Fetal weight estimation by 2D and 3D ultrasound: comparison of six formulas.

PURPOSE: To evaluate and compare the accuracy of different formulas to estimate fetal weight using 2D and 3D ultrasound. MATERIALS AND METHODS: We performed a prospective study on unselected singleton pregnancies. All scanned fetuses delivered within 7 days in absence of structural and chromosomal abnormalities were included. The fetal weight was calculated using the 3D Schild, Chang, Liang and 2D Hansmann, Merz and Hadlock formulas. Absolute and mean deviations of estimated fetal weight were calculated. RESULTS: Of 249 scanned fetuses 200 that fulfilled the criteria were included. Birth weights ranged between 535 and 5020 g. The highest correlation between estimated fetal and birth weight was achieved by applying Schild's equation, and the absolute percentage error was 5.6%. The corresponding values for 2D Hansmann, Merz and four-parametric Hadlock formulas were 7.5%, 7.9%, and 9.2%, respectively, while these were 13.1% and 30.7% for Liang's and Chang's 3D equations. Using the Schild formula, a deviation from birth weight below 10 % was achieved in 80 % of fetuses, with Hansmann's in 73.5% and with Merz in 72.5%, while this parameter was much lower in the remaining equations. CONCLUSION: The best option with the highest accuracy for sonographic fetal weight estimation was the 3D Schild equation followed by the 2D Hansmann and Merz formulas. Published data of the accuracy could be reproduced with the exception of the "Asian" 3D equations in our European population. The limited improvement in weight agreement using the 3D technique compared to the 2D technique may be outweighed by the time consumption.

[Early Diagnosis of a Fetal Skeletal Dysplasia Associated with Increased Nuchal Translucency with 2D and 3D Ultrasound]. / Frühe Diagnose einer fetalen Skelettdysplasie in Assoziation mit erhöhter Nackentransparenz mittels 2D- und 3D-Ultraschall.

We report a case of the prenatal diagnosis of a lethal skeletal dysplasia in a fetus presenting with increased nuchal translucency of 7.3 mm on a routine first trimester scan at 12 weeks of gestation. The karyotype was normal and there was no history of previous affected pregnancies. An abnormality of the fetal spine was first seen at 12 weeks of gestation, the malformation of the left hemithorax, where the processus transversi and the costal bones were replaced by a cystic structure, was detected at 13 weeks using a combination of two- and three-dimensional ultrasound. In order to identify correctly the underlying problem, at 16 weeks of gestation a detailed 2D and 3D ultrasound examination was performed. 3D surface images were calculated and a combination of surface reconstruction and maximum-mode for clear delineation of the fetal skeleton was used. In this way, the vertebral defects with absence of costal bones and processus transversi in the region of the left hemithorax, which were replaced by a cystic structure causing thoracic kyphoscoliosis and pulmonal hypoplasia and were associated with marked ventriculomegaly, could be clearly demonstrated. Although fetal autopsy was not carried out, the underlying abnormalities diagnosed by ultrasound suggest Jarcho-Levin syndrome as final diagnosis, which is characterized by multiple vertebral and rib malformations.

Prognostic factors in surgically treated stage ib-iib cervical carcinomas with special emphasis on the importance of tumor volume.

OBJECTIVE: The aim of the study was to analyze the importance of tumor volume as a prognostic factor for overall survival (OS) in surgically treated stage Ib-IIb cervical carcinoma. METHODS: One hundred thirteen of one hundred sixty-five patients with histopathological stage Ib-IIb cervical carcinoma (44 Ib1, 24 Ib2, 10 IIa, 35 IIb) treated by radical abdominal hysterectomy between 1989 and 1999, for whom tumor volume could be assessed, were included in this study. Of the 113 patients, 90 (79.6%) received postoperative radiotherapy. Measurement of tumor volume was performed on giant histological sections using a semiautomatic image analyzer. The prognostic significance of tumor volume was analyzed and compared with that of various clinicopathological parameters using uni- and multivariate statistics. RESULTS: The 5-year disease-free survival was 71.4%. Increasing tumor volume was associated with more frequent lymph node metastases and a significant decrease in OS (P = 0.0112). The Median tumor volume was smaller in stage IIa tumors than in stage Ib2 tumors, and histopathological stage did not correlate linearly with lymph node metastases as well as OS. Stage Ib2 tumors were associated with worse overall survival than stage IIa tumors. In univariate analysis, lymph node metastases, histopathological stage, lymph vascular space involvement, tumor volume, parametrial spread, and tumor involvement of resection margins were significant parameters for OS. In multivariate statistical analysis, only lymph node metastases and histopathological staging remained independent prognostic factors for OS. CONCLUSIONS: Tumor volume does not seem to confer additional prognostic information if histopathological stage and lymph node status are known. However, it may provide important prognostic information if lymph node status is not known or histopathological stage cannot be assessed.

Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis.

OBJECTIVE: Our purpose was to evaluate the risk of malignancy in surgically removed ovarian cysts that were characterized before the operation as unilocular according to transvaginal ultrasonography. STUDY DESIGN: This prospective analysis included 927 premenopausal women and 377 postmenopausal women operated on at 2 European university hospitals between January 1992 and December 1997. On the basis of ultrasonographic findings the cysts were characterized either as echo-free, without solid parts or papillary formations (group 1), or as having echogenic cyst content, with solid parts or papillary formations (group 2). Ultrasonographic and macroscopic appearances of the cysts were compared with histopathologic diagnosis. RESULTS: In group 1, in premenopausal women 3 of 413 cysts (0.73%) proved to be borderline or malignant, and in postmenopausal women 4 of 247 cysts (1.6%) proved to be borderline or malignant. The figures for cysts in group 2 were 11 of 514 cysts (2.1%) and 13 of 130 cysts (10.0%), respectively. It was not possible to differentiate by transvaginal ultrasonography between benign, borderline, and malignant cysts when solid parts or papillary formations were visualized. CONCLUSIONS: This study confirmed that the risk of malignancy associated with unilocular echo-free cysts (group 1) was low. Serial ultrasonographic follow-up should therefore be the standard procedure with unilocular echo-free cysts <50 mm in diameter. In cysts with a mean diameter of >50 mm, papillary formations or solid parts may be missed by transvaginal ultrasonography. The risk for malignancy in cysts containing papillary formations or solid parts (group 2) was 3 to 6 times higher than that in unilocular echo-free cysts.

Association of HELLP syndrome with autoimmune antibodies and glucose intolerance.

OBJECTIVE: HELLP syndrome is a severe form of preeclampsia, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP), whose pathogenesis is unclear. Autoimmunity is thought to play an important role. After the observation of development of type 1 diabetes in a patient with HELLP syndrome, we assumed a possible disease association based on autoimmune reactions. RESEARCH DESIGN AND METHODS: We examined 70 women with HELLP syndrome for the presence of autoimmune markers and glucose intolerance. Free thyroxine, triiodothyronine, thyroid-stimulating hormone, anti-thyroglobulin antibodies, thyroperoxidase antibodies, thyrotropin receptor antibodies, antinuclear antibodies (ANAs) and anti-DNA, islet cell antibodies, GADA, an oral glucose tolerance test, and HbA1c were determined postpartum. Patients with positive autoimmune markers or glucose intolerance were prospectively followed and repeated testing was performed. There were 60 women with a normal course of pregnancy matched for age, BMI, and number of pregnancies, which served as a control group. RESULTS: From the HELLP patients, 22 (31%) compared with only 6 (10%) control subjects had autoimmune antibodies (P < 0.01). There were 16 HELLP patients (23%) who exhibited only 1 kind of autoantibody (5 ANA, 9 thyroid antibodies, and 2 GADA), whereas in 6 HELLP patients (8.5%) 2 different antibodies were found. In all but 4 patients of the study group, these antibodies disappeared during 3 +/- 1.5 years of follow-up. Glucose intolerance was detected in 22 (31%) of the HELLP patients, 17 of them had impaired glucose tolerance (IGT), and 5 had diabetes, whereas only 4 subjects (6.5%) with IGT at postpartum were found in the control group (P < 0.01). During the follow-up, 2 HELLP patients were still diabetic and another 2 HELLP patients (1 GADA positive) had IGT versus 1 control subject. CONCLUSIONS: Our data give evidence that HELLP syndrome is associated with various autoimmune antibodies and glucose intolerance. Because glucose intolerance and/or autoimmune markers persisted during long-term follow-up in 6 patients with HELLP syndrome versus 1 in the control group, it may become advisable to reexamine patients with HELLP syndrome for detection of diabetes and autoimmune disorders.

Combined transvaginal B-mode and color Doppler sonography for differential diagnosis of ovarian tumors: results of a multivariate logistic regression analysis.

OBJECTIVE: Transvaginal sonography is limited in its ability to assess early stage cancers of the ovary as well as in distinguishing benign processes. As a method for characterization of tumor vascularization, color-coded Doppler sonography may be able to improve the diagnostic accuracy of B-mode sonography. METHODS: Preoperative transvaginal B-mode and Doppler sonography was performed in 63 patients with unclear adnexal lesions prior to operation. Using multiple logistic regression, the independent variables of each procedure were selected and combined to yield a diagnostic flow chart. The diagnostic accuracy of this decision matrix was tested on 257 patients with unclear adnexal tumors. RESULTS: In the 63 adnexal tumors investigated, the diagnostic impact of isolated sonomorphological assessment with evidence of a "solid area" was 78%. Using Doppler sonography, the best discrimination was achieved by displaying the vascular distribution ("central vascularization"). Combining these independent significant variables of the two procedures raised the diagnostic accuracy to 90% (sensitivity 86%, specificity 93%). The validity achieved by this combination was confirmed by the independent application of this method to the 257 adnexal tumors with unclear malignancy status (diagnostic accuracy 93%, sensitivity 92%, specificity 94%). CONCLUSIONS: The combination of sonography and Doppler sonography achieves high and reproducible diagnostic accuracy in preoperative malignancy status assessment of adnexal tumors. The additional use of Doppler sonography can thus provide significant aid both for differential diagnostics of adnexal lesions and for the choice of surgical route in the case of an existing indication for operative therapy.

[Chronic pelvic pain--a still too little appreciated disease picture]. / Der chronische Unterbauchschmerz--ein immer noch zu wenig verstandenes Krankheitsbild.

Chronic pelvic pain often means for patients as well as for their physicians a dilemma concerning diagnosis and therapy: the common medical approach does often not fit for essential therapeutic needs, which should include somatic examination as well as psychosomatic (psychotherapeutic) concepts for escaping from further somatic chronification typical for CPP-patients. The study performed during 1995-98 with 220 patients of the Department of Obstetrics & Gynecology in collaboration with the Psychosomatic Department in the St. Johann's Hospital of Salzburg has shown results about laparoscopic/pelviscopic and psychosomatic interventions in patients with chronic pelvic pain. Evidence-based somatic medicine is not able to explain the discrepancy between pathomorphology and intensity of pain in CPP-patients. The specific dilemma in treating CPP-patients could be characterized as the following: Somatisation is often the one and only symptom presented by CPP-patients to gynecologists. It is the physician's task to stay in a relationship with the patient and treat her symptomatically on somatic symptoms. The relationship will provide the chance to introduce a psychosomatic approach and engage psychotherapeutic work on the reluctance of accepting a psychogenesis of CPP. Gynecologists lack psychosomatic knowledge and concepts for treatment and therefore often contribute to the chronification of CPP in patients approached only in somatic terms.

Three-dimensional power Doppler sonography: imaging and quantifying blood flow and vascularization.

OBJECTIVES: To assess the feasibility of imaging low-velocity blood flow in adnexal masses by transvaginal three-dimensional power Doppler sonography, to analyze three-dimensional power Doppler sonography data sets with a new computer-assisted method and to test the reproducibility of the technique. METHODS: A commercially available 5-MHz Combison 530 ultrasound system was used to perform three-dimensional power Doppler sonography transvaginally. A cube (= volume of interest) was defined enclosing the vessels of the cyst and the Cartesian characteristics were stored on a hard disk. This cube was analyzed using specially designed software. Five indices representing vascularization (the vascularization index (VI) or blood flow (the flow index (FI)) or both (the vascularization-flow index (VFI)) were calculated. The intraobserver repeatability of cube definition and scan repetition was assessed using Hartley's test for homogeneous variances. Interobserver agreement was assessed by the Pearson correlation coefficient. RESULTS: Imaging of vessels with low-velocity blood flow by three-dimensional power Doppler sonography and cube definition was possible in all adnexal massed studied. In some cases even induced non-vascular flow related to endometriosis was detected. The calculated F value with intraobserver repeated Cartesian file-saving ranged from 0 to 18.8, with intraobserver scan repetition from 4.74 to 24.8 for VI, FI 1, FI 2 and VFI 1; for VFI 2 the calculated F value was 64. The interobserver correlation coefficient ranged between 0.83 and 0.92 for VI, FI 1, FI 2 and VFI 1; for VFI 2 the correlation coefficient was less than 0.75. CONCLUSION: Vessels with low-velocity blood flow can be imaged using three-dimensional power Doppler sonography. Induced non-vascular flow was detected in endometriotic cyst fluid. Three-dimensional power Doppler sonography combined with the cube method gave reproducible information for all indices except VFI 2. These indices might prove to be a new predictor in all fields of neoangiogenesis. The clinical relevance remains to be determined.

Primary neuroendocrine differentiated mucinous adenocarcinoma of the vulva: case report and review of the literature.

Only a few cases on mucinous adenocarcinomas of the vulva have been reported. In this study, we present a case of a 75-year-old woman with a tumor in the left major labium. Because biopsy had shown formations of squamous cell carcinoma, radical vulvectomy with bilateral inguinal and femoral lymph node dissection were performed. At that time, histology was interpreted as small-cell, anaplastic carcinoma, with focal epidermoid differentiation. Postoperative radiation therapy was performed. Sixteen months after surgery, the patient presented with bilateral breast carcinomas. Histology showed a scirrhous carcinoma of the left and a medullary carcinoma of the right breast, but no lymph node metastases. Histochemical and immunohistochemical re-examination of the vulvar carcinoma now revealed a mucinous adenocarcinoma with neuroendocrine differentiation. The tumor expressed neuroendocrine markers such as chromogranin A and protein gene-product (PGP) 9.5, as well as peptides of the vasoactive intestinal polypeptide (VIP) family, and serotonin. Histochemical silver stains demonstrated Grimelius argyrophilia and Masson argentaffinity. Because of positive estrogen and progesterone receptor status of both breast cancers, postoperative Tamoxifen therapy was performed. The patient is still alive four years after vulvectomy.

Oral Anticoagulation in patients with gynecological cancer and radiotherapy: a retrospective analysis of 132 patients.

Venous thromboembolism is reported to be a leading cause of death and morbidity after surgery and during radiotherapy for gynecologic malignancies. This study was performed to evaluate the incidence of thromboembolism as well as the benefit and risk of its prophylaxis with coumarin in this patient selection. Between 1988 and 1992, 132 patients with gynecologic malignancies underwent postoperative or primary radiotherapy (53 patients without prior surgery). Heparin (5000 IU t.i.d., s.c.) was administered perioperatively, and coumarin (International normalized ratio = INR target 2.0-3.5) was given to all patients during radiotherapy. Daily visits for inspection of the legs and for possible symptoms and signs of thromboembolism were performed. In case of diagnostic doubts, impedance plethysmography and phlebography for diagnosis of venous thrombosis, and lung scanning for diagnosis of pulmonary embolism were performed. Among the 132 patients, 9 (6.8%) developed deep venous thrombosis of the renal vein and of the inferior caval vein occurred in one additional patient. Pulmonary embolism was detected in 5 patients (3.8%). All thromboembolic events were without lethal outcome. Bleeding episodes were observed in 7 patients (5.3%); in two of them a major bleeding led to cessation of coumarin administration. The prophylaxis of thromboembolism in gynecologic oncology with coumarin seems to be effective, safe and inexpensive.

Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection.

Recently, various conservative regimens for the treatment of cervical pregnancy have been introduced to preserve fertility in young women, with methotrexate being one of the most widely used drugs. The success of conservative treatment depends on early preoperative diagnosis. We report three cases of first trimester cervical pregnancy, successfully treated by curettage to evacuate the conceptus, followed by local prostaglandin instillation to prevent severe haemorrhage. In one patient, intra-amniotic instillation of hyperosmolar glucose was necessary to terminate fetal cardiac activity. beta-Human chorionic gonadotrophin returned to normal within 3 weeks in one patient and within 7 weeks in another, both of whom became pregnant again within 1 year, resulting in term deliveries. The third patient was lost to follow-up after 1 week. The advantage of prostaglandin and curettage is the absence of major side-effects to the mother or the fetus of a subsequent pregnancy. The management strategies used in the treatment of cervical pregnancies and the results obtained since the introduction of methotrexate in 1989 are discussed in the context of previously published literature. The incidence of subsequent pregnancies among women treated medically versus women treated surgically is reported.

Pregnancy after ovarian stimulation and intrauterine insemination in a woman with cavernous macrohemangioma of the liver. A case report.

BACKGROUND: There are only a few reports on cavernous hepatic hemangiomas after hormonal substitution or during pregnancy. So far, there have been no publications on ovulation stimulation in such patients. CASE: We report on a 31-year-old, asymptomatic, healthy woman with an incidental ultrasound finding of a cavernous macrohemangioma (diameter, 14 cm) of the liver. For treatment of primary infertility, clomiphene citrate therapy had been administered repeatedly in the past. Because these treatments were not successful and andrologic subfertility existed, homologous intrauterine insemination was recommended. The first treatment cycle with clomiphene citrate, human chorionic gonadotropin and subsequent intrauterine insemination was successful. During pregnancy, 2.5-cm growth of the liver hemangioma and a smaller, second lesion occurred but remained asymptomatic. Primary cesarean section was performed at 37 weeks' gestation to prevent rupture or hemorrhage of the hepatic hemangioma. Macrohemangiomas of the liver are associated with the risk of rupture and severe hemorrhage due to pressure during pregnancy and delivery. CONCLUSION: During ovulation stimulation, pregnancy and the immediately postpartum period, there was no change in this benign tumor.

An evaluation of the Filshie clip for postpartum sterilization in Austria.

Voluntary sterilization is a popular method of family size limitation. Among other techniques for surgical induction of female sterility, the application of various kinds of clips to the Fallopian tubes has been introduced. The Filshie clips consist of rubber-lined titanium and their use for interval sterilization has been repeatedly published. So far, there are only a few reports regarding the use of Filshie clips during the postpartum period, when tubes are edematous and more friable. Therefore, 300 women voluntarily requesting postpartum surgical sterilization for the purpose of family size limitation were enrolled into a prospective trial. Within 72 h of delivery, 282 women were sterilized under general anesthesia using a subumbilical minilaparotomy approach and Filshie clip application. Of these women, 251 were available for follow-up examination at 6 weeks, 240 at 6 months, 234 at 12 months, and 209 at 24 months after the sterilization procedure. Complication rates were low, and there were no pregnancies during the follow-up period. These results indicate that the application of Filshie clips is a safe and efficacious method of surgical female sterilization in the postpartum period.

Localization and distribution of vasoactive neuropeptides in the human placenta.

Neuropeptides play an important role in the regional regulation of blood flow and hormone secretion. Few studies report the presence of peptides in the human placenta. Our experiment evaluates neuropeptides in the human placenta using immunocytochemical techniques. Representative tissue sections from full-term placentae were fixed immediately after delivery and processed into paraffin sections or frozen. They were treated with multiple immunofluorescence, streptavidin-biotin-peroxidase complex and immunogold-silver staining techniques in combination with well-established monoclonal and polyclonal antibodies, using appropriate absorption controls to ensure the validity of the staining. Vasoactive intestinal polypeptide (VIP), calcitonin gene-related peptide (CGRP), neuropeptide tyrosine (NPY), galanin, somatostatin, met-enkephaline, helodermin and substance P-like immunoreactivities were demonstrated within decidual cells. Endothelin-1 was found in both trophoblasts and endothelial cells. Peptide immunoreactivities in the human placenta especially at the decidual interface between mother and fetus supports a role for the diffuse neuroendocrine system (DNES) in the regulation of placental blood flow critical for fetal growth and development.