Diagnostic Concordance and Discrepancies in 3D TVUS and MRI of Congenital Uterine Malformations across the ASRM 2016, ASRM 2021, ESHRE/ESGE 2016, and CUME 2018.

BACKGROUND: The classification of Congenital Uterine Malformations (CONUTA) relies on coronal imaging of the uterus using 3D TVUS and MRI. In everyday practice, radiologists and gynaecologists often struggle to confidently categorize CONUTA due to varying classification systems and the lack of worldwide consensus. OBJECTIVES: The aim of this study was to evaluate the diagnostic concordance and discrepancies between two imaging techniques within the context of the ASRM, ESHRE/ESGE, and CUME systems. METHODS: Ninety-four patients suspected of having CONUTA underwent evaluation: 67 underwent 3D TVUS, 53 had MRI scans, and 34 were examined using both imaging techniques. An initial cross-listing table of ASRM, ESHRE/ESGE, and CUME was created, and a flowchart schema was used to define the type of congenital uterine anomaly for each system The prevalence of anomalies in each system was calculated, and Fleiss' Kappa was used to assess and determine the level of agreement. RESULTS: Class VI arcuate uterus was the most common form in ASRM 2016 and 2021, while the partially septate uterus predominated in the CUME 2018 and ESHRE/ESGE 2016 classification systems. CONCLUSION: There is no discordance between classification systems for all fusion defects and complete septate type of absorption defects. In the ESHRE/ESGE system, nearly half of the abnormal uteruses were categorized as partially septate. However, the CUME system proved less effective in distinguishing between normal and arcuate uteruses.

When a balloon catheter or tenaculum is required for cervical traction during hysterosalpingography.

The aim of this study was to define the actual rate of the traction needed and the balloon catheter or tenaculum requirement for hysterosalpingography (HSG) examinations, and to investigate the correlation between pain scores with the type of traction, operator, parity or the type of infertility. 788 patients undergoing HSG participated in the trial. The HSG examinations were completed in 58% of the patients (458) without any traction. Traction was needed in 42% of patients, those with the balloon catheter in 26.9%, and those with the tenaculum only at 15%. Patients with balloon catheter traction had similar pain scores to those using tenaculum traction. The pain scores changed according to the operator. HSG examinations should be performed step-by-step and the need for traction evaluated during the procedure.IMPACT STATEMENTWhat is already known on this subject? HSG is a technique to evaluate fallopian tube patency and other potential intrauterine pathology in infertile women.What do the results of this study add? Traction was not needed in more than half of the HSG examinations. The pain due to the balloon catheter and tenaculum is similar.What the implications are of these findings for clinical practice and/or further research? HSG examinations should be performed step-by-step by checking the need for traction. Traction with the balloon catheter prevents the uterine spasm, infection and bleeding complications during or after the HSG.

Reference ranges for flow velocities and the indices of the ductus venosus in low-risk pregnancies

Objective: Ductus venosus blood flow velocity measurements are mandatory in many clinical indications. The evaluation of the flow is performed either by comparing results with general reference tables or by qualitative assessment of the "a" flow, in regard to reversed or absent flow in the spectral waveforms. The aim was to develop normal reference ranges in low-risk pregnancies in our population. Material and Methods: Measurements of flow velocities (S, v, D, a) and indices (pulsatility index for veins, peak velocity index for veins, a/S, S/a) were performed by a single experienced specialist in 1279 singleton, uncomplicated pregnancies between 11 and 40 weeks gestation. The absolute flow velocities (S, v, D, a, VmPeak) and indices were obtained from spectral waveforms using the equipment producer's inbuilt system. The still images were stored in the picture archiving and communication system. Results: The predicted reference ranges of the ductus venosus blood flow velocities according to the gestational age are shown in tables and graphics. Predicted reference curves based on the 5th and 95th percentiles according to gestational week were plotted and are given in tables and figures. Conclusion: Normal reference ranges for absolute flow velocities and indices were calculated from a population of uncomplicated pregnancies attending a tertiary care center. The measurements were made from both the classic patterns of the waveforms and also considered variants of the spectral waveforms, which have recently been reported, for the first time in the medical literature.

Noninvasive determination of the fetal cardiac interatrial pressure gradients by Doppler ultrasonography: preliminary results.

OBJECTIVE: In 2000, Johnson et al. measured the atrial pressures puncturing the atria invasively in 19 fetuses that will be terminated. In this study, it is aimed to define the fetal cardiac interatrial pressure gradient noninvasively. The pressure gradients were calculated using the ductus venosus (DV) and pulmonary vein (PV) blood flow velocities and Bernoulli equation for flowing fluids. METHODS: "S," "a," and the time-averaged maximum velocities in both veins of 246 fetuses were used in the simplified Bernoulli equation; Δp=4 (VDV2-VPV2). Additionally, the umbilical vein maximum velocity is measured in order to calculate ducto-umbilical pressure gradient. RESULTS: The average interatrial pressure gradient was biggest in the ventricular systole and the least gradient was in the atrial systole of a cardiac cycle. The pressure gradient changes throughout the second and the third trimester have four periods with two increases and two decreases. CONCLUSIONS: The interatrial and ducto-umbilical pressure gradients can be measured noninvasively in order to follow the hemodynamic of the fetal circulatory system.

Spontaneous unilateral quadruplet tubal ectopic pregnancy.

Ectopic pregnancy (EP) is defined as the implantation of the fertilized ovum outside the uterine cavity. Importantly, the implantation site is tubal in 95% of the cases. Multiple EPs are extremely rare. We present a case of a 25-year-old patient, gravida 2 para 1, with amenorrhea accompanied by the complaints of vaginal bleeding and abdominal pain. She was admitted to the emergency department. Trans-vaginal ultrasound revealed a left ovarian anechoic cyst of 30 mm and four embryos in the right tube with positive cardiac activities. An emergency laparotomy found the rupture of tubal pregnancy on the right side, which ultimately led to hemo-peritoneum. Therefore, we performed right salpingectomy. This is the first well-documented case of a patient with spontaneous unilateral quadruplet tubal EP.

Quantitative measurements of celeration times and indexes in the ductus venosus spectral Doppler waveforms in normal fetuses.

Background Ductus venosus spectral waveform has two peaks and two nadirs: S, v, D and a velocities, which are obtained after to some extent of accelerations or decelerations throughout a cardiac cycle. It is aimed to define the actual celeration times and indexes and their relationships with the fetal heart rate (FHR). Methods The acceleration times and indexes were measured in 357 patients between 11 and 40 weeks of pregnancies with low risk. Results The FHR has a gradual increasing negative correlation from time for S to time for a with each of the cardiac times of phases according to the statistical analysis (correlations were minus 190, 269, 407 and 541 for S, v, D and a phase times, respectively). The acceleration aS and the deceleration Da have positive correlations with the FHR; however, the deceleration Sv and the acceleration vD do not correlate with the FHR. Conclusion The deceleration Da time and index are the main components for determining the FHR in fetuses. Therefore, the atrial contraction is the strongest component for determining the FHR in fetuses.

Normal variants of ductus venosus spectral Doppler flow patterns in normal pregnancies.

Objectives: Ductus venosus (DV) Doppler examinations in pregnancy have a widespread use for several important indications and play a crucial role in order to determine the fetal well-being. DV is usually visualized by the color Doppler mapping. We observed the instantaneous spectral flow type changes in pulsed Doppler examinations in spite of performing with the correct technique published by several authors. The variability of the pattern makes the sonographer/physician to be unsure for the correct placements of the sample gate despite fulfilling the all the criteria required for the vessel sampling. It is aimed in the study to define variations of the normal DV spectral flow types in the duration of the pulsed Doppler examinations instead of in a single cardiac cycle in normal pregnancies.Methods: This prospective study was conducted between January 2016 and February 2017. Wide-band Doppler technique was used for color mapping of the DV. Normal spectral Doppler waveforms in pregnancies are classified as types. When DV spectral flow pattern was not in the standard type, the spectral flow patterns were obtained from not only the umbilical artery and/or middle cerebral artery. Maximum and minimum blood flow velocities in the umbilical vein are measured. All Doppler examinations are performed by a single experienced specialist (CG), who had been certificated for DV flow and Doppler examinations by the Fetal Medicine Foundation.Results: A total of seven types of flow patterns were recorded during the study period and DV flow patterns were divided into two main categories as classic flow pattern and the other patterns. The classic pattern was observed in 160 (99.4%) cases in the first trimester, 495 (94.1%) cases in the second trimester and 206 (60.8%) cases in the third trimester.Conclusions: We think that the fetal circulation is complicated more than estimated. There might be some endocrine agents released in the instantaneous physiologic reactions and changing the venous return abruptly or due to decreasing of the cardiac output directed to the placenta after 34 weeks influence the volume of the circulating blood in the fetus and so thereby the flow velocities instantaneously. The spectral waveform recognition approach is not reliable to identify if the DV spectral Doppler pattern is not the classic (standard) type and the DV should be visualized by wide-band color Doppler techniques particularly in the third trimester for the pulsed Doppler examinations. Studies are needed to evaluate the normal spectral variants of the flows correlated with the physiological compensatory mechanisms.

The rectal vaginal opacification with water and the antiperistaltic agent in magnetic resonance scanning of the intestinal endometriosis.

The diagnosis of deep intestinal endometriosis is mandatory to plan treatment and for follow-up; however, there is no consensus worldwide in the use of rectal/ vaginal opacification and anti-peristaltic agents for magnetic resonance imaging (MRI) scanning, being defined as an option for the examination. The transvaginal ultrasound images of previous MRI with the standard protocol, and recent MRI in our institution with rectal/vaginal opacification with water and the anti-peristaltic agent are presented in four cases for comparison, respectively. The technique in our institution seems to be more effective than routine pelvic MRI scans in the intestinal endometriosis.

The types of connections between the portal sinus and main portal vein in foetuses / Tipos de conexiones entre el seno portal y la vena porta principal en fetos

In the prenatal period, the three types of connections between the portal sinus and main portal vein have been published in the literature: T, X and H-shaped. The T type is the most frequent in the literature, and the aim of our study is to define the percentage of the connection types during the prenatal period in our population. In this prospective study, 237 women between 20 and 38 weeks of pregnancy without a foetal anomaly or pregnancy-related complications were included, and the precordial veins of the foetuses were examined using a wide-band color Doppler technique. The types of connections were determined by two specialists according to the shape of the colour coded vessels in Doppler examinations. The criteria of Czubalski & Aleksandrowicz (2000) were used. All of the connection types in patients were confirmed using video clips and were stored in the picture archiving and communication system. In 237 patients, the types of connection were determined by the first specialist as 189 foetuses (79.7 %) with the X-shaped or side-to-side connection, 16 foetuses (6.8 %) with the T-shaped or end-to-side type and 32 foetuses (13.5 %) with the H-shaped or parallel-coursed vessels connected with a short segment. The most common types of connections between the portal sinus and main portal vein in foetuses are X shaped or side-to-side, which is contrary to previous studies.

En el período prenatal, se han publicado en la literatura los tres tipos de conexiones entre el seno portal y la vena porta principal: en forma de T, X y H. El tipo T es el más frecuente, y el objetivo de nuestro estudio fue definir el porcentaje de tipos de conexión durante el período prenatal en nuestra población. En este estudio prospectivo, se incluyeron 237 mujeres entre 20 y 38 semanas de embarazo, sin anomalías fetales o complicaciones relacionadas con el embarazo, y se examinaron las venas precordiales de los fetos utilizando una técnica Doppler de banda ancha. Los tipos de conexiones fueron determinados por dos especialistas según la forma de los vasos codificados por color en los exámenes Doppler. Se utilizaron los criterios del estudio de Czubalski & Aleksandrowicz. Todos los tipos de conexión en los pacientes se confirmaron mediante videoclips y se almacenaron en el sistema de comunicación y en archivo de imágenes. En 237 pacientes, el primer especialista determinó en 189 fetos (79,7 %) la conexión en forma de X o de lado a lado; en 16 fetos (6,8 %) la forma de T o Tipo de extremo a lado; y en 32 fetos (13,5 %) los vasos en forma de H o paralelos, conectados con un segmento corto. Los tipos más comunes de conexiones entre el seno portal y la vena porta principal en los fetos son en forma de X o de lado a lado, lo que es contrario a estudios anteriores.

Natural course of hepatic focal nodular hyperplasia from childhood to adulthood and review of the literature.

Focal nodular hyperplasia (FNH) is the second most common benign tumor of the liver and constitutes 4% of all primary hepatic tumors in pediatric population. Imaging characteristics of FNH in adults are well known, but those in children have rarely been reported. Here we describe the natural course of a giant hepatic FNH, which was followed up from childhood to adulthood for 12 years using computed tomography (CT) imaging and liver enzyme tests (LET). Differences in CT imaging characteristics were demonstrated. Changes were found in the FNH size in CT images and they were correlated with LET findings. The regression of FNH in our case was compared with the findings in the literature. Hepatic capsular retraction was observed in a benign focal liver lesion in the medical literature for the first time.

The relationship between the umbilicus and the aortic bifurcation in Turkish women: implications for laparoscopic entry.

PURPOSE: We aimed to determine the location and vertical distance of the umbilicus relative to the aortic bifurcation using computed tomography (CT), and assess their relationship with BMI among Turkish women and their implications for laparoscopic entry. METHODS: This cross-sectional study included a total of 209 women undergoing abdominopelvic CT; the vertical distance between the aortic bifurcation and the umbilicus was evaluated on coronal sections. The distance between the skin and the parietal peritoneum was measured from the umbilical pit to the peritoneum, and the distance between the skin and the aorta was measured from the umbilical pit to the surface of the aortic bifurcation. The measurements were performed along the sagittal plane. The age, height, and weight of the patients were recorded. For comparison, women were divided into three groups according to BMI. RESULTS: The aortic bifurcation was located above (cephalic to) the umbilicus in 30 patients in the non-obese group (48.4%), 54 patients in the overweight group (55.7%), and 34 patients (68%) in the obese group. The mean distances between the umbilicus and the parietal peritoneum were 15.1 ± 6.4, 19 ± 5.5, 27.2 ± 10.8 mm, respectively, in the non-obese group, overweight group, and obese group. The mean distances between the umbilicus and the aorta were 85.8 ± 26.3, 110 ± 2.9, 132.1 ± 26.7 mm, respectively, in the non-obese group, overweight group, and obese group. CONCLUSIONS: The location of the umbilicus relative to the aortic bifurcation can vary according to age, BMI and ethnicity or nationality of patients; therefore, a surgeon should not stick to a particular angle of insertion during laparoscopic entry. It is better for surgeons to know their unique patient population.

How to get ductus venosus flow velocity waveforms between 11 and 14 weeks: Candle Flame and Falling Drop Signs.

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Successful Treatment of Uterine Arteriovenous Malformation due to Uterine Trauma.

Uterine arteriovenous malformation (AVM) is defined as abnormal and nonfunctional connections between the uterine arteries and veins. Although the patients typically present with vaginal bleeding, some patients may experience life-threatening massive bleeding in some circumstances. The treatment of choice depends on the symptoms, age, desire for future fertility, and localization and size of the lesion; however, embolization of the uterine artery is the first choice in symptomatic AVM in patients at reproductive age with expectations of future fertility. We report a case of acquired AVM (after D/C) with an extensive lesion, which was successfully treated with bilateral uterine artery embolization (UAE).

Hepatic cystic echinococcosis: percutaneous treatment as an outpatient procedure.

OBJECTIVE: To demonstrate utility and safety of the puncture aspiration injection and reaspiration (PAIR) technique for outpatients. METHODS: Percutaneous treatment with US guidance was applied to 33 patients for 44 cysts. Patients treated with the PAIR technique, were outpatients. PAIR and catheterization technique were evaluated for efficacy and safety of procedure and complication rates. RESULTS: Thirty-five of 44 cysts were treated with the PAIR and 9 of 44 were treated with the catheterization technique. The success rate of the cysts Gharbi type 1 (CE1) and type 2 (CE3a) treated with the PAIR technique was 100%. In the follow up of 9 cysts treated with the catheterization technique, 2 of them (22%) developed cyst infection and 1 (11%) developed a biliary fistula. CONCLUSIONS: The PAIR technique was found to be an effective and safe approach in order to treat Gharbi type 1 and type 2 cysts percutaneously for outpatients. It has a very low complication rate in comparison with the catheterization technique. So every effort should be made to finish the treatment with PAIR technique.

Gray scale histogram analysis of solid breast lesions with ultrasonography: can lesion echogenicity ratio be used to differentiate the malignancy?

PURPOSE: The aim of this study was to investigate the diagnostic performance of lesion echogenicity ratios (LER) calculated by image histogram analysis for distinction of malignant and benign breast lesions. MATERIAL AND METHODS: A total of 55 patients (mean age, 44 years) with 59 lesions were included. Ultrasound images were analyzed retrospectively. RESULTS: Mean LER values in benign and malignant lesions were 1.63±0.41 and 3.1±0.87, respectively. The difference between LER values of benign and malignant breast lesions was statistically significant (P<.001). CONCLUSION: LER can be used as an adjunct ultrasound parameter to differentiate between benign and malignant breast lesions.

Pleomorphic adenoma originates from inferior nasal turbinate causing epiphora.

Pleomorphic adenoma is the most common benign tumor of the salivary glands. A 62-year-old female patient presented with epiphora and was suffering from breathing difficulties. With the diagnostic nasal endoscopy, a mass, originating from right inferior nasal turbinate and filling the entire nasal cavity, was seen. Originating from the inferior nasal turbinate is a very rare entity. Paranasal sinus computed tomography and magnetic resonance images revealed a mass that fills and expands the right nasal cavity. Mass was hypoechoic in B-mode ultrasonography and hypovascular in color Doppler ultrasonography, and rate of tissue stiffness was high in sonoelastography. These were helpful for the diagnosis.

MR imaging of ectopic pregnancy with an emphasis on unusual implantation sites.

Ectopic pregnancy (EP) is a life-threatening condition and remains the leading cause of death in the first trimester of pregnancy, although the mortality rate has significantly decreased over the past few decades because of earlier diagnoses and great improvements in treatment. EP is most commonly located in the ampullary portion of the fallopian tube and rarely in unusual sites such as the interstitium, cervix, cesarean scar, anomalous rudimentary horn of the uterus and peritoneal abdominal cavity. MRI may confirm or give additional information to ultrasonography, which is the most user-dependent imaging modality. Magnetic resonance imaging can accurately localize the site of abnormal implantation. It could be helpful for EP patient treatment by distinguishing the ruptured and unruptured cases before methotrexate treatment. MRI is quite sensitive to blood and can identify the hemorrhage phase.

Pseudoaneurysm of the genicular artery after wound closure using a skin stapler in a child.

A 9-year-old child with a left humerus fracture also had minor skin cuts on the right knee, which were closed with a skin stapler. After 1 week, a medial superior genicular artery pseudoaneurysm developed, which was treated by ultrasound-guided compression. This case illustrates a unique complication of the use of a skin stapler device.

Ultrasound guided percutaneous treatment and follow-up of Baker's cyst in knee osteoarthritis.

OBJECTIVE: Purpose of this study is to assess sonographic changes and clinical response in different subgroups of Baker's cyst patients with knee osteoarthritis after a single session of ultrasound-guided percutaneous aspiration and corticosteroid injection. MATERIALS AND METHODS: Thirty-two knee osteoarthritis patients (46-85 years, mean 58.97±9.88) with symptomatic Baker's cyst diagnosed at ultrasonography were included in the study. To determine the grade of the symptoms, Visual Analogue Scale was applied. The patients were grouped in two, as simple (n=24) and complex (n=8) Baker's cyst. Thirty-two ultrasound-guided cyst aspirations concomitant 1 ml betamethasone injection (24 simple, 8 complex subgroups) were performed. Patients were followed clinically as well as via ultrasonography for 6 months after procedures. RESULTS: A significant decrease in volume of the Baker's cysts after percutaneous treatment was accompanied by a significant clinical improvement. Moreover, the volume reduction of Baker's cyst after the treatment was significantly correlated with the clinical improvement (Pearson correlation coefficient=0.542, p=0.001). All 6 Baker's cysts relapsed at ultrasonography were complex type. Furthermore, a comparison of patients with simple Baker's cysts and those with complex Baker's cysts demonstrated no significant change in Visual Analogue Scale scores between two groups (p=0.061, Mann-Whitney U). No complications (minor or major) occurred secondary to percutaneous treatment. CONCLUSION: Baker's cysts can be grouped as simple and complex groups via ultrasonography prior to the treatment. Cyst aspiration with ultrasound-guided corticosteroid injection yields clinical improvement and cyst volume reduction in all subgroups of patients with Baker's cyst secondary to knee osteoarthritis.

Diagnostics of peripherally located intrathoracic lipoma.

In the differential diagnosis of lipomas, fibromatous hamartoma, liposarcoma, fibrolipoma and teratoma may be mentioned as fat-containing lesions of peripheral localization. However, these lesions are different from lipomas in that they contain soft tissue components and are not homogeneous. Furthermore, they are much larger than lipomas, are infiltrative and their CT density is greater than -50 HU. Though it is emphsized that up to the present time surgery has been the gold standard method in the recognition and treatment, considering the risks of surgical procedures, we are of the opinion that diagnosis can be established and the follow-up can be managed with advanced radiological methods and that there is no necessity for invasive interventions especially in asymptomatic patients.