse or partially echogenic mass usually demonstrating sound attenuation; 3) fluid-fluid/fat-fluid levels; 4) dermoid mesh with hyperechogenic calcifications indicating the presence of bone, teeth, or other ectodermally-derived structure; 5) multiple mobile spherical structures (fat globules). RESULTS: Dermoids present a wide spectrum of images depending on the predominant tissue type. In the vast majority of cases there are dense echogenic structures that correspond to complex masses of fatty tissue, sebum, hair, epithelial remnants, along with cartilage or bone. If we catalogue all the images together, the pathognomonic of dermoid are: 1) cystic or solid cystic lesions with a Rokitansky nodule, with bone, teeth or cartilage (six cases, 22.2%); 2) a solid mass with or without attenuation that corresponds with pure sebum (five cases, 18.5%); 3) a diffuse mass with fine bands that correspond with hair inside sebum (four cases, 12.9%) and that may form meshes or plugs corresponding with a mixture of fat, sebum, and hair (three cases, 11.5%). CONCLUSIONS: HDLive U.S. provides some images of exceptional quality that enhance the definition of the structures of these tumors (fat, hair, cartilage, bone, etc.) compared to 2D/3D/4D.

Semi-automatic Sono T measurement of nuchal translucency.

A prospective study of 63 singleton pregnancies between 11 + 0 and 13 + 6 weeks gestation underwent semi-automatic nuchal translucency (NT) measurement and were compared with two-dimensional ultrasonography (2D US). Inter-observer variation and the repeatability were evaluated. Sono T automatically achieves mid-sagittal plane views and measures the maximum NT thickness. Measurements have less inter-observer variation (CI = -0.13, -0.04) when compared with 2D measurements (CI = -0.45, 0.28). It is reproducible and comparable to conventional 2D US technique for NT measurement. However, incorporating Sono T into routine practice requires further program refinements in order to reduce erroneous NT measurements.

Predicting ovarian reserve and reproductive outcome using antimüllerian hormone (AMH) and antral follicle count (AFC) in patients with previous assisted reproduction technique (ART) failure.

PURPOSE OF INVESTIGATION: The main objective of our prospective, observational, analytical research work was to determine whether Anti-Müllerian hormone (AMH) and antral follicle count (AFC) could be effectively used as predictors of ovarian reserve and, possibly, of reproductive outcome with ART. METHODS: We studied 143 IVF/ET cycles in patients with a previous history of ART failure, all of them supposed to be of poor prognosis, who had agreed to another ART attempt after knowing their AMH, AFC, and base hormone (FSH, LH, 17 beta-estradiol) levels. RESULTS: AMH and AFC showed a positive correlation with the number of oocytes retrieved (p = 0.0016) and (p < 0.0001), respectively and with percentage of MII oocytes, (p = 0.00756) and (p < 0.001). The combined use of these markers showed an area under the curve of 82.2% for oocytes retrieved. Our results shows a very high cancelation (22% of started cycles) and very low pregnancy rates (6.7% and 9.8%) in low and normoresponders, respectively. CONCLUSIONS: AMH levels and AFC are reliable indicators of ovarian reserve. Patients with ovarian reserve levels that predict a very low probability of success should be informed that the poor prognosis associated with these values may not justify the expense of IVF/ET.

Triggering with GnRH agonist in oocyte-donation cycles: oestradiol monitoring is not necessary during ovarian stimulation.

This prospective observational study evaluated the efficacy and safety of oocyte-donation cycles triggered with a gonadotrophin-releasing hormone (GnRH) agonist without monitoring oestradiol concentrations during ovarian stimulation. A total of 97 oocyte donors received recombinant FSH (150-225/day) and GnRH antagonists (0.25mg/day). Oocyte maturation was triggered with 0.2mg triptorelin s.c. Donors aged 25.4 ± 4.1 years were stimulated for 8.8 ± 0.9 days and underwent 2.9 ± 0.5 (2-4) ultrasound assessments. Total FSH dose was 1703.4 ± 304.7IU, antagonists were administered for 4.3 ± 1.0 days, 14.7 ± 8.8 oocytes were retrieved and there were no cases of ovarian hyperstimulation syndrome. Recipients (n=123) aged 40.3 ± 3.4 years received 10.9 ± 4.3 oocytes, 88.7% of which were metaphase II. Intracytoplasmic sperm injection fertilization rate was 79% and 2.18 ± 0.6 (1-3) embryos were transferred. The pregnancy, clinical pregnancy and twin pregnancy rates were 64.2%, 57.7% and 19.7%, respectively. In conclusion, given the high efficacy and safety of the GnRH-antagonist protocol triggered with a GnRH agonist, the monitoring of oestradiol concentrations is not necessary. Ultrasound monitoring is enough for an adequate follow up of the stimulation cycle in oocyte donors.

Cycles triggered with GnRH agonist: exploring low-dose HCG for luteal support.

The aim of this study in patients at risk of ovarian hyperstimulation syndrome (OHSS) was to determine the efficacy and safety of luteal support using human chorionic gonadotrophin (HCG) after triggering ovulation with gonadotrophin-releasing hormone (GnRH) agonist in IVF/intracytoplasmic sperm injection antagonist cycles. A total of 192 OHSS-risk patients, following a GnRH antagonist protocol (0.25mg/day cetrorelix) during recombinant FSH stimulation, were triggered with 1.5mg s.c. leuproreline for ovulation. A total of three boluses of HCG were used for luteal support, 1000IU (group A, n=44), 500IU (group B, n=115) or 250IU (group C, n=33) every third day, starting the day after oocyte retrieval. For the reproductive outcome, main variables were biochemical and clinical pregnancy rates, and for OHSS, the variables were the numbers of moderate and severe OHSS cases. Overall pregnancy rate was 51.8% and clinical pregnancy rate was 43.4%. This study observed eight cases of moderate (4.2%) and seven of severe OHSS (3.6%). Six out of the seven (85.7%) severe cases were late-onset OHSS, related to pregnancy. In conclusion, GnRH agonist single dose for triggering ovulation and low doses of HCG used as luteal-phase support seem to secure a normal pregnancy outcome without increasing the OHSS risk.

High doses of GnRH antagonists are efficient in the management of severe ovarian hyperstimulation syndrome.

OBJECTIVE: To determine whether treatment of severe ovarian hyperstimulation syndrome (OHSS) with high-dose gonadotropin-releasing hormone (GnRH) antagonist, due to its luteolytic effect, is an effective method of management. METHODS: Six infertile patients who had been scheduled for embryo transfer and developed early-onset severe OHSS with ascites and hemoconcentration were chosen for treatment with 3.0 mg of a GnRH antagonist (Cetrotide; Cetrorelix, Serono, Madrid, Spain). The response of these patients was compared with five patients with severe early-onset OHSS who received support therapy alone. All patients were evaluated clinically, echographically, and hematologically. RESULTS: Estradiol (E2) levels dropped significantly a few days after treatment. Peritoneal fluid regression measured by ultrasound was faster on the study group compared with controls. Hematocrit remained comparable in both groups during follow-up. In two cases a second bolus of GnRH-antagonist was used due to clinical and biochemical findings during the four days of observation following the initial dose. None of the patients treated with GnRH antagonists required paracentesis. CONCLUSIONS: Treatment with high doses of GnRH antagonists seems to be effective in the management of severe OHSS.

Nuevas aplicaciones en el diagnóstico ecográfico en 3D-4D en malformaciones fetales / New applications of 3D-4D ultrasonographic diagnosis of fetal malformations

Durante los tres últimos años han aparecido numerosas revisiones y nuevas modalidades ecográficas, tales como la tomografía con ultrasonidos, el VOCAL, el STIC, el modo inverso, el reverso, etc., que han revolucionado nuevamente las posibilidades de mejorar o completar el diagnóstico de las malformaciones fetales. El empleo de la tecnología 3D-4D puede aplicarse en la gran mayoría de las malformaciones y, combinado con la visión de la cinética fetal, ha mostrado que permite reducir el tiempo de exploración precisado para una completa visualización y mejor definición de las malformaciones

In the last 3 years, numerous revisions and new ultrasound modalities have emerged, such as ultrasound tomography, VOCAL, STIC, inverse mode, reverse mode, etc. These state of the art technologies have improved and/or completed the diagnosis of fetal malformations. These 3D-4D techniques can be applied to most malformations. In combination with fetal kinetics, this technology reduces the time spent in examination and improves visualization of malformations

Gestación ectópica: evolución diagnóstica y terapéutica en la última década / Ectopic pregnancy: changes in diagnosis and treatment in the last

El embarazo ectópico representa la implantación de una gestación fuera de la cavidad uterina. Esta situación patológica se conoce desde el siglo xvii, y presenta una incidencia aproximada de 11-18 casos por cada 1.000 partos. Sin lugar a dudas, esta implantación gestacional patológica representa una de las complicaciones más graves del embarazo, y su incidencia se ha visto incrementada notoriamente en los últimos 20 años. En el presente artículo revisamos la evolución en nuestro centro de esta enfermedad (AU)

Ectopic pregnancy consists of implantation of an embryo outside the uterine cavity. This abnormality has been known since the seventeenth century and the incidence is approximately 11-18 cases per 1,000 deliveries. Ectopic pregnancy is undoubtedly one of the most dangerous complications in pregnancy, and its incidence has risen markedly in the last 20 years. The present study reviews changes in the incidence, etiologic factors, diagnosis and treatment of this complication in our center (AU)

Prenatally detected double trisomy: Klinefelter and Down syndrome.

Double trisomies are a rare occurrence. We report the first case of a Down and Klinefelter's syndrome (48,XXY,+21) in a fetus that was prenatally diagnosed during the 15th week of pregnancy. Even though the nasal bone was present, and the color-Doppler study of the ductus venosus and the nuchal thickness were normal, the maternal serum test results indicated an increased risk of Down syndrome and consequentially a genetic amniocentesis was performed. A 48,XXY,+21 karyotype was observed and the patient decided to terminate the pregnancy. In this case, we did not find the typical ultrasound (US) signs that would have led us to the chromosomopathy; furthermore, we emphasize the advantages of using biochemical screening which, in our case, were crucial in arriving at the correct diagnosis.

Empleo prenatal de esteroides: riesgos y beneficios / Prenatal steroid use: risks and benefits

El empleo de corticoides ante la posibilidad de un parto prematuro ha disminuido la incidencia de distrés respiratorio, hemorragia intraventricular y muerte neonatal. En aquellas mujeres en que el parto se pospone más allá de una semana, el empleo de nuevas dosis semanales ha sido empleado en la práctica obstétrica pese a que hay poca evidencia de su eficacia. Nuevos estudios sugieren en estas pautas repetidas pocos beneficios y riesgos potenciales, por lo que sugieren las dosis únicas (AU)

A single course of corticosteroids given to women before an anticipated preterm birth reduces the incidence of respiratory distress syndrome, intraventricular hemorrhage, and neonatal death. For women who do not deliver within 1 week, administration of repeat courses of corticosteroids has become common obstetric practice, despite little evidence of efficacy. Emerging data suggest that this practice produces little benefit and may potentially be harmful. Therefore, the use of corticosteroids to improve perinatal outcomes should be restricted to a single course (AU)

Tumor de Krukenberg secundario a adenocarcinoide apendicular / Krukenberg tumor secondary to appendiceal adenocarcinoid

Las metástasis ováricas de tumores apendiculares son excepcionales. Presentamos el caso de una mujer de 38 años con una tumoración ovárica bilateral sometida a histerectomía total con salpingo-ooforectomía bilateral, apendicectomía y omentectomía. El estudio anatomopatológico reveló la presencia de un tumor de Krukenberg secundario a un adenocarcinoide oculto de apéndice. Asimismo, se realiza una actualización de estos casos

Ovarian metastasis from appendiceal neoplasms are rare. We present the case of a 38-year-old woman with bilateral ovarian tumors who underwent bilateral salpingo-oophorectomy, total hysterectomy, appendectomy and omentectomy. Pathological diagnosis was Krukenberg tumor from an occult appendiceal adenocarcinoid. We also review the literature on this topic

Endometrial leptin and leptin receptor expression in women with severe/moderate endometriosis.

The leptin system has been implicated in reproductive function, acting at endocrine and paracrine levels. Recently, deregulation of this gene family has been linked to endometrial changes caused by endometriosis. In the present study, we compare the expression of leptin receptor mRNA during the pre-receptive (LH+2) and receptive (LH+9) phases in the eutopic endometrium from patients with severe/moderate endometriosis (n = 30) versus fertile controls (n = 12). In each patient, two endometrial samples were obtained at LH+2 and LH+9 in their natural cycles. When real-time quantitative fluorescent PCR was performed, an up-regulation of OB-RL and all the isoforms investigated was observed at LH+9 versus LH+2 in patients with and without endometriosis. However, no difference was found in the expression pattern of the total leptin receptor OB-RT, or in its long OB-RL and soluble HuB219.3 forms when the eutopic endometria of patients with severe/moderate endometriosis and fertile controls were compared. By means of in situ hybridization, total leptin receptor mRNA was localized in the luminal epithelium and the glands of the endometrium. The immunohistochemical analysis of the long form of leptin receptor was also performed in order to confirm these findings at the protein level. Finally, we have also shown similar leptin mRNA expression in both the control group and patients with endometriosis. In conclusion, we have not identified differences in the endometrial expression and localization of leptin and the leptin receptor when comparing the eutopic endometrium of women with severe/moderate endometriosis and fertile controls.

Útero septo con duplicación cervical: una anomalía mülleriana infrecuente / Septate uterus with cervical duplication: an infrequent Müllerian abnormality

En el presente caso hemos descrito una variante mülleriana infrecuente (útero septo y cérvix doble), que resulta inconsistente con la embriología clásica. Asimismo, hemos realizado un diagnóstico correcto mediante el empleo de ecografía tridimensional, que representa el primer caso de la bibliografía mundial descrito mediante esta técnica ecográfica. Por último, hemos repasado las opciones terapéuticas y discutido su inclusión futura en la clasificación de las malformaciones uterinas. (AU)

Ecografía tridimensional y diagnóstico prenatal. Pasado, presente y futuro / Ultrasound 3D and prenatal diagnosis. Past, present and future

Sin dejar a un lado la ecografía bidimensional, la ecografía 3D combinada con la 2D permite la visualización de imágenes inaccesibles a la ecografía convencional. La ecografía 3D abre unas amplias perspectivas en el campo del diagnóstico prenatal, no sólo malformativo, sino en la confirmación de una extensa gama de marcadores de cromosomopatías, posicionándose además, firmemente, en el campo ginecológico, patología reproductiva y oncología. La última palabra sobre los avances tecnológicos de este modo ecográfico aún no se ha dicho (AU)

Artrogriposis múltiple congénita (contracturas congénitas múltiples): revisión / Arthrogryposis multiplex congenita (multiple congenital contractures): a review

La artrogriposis o contracturas múltiples es la aparición de contracciones articulares de etiología variable en el período prenatal. La artrogriposis puede ser el resultado de un déficit neurológico, de alteraciones neuromusculares, de anomalías del tejido conectivo, de bridas amnióticas o de anomalías posicionales fetales. La artrogriposis puede ser el resultado de causas sin aparente relación hereditaria (neuropáticas) o proceder de factores hereditarios (la forma miopática, por ejemplo). El diagnóstico ecográfico depende de la observación de la ausencia o la escasa motilidad de los miembros y de anomalías de posición de las contracturas articulares. El pronóstico depende de la etiología específica de las contracturas. Se describe la incidencia de anomalías contracturales y otras malformaciones acompañantes sobre la base de 8 casos observados con ecografía tridimensional. (AU)

Diagnóstico precoz de fetos triploides / Early diagnosis of triploid foetus

Las gestaciones triploides en las cuales el feto evoluciona favorablemente más allá del primer trimestre suponen una rareza. El diagnóstico precoz de dichas gestaciones triploides representa un desafio para los profesionales dedicados al diagnóstico prenatal. El presente caso, diagnosticado correctamente en una fase precoz, nos permite llevar a cabo una valoración de las diferentes técnicas diagnósticas de las que disponemos en la actualidad, haciendo especial énfasis en el empleo de la ecografía tridimensional (AU)

Fetus acardius: two- and three-dimensional ultrasonographic diagnoses.

OBJECTIVE: To determine whether ultrasonographic detection of acardiac fetuses and diagnostic accuracy of related malformations improve with complementary use of two-dimensional ultrasonography, three-dimensional ultrasonography, and Doppler scanning. METHODS: Three pregnant women with multifetal gestations who were found to have discordant fetuses on initial two-dimensional ultrasonographic scanning were subsequently scanned with three-dimensional ultrasonography and color Doppler ultrasonography. RESULTS: Although the possibility of acardiac fetuses was entertained in all cases after two-dimensional ultrasonographic scanning, the diagnosis was confirmed, and the accuracy and extent of fetal malformations were established with three-dimensional ultrasonography and color Doppler scanning. Two of the women had twin gestations, and the third woman had a triplet gestation. Among the women with twin gestations, 1 donor twin had no abnormalities, and the other donor twin had a diagnosis of arthrogryposis and gastroschisis. The woman with triplets had 1 acardiac fetus; the donor fetus was anencephalic; and the third fetus had alobar holoprosencephaly. CONCLUSIONS: Complementary use of two-dimensional ultrasonography, three-dimensional ultrasonography, and color Doppler scanning improves diagnostic accuracy and the ability to evaluate the extent and severity of organ compromise in pregnancies complicated by acardiac fetuses.