The influence of leptin on placental and fetal volume measured by three-dimensional ultrasound in the second trimester.

For a couple of years mechanisms influencing placental and fetal growth and the functioning of leptin, the protein product of the ob/ob gene, have been subjects of intensive research. This study's aim was to investigate whether maternal serum leptin and amniotic fluid leptin have an influence on placental and fetal size measured by three-dimensional ultrasound in the second trimester. To determine this, 40 women with a singleton intrauterine pregnancy at the time of the amniocentesis were included in the study. Placental and fetal volume measurements were obtained and correlated to maternal serum leptin, amniotic fluid leptin, body mass index and gestational age. Multiple regression analysis identified amniotic fluid leptin as an independent negative predictor of placental and fetal volume (r = -2.29, p = 0.032 and r = -0.95, p = 0.011, respectively). In contrast, there was no correlation between maternal serum leptin and placental or fetal volume. The median leptin level in amniotic fluid (9.5 ng/ml) was significantly lower than in maternal blood (18.6 ng/ml). However, there was no significant correlation between maternal serum leptin and amniotic fluid leptin (r = 0.208, n.s.). Body mass index did not reveal any significant influences on placental or fetal volume. The relatively high level of amniotic fluid leptin and its inverse correlation on placental and fetal volume in the second trimester suggest that it possibly plays a role as an anti-placental growth hormone or feedback modulator of substrate supply to the fetus and placenta.

Reproducibility of three-dimensional ultrasound diagnosis of congenital uterine anomalies.

OBJECTIVE: To examine the reproducibility of the diagnosis of congenital uterine anomalies and the repeatability of measurements of uterine cavity dimensions using three-dimensional (3D) ultrasound. METHODS: The reproducibility of diagnosis of congenital uterine anomalies was examined by re-slicing stored 3D ultrasound volumes. Each data set was evaluated by two independent observers. Assessment of uterine morphology was performed in a standardized plane, with the interstitial portions of the Fallopian tubes used as reference points. Additionally, in 35 cases of congenital uterine anomalies the width of the uterine cavity (W), fundal distortion (F) and the length of unaffected uterine cavity (C) were measured. Intraobserver and interobserver variabilities were evaluated by each observer performing all three measurements twice. RESULTS: Eighty-three 3D ultrasound volumes were examined. Both operators classified 27 uteri as normal, 33 as arcuate, 19 as subseptate and three as unicornuate. A single case of uterine anomaly was described as arcuate uterus by one operator and subseptate by another (kappa 0.97). The intraobserver variability for each of the three measurements (W, F and C) was satisfactory with limits of agreement ranging from +/-1.43 to +/-2.51 mm. The examination of the interobserver variability showed no significant differences between the two observers (F = 0.484, P > 0.05). CONCLUSION: 3D ultrasound is a reproducible method for the diagnosis of congenital uterine anomalies and for the measurement of uterine cavity dimensions.

First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar.

OBJECTIVE: To describe first-trimester ultrasound diagnosis and management of pregnancies implanted into uterine Cesarean section scars. METHODS: All women referred for an ultrasound scan because of suspected early pregnancy complications were screened for pregnancies implanted into a previous Cesarean section scar. The management of Cesarean section scar pregnancies included transvaginal surgical evacuation, medical treatment with local injection of 25 mg methotrexate into the exocelomic cavity and expectant management. RESULTS: Eighteen Cesarean section scar pregnancies were diagnosed in a 4-year period. The prevalence in the local population was 1 : 1800 pregnancies. Surgical treatment was used in eight women and it was successful in all cases. The respective success rates of medical treatment and expectant management were 5/7 (71%) and 1/3 (33%). Five women (28%) required blood transfusion and one woman (6%) had a hysterectomy. CONCLUSIONS: Cesarean section scar pregnancies are more common than previously thought. When the diagnosis is made in the first trimester the prognosis is good and the risk of hysterectomy is relatively low.

A comparative study of the morphology of congenital uterine anomalies in women with and without a history of recurrent first trimester miscarriage.

BACKGROUND: The true impact of congenital uterine anomalies on reproductive outcomes is unknown. The aim of this study was to examine differences in the morphology of uterine anomalies found in women with and without a history of recurrent miscarriage. METHODS: A total of 509 women with a history of unexplained recurrent miscarriage and 1976 low risk women were examined for the presence of congenital uterine anomalies by three-dimensional ultrasound. The anomalies were classified according to the American Fertility Society classification. In addition, the size of fundal distortion (F) and the length of the remaining uterine cavity (C) were measured to calculate a distortion ratio (F/F+C). The findings were compared with the measurements obtained in low risk women with an incidental finding of uterine anomaly. RESULTS: In all, 121 anomalies were detected in the recurrent miscarriage group and 105 in low risk women. There was no significant difference in relative frequency of various anomalies or depth of fundal distortion between the two groups. However, with both arcuate and subseptate uteri, the length of remaining uterine cavity was significantly shorter (P < 0.01) and the distortion ratio was significantly higher (P < 0.01) in the recurrent miscarriage group. CONCLUSION: The distortion of uterine anatomy is more severe in congenital anomalies, which are found in women with a history of recurrent first trimester miscarriage.

Expectant management of early pregnancies of unknown location: a prospective evaluation of methods to predict spontaneous resolution of pregnancy.

OBJECTIVE: To assess prospectively the ability of two multiparameter diagnostic models and their individual components to predict the outcome of early pregnancies which could not be identified on transvaginal ultrasound scan. DESIGN: Prospective observational study. SETTING: Dedicated early pregnancy unit in an inner city teaching hospital. POPULATION: Women with a positive urine pregnancy test and clinical suspicion of early pregnancy complications. METHODS: A full medical history, clinical examination and transvaginal ultrasound scan were carried out at the initial visit. When the location of the pregnancy could not be ascertained by ultrasound, serum beta-human chorionic gonadotrophin (beta-hCG) and progesterone levels were measured. All women were managed expectantly until either a normal pregnancy was visualised on scan; the pregnancy resolved spontaneously or intervention was required due to a worsening of clinical symptoms or non-declining beta-hCG levels. MAIN OUTCOME MEASURES: Spontaneous resolution of pregnancy (i.e. cessation of symptoms and decline in serum beta-hCG level to < 20 iu/L) without need for any active intervention. RESULTS: Of the 104 women recruited, 72 (69%) pregnancies resolved spontaneously. Both multiparameter diagnostic models identified resolving pregnancies with positive predictive values > or = 95%. Their performances were not significantly better compared with individual progesterone levels which achieved a positive predictive value of 97% using a cutoff level of 20 nmol/L. CONCLUSION: Serum progesterone measurement alone is as accurate as more complex diagnostic models for the prediction of successful expectant management in pregnancies of unknown location.

Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening.

OBJECTIVE: To determine reproductive outcomes in women with congenital uterine anomalies detected incidentally by three-dimensional ultrasound. METHODS: We studied 1089 women with no history of infertility or recurrent miscarriage who were seen for a transvaginal ultrasound scan. They were screened for uterine abnormalities using three-dimensional ultrasound. We determined prevalence of miscarriage and preterm labor in women with normal and abnormal uterine morphology. RESULTS: We found that 983 women had a normally shaped uterine cavity, 72 an arcuate, 29 a subseptate, and five a bicornuate uterus. Women with a subseptate uterus had a significantly higher proportion of first-trimester loss (Zeta = 4.68, P <.01) compared with women with a normal uterus. Women with an arcuate uterus had a significantly greater proportion of second-trimester loss (Zeta = 5.76, P <.01) and preterm labor (Zeta = 4.1, P <.01). There were no other significant differences in pregnancy outcomes between women with normal and abnormal uterine morphology. CONCLUSION: This study shows the potential value of three-dimensional ultrasound and confirmed that women with congenital uterine anomalies were more likely to have adverse pregnancy outcomes than women with a normal uterus.

Serum CA125 at 11-14 weeks of gestation in women with morphologically normal ovaries.

In a number of pregnant women ovarian cysts are found incidentally during the routine first trimester scan. These cysts may pose diagnostic difficulties, and the measurement of serum CA125 levels can be used to aid management. In this study we measured maternal serum CA125 levels in 188 women with uncomplicated pregnancies between 11-14 weeks of gestation. All women had morphologically normal ovaries observed on ultrasound examination. The median serum CA125 levels were 23.4 U/mL (range 2.2-166.3 U/mL, 95% reference interval 5.28-70.15) and did not change significantly with gestation. We conclude that CA125 levels are increased at 11-14 weeks of gestation and cut off values which are used to assess the nature of ovarian cysts in nonpregnant women cannot be applied to pregnant women at this gestation.

The expectant management of women with early pregnancy of unknown location.

OBJECTIVE: To assess the results of expectant management in women with pregnancy of unknown location and to identify diagnostic parameters that are predictive of spontaneous pregnancy resolution. DESIGN: Prospective, observational study. SUBJECTS: Women with a positive pregnancy test and suspected early pregnancy complications who were referred for ultrasound assessment. METHODS: Women were first examined by transvaginal ultrasound to establish the location and viability of pregnancy. All women with pregnancies that could not be located on the scan had a blood sample taken to quantify the serum human chorionic gonadotropin (hCG) and progesterone levels. Management was expectant until the pregnancy was identified, the condition resolved spontaneously or an intervention was required because clinical symptoms deteriorated or hCG levels did not decline. For each woman, age, clinical symptoms (pain and bleeding), menstrual dates, past gynecological history, endometrial thickness and levels of serum hCG and progesterone were recorded. All parameters were tested by univariate analysis and then analyzed in a stepwise procedure to form a logistic regression model for predicting spontaneous resolution of pregnancy. RESULTS: A total of 1625 women were included in the study. In 135 cases (8%) the location of pregnancy was unknown. Complete data sets were obtained in 127 cases. These included 34 (27%) normal intrauterine pregnancies, 11 (9%) miscarriages and 18 (14%) ectopic pregnancies. A total of 64 (50%) pregnancies resolved spontaneously. Stepwise analysis showed that four diagnostic parameters--vaginal bleeding, endometrial thickness, serum hCG level and progesterone level--contributed significantly to the predictive power of the logistic model. With the use of this model, spontaneous pregnancy resolution could be predicted at the initial visit with a sensitivity and specificity of 92%. CONCLUSIONS: The majority of pregnancies of unknown location are abnormal: many resolve spontaneously when managed expectantly. A logistic model may be used at the initial visit to identify those cases in which the pregnancy is likely to resolve without the need for intervention.