Screening de primer trimestre de preeclampsia tardía en gestantes de bajo riesgo en un centro de bajo volumen obstétrico: validación externa de un modelo predictivo / First trimester screening of late-onset preeclampsia in a low risk and low volume obstetrical setting: external validation of a predictive model

Fundamento: La validación externa de un modelo predictivo de predicción de preeclampsia tardía en un centro de bajo volumen obstétrico en gestantes de bajo riesgo obstétrico. Métodos: Estudio prospectivo de 174 gestaciones únicas de 11+0 a 13+6 semanas de gestación en la Clínica Universidad de Navarra desde septiembre 2011 a marzo de 2013, que fue considerado como una cohorte de validación de un modelo descrito anteriormente para preeclampsia tardía en el hospital Clínic de Barcelona). Resultados: Un total de 7 (4%) mujeres desarrollaron PE tardía. En la cohorte de validación el área bajo la curva del modelo fue de 0,69 (IC del 95% 0,45 a 0,93). Las tasas de detección para un 5, 10 y 15% de tasas de falsos positivos fueron 21,9, 31,4 y 38,6%. Al comparar las áreas bajo la curva de la cohorte de validación con la cohorte de la construcción, no se encontraron diferencias estadísticamente significativas (p = 0,68). Conclusión: La combinación de la historia clínica materna, la proteína placentaria A-asociada al embarazo y presión arterial media es moderadamente útil para predecir preeclampsia tardía en gestantes de bajo riesgo y en un centro de bajo volumen obstétrico. El modelo predictivo del hospital Clinic de Barcelona es una herramienta válida para predecir preeclampsia tardía en este entorno (AU)

Background: The external validation of predictive model of late preeclampsia in a low volume and low risk obstetrical setting. Methods: A cohort was created of 174 singleton pregnancies of 11+0-13+6 gestational weeks at Clinica Universidad Navarra from September 2011 to March 2013, which was considered as a validation cohort of a previously described model for late PE (Hospital Clinic, Barcelona). Results: A total of 7 (4%) women developed late PE. In the validation cohort the area under the curve of the model was 0.69 (95% CI 0.45-0.93). Detection rates for a 5, 10 and 15% of false positive rates were 21.9, 31.4% and 38.6% respectively. When comparing the areas under the curve of the validation cohort with the construction cohort, no statistical differences were found (p=0.68). Conclusion: The combination of maternal history, pregnancy associated plasma protein-A and mean arterial pressure is moderately useful to predict preeclampsia in a low risk and low volume obstetrical setting. The predictive model of the Clinic Hospital of Barcelona is a valid tool in predicting late preeclampsia in this setting (AU)

Performance of three-dimensional power Doppler angiography as third-step assessment in differential diagnosis of adnexal masses.

OBJECTIVE: To evaluate the contribution of three-dimensional (3D) power Doppler angiography (3D-PDA) to the differential diagnosis of adnexal masses. METHODS: This was a prospective study in women diagnosed with a persistent adnexal mass and subsequently scheduled for surgery in a tertiary university hospital. All women were evaluated by transvaginal/transrectal ultrasound according to a predetermined three-step protocol, with transabdominal ultrasound being performed in some cases. First, morphological evaluation of the mass was performed using gray-scale 'pattern recognition' (first step). Lesions diagnosed as having a benign pattern were considered as being at low risk of malignancy whereas tumors with solid components, ascites and/or signs of carcinomatosis were considered as being at high risk of malignancy. In both cases no further test was performed and a decision regarding clinical management, either for follow-up or surgery, was taken. Tumors with solid components but without signs of ascites or carcinomatosis were considered as being at intermediate risk of malignancy. These lesions were assessed by two-dimensional (2D) PDA to evaluate tumor vascularity (color score) (second step). Solid tumors with a color score of 1 or 2 were considered as benign and no further test was performed, while tumors with a color score of 2, 3 or 4 within solid components or a color score of 3 or 4 in the case of a solid tumor were considered as malignant. The latter group underwent 3D-PDA assessment (third step). Vascularization index (VI) was calculated in a 1-mL sphere of the most vascularized area of the tumor. When a VI ≥ 24.015% was found, the tumor was considered as malignant. All masses were removed surgically and definitive histological diagnosis was used as the gold standard. Sensitivity and specificity for each strategy were calculated and compared. In the case of bilateral tumors, only the more suspicious one was used for analysis. RESULTS: A total of 367 adnexal masses diagnosed in 367 women (mean age, 46.5 (range, 18-80) years) were evaluated during the study period. Of these, 86 masses were malignant and 281 were benign. The sensitivity and specificity for each assessment strategy were as follows: one-step, 97.7% and 78.6%; two-step, 94.2% and 97.9% (P < 0.001 for specificity when compared with that of one-step); three-step, 90.7% and 98.9% (not statistically significant when compared with that of two-step). CONCLUSIONS: The addition of 2D-PDA in the differential diagnosis of an adnexal mass significantly increases specificity while sensitivity remains high; however performing subsequent 3D-PDA does not provide additional information or further improve diagnostic performance subsequent to 2D-PDA.

[First trimester screening of late-onset preeclampsia in a low risk and low volume obstetrical setting: external validation of a predictive model]. / Screening de primer trimestre de preeclampsia tardía en gestantes de bajo riesgo en un centro de bajo volumen obstétrico: validación externa de un modelo predictivo

BACKGROUND: The external validation of predictive model of late preeclampsia in a low volume and low risk obstetrical setting. METHODS: A cohort was created of 174 singleton pregnancies of 11+0-13+6 gestational weeks at Clinica Universidad Navarra from September 2011 to March 2013, which was considered as a validation cohort of a previously described model for late PE (Hospital Clinic, Barcelona). RESULTS: A total of 7 (4%) women developed late PE. In the validation cohort the area under the curve of the model was 0.69 (95% CI 0.45-0.93). Detection rates for a 5, 10 and 15% of false positive rates were 21.9, 31.4% and 38.6% respec-tively. When comparing the areas under the curve of the validation cohort with the construction cohort, no statistical differences were found (p=0.68). CONCLUSION: The combination of maternal history, pregnancy associated plasma protein-A and mean arterial pressure is moderately useful to predict preeclampsia in a low risk and low volume obstetrical setting. The predictive model of the Clinic Hospital of Barcelona is a valid tool in predicting late preeclampsia in this setting.

Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system.

OBJECTIVES: To prospectively evaluate an ultrasound-based scoring system as a method for triaging asymptomatic women presenting with an adnexal mass for surgical treatment. METHODS: Two hundred and four adnexal masses in 189 asymptomatic women undergoing elective surgical treatment at our institution were included in this prospective study. Patients were evaluated by transvaginal power Doppler ultrasound imaging before surgery. Patients were classified as low risk or high risk for malignancy according to an ultrasound-based scoring system. Women with a low risk for malignancy were scheduled for laparoscopy and patients with a high risk for malignancy were scheduled for laparotomy. However, patients classified as low risk by the ultrasound scoring system, but with a tumor size >or= 10 cm or clinical suspicion of pelvic adhesions, were instead considered to be at intermediate risk and were scheduled for laparotomy. Some patients classified as high risk were scheduled for an operative laparoscopy by an expert in gynecological oncology. RESULTS: One hundred and thirty-four (65.7%) masses were considered to be low risk and were treated by a laparoscopically guided procedure. All these tumors were benign. Forty-seven (23%) masses were classified as high risk, of which 39 tumors were malignant and eight benign. Twenty-three (11.3%) tumors were considered to be intermediate risk and were scheduled for primary laparotomy. In this group, 21 (91.3%) tumors proved to be benign and two (8.7%) were malignant. CONCLUSIONS: Ultrasound-based triage of asymptomatic women diagnosed with a persistent adnexal mass is effective for selecting the surgical approach.

Ecografía tridimensional en la evaluación de los tumores de ovario / Three-dimensional ultrasound in ovarian tumors

El diagnóstico diferencial de los tumores de ovario sigue siendo unreto importante para el ginecólogo. Un diagnóstico preciso es desuma importancia para una correcta planificación de la conducta aseguir. Dicho diagnóstico diferencial se basa en los datos clínicos dela paciente, la sintomatología que presenta, la exploración física y,fundamentalmente, en la ecografía bidimensional. Recientemente seha incorporado una nueva tecnología: la ecografía tridimensional.Esta técnica permite una mejor evaluación morfológica y un análisismás detallado de la vascularización tumoral. En el presente artículose revisan las indicaciones que puede tener la ecografía tridimensionalen la evaluación de los tumores de ovario

The differential diagnosis of ovarian tumors still represents a clinicalchallenge. A precise diagnosis is essential to select the best managementoption for the patients. Such a diagnosis is based on clinical data,physical examination and image techniques, especially two-dimensionalultrasound. Recently, three-dimensional ultrasound has becomeavailable. This technique allows a more detailed morphologic andvascular analysis of ovarian tumors. In this article current indicationsfor three-dimensional ultrasound in ovarian tumors will be review

Assessment of a new logistic model in the preoperative evaluation of adnexal masses.

OBJECTIVE: To assess a new logistic regression model developed to predict malignancy in adnexal masses. METHODS: In the first part of this study, we developed a logistic model by applying logistic regression analysis in a series of 268 adnexal masses (203 benign and 65 malignant lesions) in 248 patients (mean age, 43.6 years; SD, 14.2 years) evaluated and treated at our institution. Eleven parameters were entered in the logistic regression analysis in a forward stepwise way. In the second part of the study, we evaluated the model's diagnostic performance in a further set of 135 adnexal masses (103 benign and 32 malignant tumors) in 129 patients (mean age, 44.4 years; SD, 14.6 years). This diagnostic performance was compared with that of age, tumor volume, Sassone's and Ferrazzi's B-mode ultrasonographic morphologic scoring systems, serum cancer antigen 125 level, and the tumor's lowest resistive index. Comparison was done by calculating the area under the receiver operating characteristic curve. RESULTS: In logistic analysis, only menopausal status, the presence of papillary projections, the logarithm of the cancer antigen 125 value, tumor blood flow location, and the lowest resistive index were retained in the model. The model had the best area under the curve (0.97), significantly higher than patient age (area under the curve, 0.78; P = .001), tumor volume (area under the curve, 0.68; P < .0001), cancer antigen 125 (area under the curve, 0.88; P = .008), lowest resistive index (area under the curve, 0.85; P = .011), Ferrazzi's scoring system (area under the curve, 0.89; P = .01), and maximal peak systolic velocity (area under the curve, 0.71; P< .0001). Comparison with Sassone's scoring system (area under the curve, 0.91) did not reach statistical significance, but a clear trend was found (P = .116). CONCLUSIONS: The model had the best diagnostic performance for discriminating between benign and malignant adnexal masses. A clinical prospective evaluation is needed to confirm its actual value.

In vivo validation of the time domain velocity measurement technique of blood flow in human fetuses.

Time domain ultrasonography is an alternative to Doppler analysis of blood flow direction and velocity. The time domain technique uses timing information between successive echo pulses to measure flow velocities directly through a color display map. This study was undertaken to validate this technique for measuring peak systolic velocity compared to the pulsed-wave Doppler method in human fetuses. Twenty normally developing fetuses were included in the study. The fetal abdominal aorta and the umbilical artery were studied in 12 and eight cases, respectively. We first estimated flow velocity using time domain ultrasonography and immediately after pulsed Doppler was used. The intraclass correlation coefficient was used to assess the agreement between measurements. A close correlation was found (intraclass correlation coefficient = 0.96). Our results show that time domain ultrasonography seems to be a valid technique for imaging fetal vessels and for measuring blood flow velocity.

The role of transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma.

OBJECTIVE: To assess the diagnostic accuracy of transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler in differentiating ovarian endometriomas from other nonendometriotic masses. DESIGN: Prospective study with pathological confirmation of sonographic diagnosis. SETTING: Department of Obstetrics and Gynecology at a university hospital. PATIENT(S): A series of 78 consecutive patients diagnosed as having an adnexal mass and scheduled for surgery, between January 1995 and March 1996. INTERVENTION(S): Transvaginal ultrasonography and color velocity imaging and pulsed Doppler was performed before surgery in all patients. A total of 82 masses were diagnosed (four patients had bilateral masses). CA-125 plasma levels were measured in all patients. Ultrasound diagnosis was compared with definitive histopathological diagnosis. MAIN OUTCOME MEASURE(S): The presence of a round-shaped homogeneous cyst with low-level echoes was considered as sonographic diagnosis of ovarian endometrioma. The typical vascular pattern from endometrioma was considered as "pericystic flow at the level of the ovarian hilius." The sensitivity, specificity, and positive and negative predictive values were calculated for transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler. RESULT(S): Twenty-seven (32.9%) of the 82 masses were proven to be ovarian endometriomas. Morphological assessment diagnosed correctly 24 (88.9%) of 27 endometriomas (false-positive rate: 9%). Typical flow pattern was present in 90.5% of endometriomas (false-positive rate: 80%). CA-125 levels in patients with endometrioma (45.6 +/- 6.3 U/mL; mean +/- SEM) were significantly higher than in patients with nonendometriotic masses (26.5 +/- 5.5 U/mL). The sensitivity, specificity, and positive and negative predictive values of transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler were 88.9%, 91%, 84.2%, and 94.5%, and 76.2%, 88.9%, 82.4%, and 82.4%, respectively. For CA-125 levels, using a cutoff > or = 35 U/mL, these figures were 79.3%, 84.6%, 79.3%, and 84.6%, respectively. CONCLUSION(S): The use of color velocity imaging and pulsed Doppler does not improve the diagnostic accuracy of transvaginal ultrasonography alone in the diagnosis of ovarian endometrioma.

[Surgical options in the treatment of polycystic ovary syndrome]. / Opción quirúrgica en el tratamiento del síndrome del ovario poliquístico.

Since it was defined, SOP has been related to surgery. Before clomifero was introduced, ovarian wedge resection was the only way to stimulate ovulation and gestation in women with this syndrome. Surgical techniques were derelict in favour of less aggressive medical treatments. However, surgery has reduced its side effects due to the incorporation of laparoscopic techniques and other advances. Because of this fact, surgery is being reintroduced in the treatment of polycystic ovarian disease.

Corpus luteum blood flow in abnormal early pregnancy.

Thirty-eight consecutive patients with the diagnosis of abnormal early singleton pregnancy were studied with transvaginal color velocity imaging and pulsed Doppler ultrasonography to assess corpus luteum blood flow. Mean gestational age was 8.5 weeks (range, 6 to 12 weeks). Patients' mean age was 30.9 years (range, 24 to 43 years). There were 19 (50%) threatened abortions, 13 (34.2%) missed abortions, and six (15.8%) anembryonic pregnancies. Blood flow impedance in the corpus luteum was estimated by calculating the resistive index. The results of this study group were compared with those obtained in a series of 85 normal singleton early pregnancies used as controls. Overall, detection of corpus luteum blood flow was 78.9% in study group and 76.4% in control group (P = 0.51). Mean resistive index +/- standard deviation in the control group was 0.50 +/- 0.10; the corresponding values in threatened abortion, anembryonic pregnancy, and missed abortion were 0.52 +/- 0.10, 0.42 +/- 0.06, and 0.57 +/- 0.05, respectively. No statistical. differences in mean resistive index were found among threatened abortion and anembryonic pregnancy with respect to control group. A higher mean resistive index was observed in missed abortion than in control group (P < 0.01). In conclusion, our data show that luteal vascularization might be decreased in missed abortion but not in threatened abortion and anembryonic pregnancy.

Assessment of luteal blood flow in normal early pregnancy.

A cross-sectional study was performed in 85 low-risk singleton first trimester pregnancies to assess corpus luteum blood flow during this period. Gestational age, established by measuring crown-rump length, ranged from 6 to 12 weeks. All cases were studied by transvaginal color velocity imaging and pulsed Doppler ultrasonography. After corpus luteum blood flow was identified by color velocity imaging, the resistive index and pulsatility index were calculated to assess vascular resistance. Overall, detection rate of corpus luteum blood flow was 75.2%. No statistical differences were found in mean resistive index and pulsatility index among gestational weeks studied. Linear regression analysis showed that nonsignificant changes in resistive and pulsatility indices occur during the first weeks of normal early pregnancy (R2 = 0.0059 for resistive index, R2 = 0.0008 for pulsatility index). In conclusion, luteal blood flow is constant during normal early pregnancy.

Comparative study of transvaginal ultrasonography and hysteroscopy in postmenopausal bleeding.

Twenty-eight women with postmenopausal bleeding were retrospectively studied to assess the accuracy of transvaginal sonography (TVS) and hysteroscopy for diagnosing endometrial pathology. TVS was performed in all patients. Considering a cutoff value of < or = 5 mm as normal, TVS showed normal findings in 14 patients (50%) and suggested endometrial abnormalities in other 14 (50%). Hysteroscopy could be performed in 24 patients (85.7%). In 17 (70.2%) cases no abnormality was found; an endometrial polyp was suspected in 6 (25%) and endometrial hyperplasia in 1 (4.8%) patient. All patients underwent endometrial biopsy or dilatation and curettage for histopathologic study. Sensitivity, specificity, and positive and negative predictive values for TVS and hysteroscopy were 100, 60.8, 35.7, and 100% and 100, 89.4, 71.4, and 100%, respectively. In our experience, both methods were highly sensitive, but hysteroscopy was more specific than TVS.

The reliability of transvaginal ultrasonography to detect retained tissue after spontaneous first-trimester abortion, clinically thought to be complete.

In order to assess the reliability of transvaginal ultrasonography for the detection of trophoblastic tissue retained after spontaneous first-trimester abortion and clinically thought to be complete, the clinical, sonographic and pathological data of 33 women were retrospectively analyzed. The patients' mean age was 34 years (range 24-48). The mean gestational age at presentation of symptoms was 8 weeks (range 5.1-11.1). Transvaginal sonography showed that in 18 cases retained tissue was absent, and that in 15 patients, retained trophoblastic tissue was suspected. Pathological reports (following dilatation and curettage) confirmed the absence of retained tissue in 17 cases and demonstrated its presence in 16 patients (13 in whom retained tissue was suspected by sonography and three in whom retained tissue was not suspected). Sensitivity, specificity, positive predictive value and negative predictive value in our series were 81%, 94%, 93% and 83%, respectively for the detection of retained trophoblastic tissue. We conclude that transvaginal ultrasonography is a reliable method to detect the presence of retained trophoblastic tissue following spontaneous first-trimester abortion, clinically thought to be complete.

Granular cell tumor of vulva on episiotomy scar.

The granular cell tumor (GCT) is a rare neoplasm derived from Schwann cells and is considered to be a benign tumor. The vulvar region is one of the common sites for these lesions. Vulvar occurrence of GCT constitutes about 7% of cases. To our knowledge, this is the first case of granular cell tumor of the vulva on an episiotomy scar. GCT should be considered in the differential diagnosis of a benign tumor of the vulva and reactive granular cell lesions.

[Development of utero-chorionic vascular resistance in early pregnancy]. / Evolución de las resistencias vasculares uterocoriales en la gestación precoz.

The physiologic evolution of the utero-chorionic vascular resistances during the first trimester of pregnancy is described. With the use of pulsed Doppler, 25 normal pregnancies were followed weekly, performing 288 scans between the 6th and the 12th weeks of pregnancy. The detection of the FVW was done at the level of the uterine and retro-chorionic vessels. There is a progressive decrease of the vascular resistances to flow, with significant differences (p less than 0.001) between the values before and after the 9th week. The physiologic implications and its possible application to the study of the gestational pathology are commented.

[Rokitansky-Kuster-Hauser-Mayer syndrome. Psychological aspects in current technics in the creation of a neovagina apropos of 2 cases]. / Síndrome de Rokitansky-Kuster-Hauser-Mayer. Aspectos psicológicos y técnicas actuales en la creación de neovagina a propósito de dos casos.

A review is made of the actual status of the Rokitansky-Hauser-Kuster-Mayer Syndrome in the following aspects: clinic, diagnostic and actual techniques in the construction of a neovagina. An special remark is made on the importance of the psychologyc and psychosocial aspects in the management, diagnostic and treatment of this patients. Two cases are presented.