Ultrasonography Archives - Revista Brasileira de Ginecologia e Obstetrícia
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2008;30(10):524-530
DOI 10.1590/S0100-72032008001000008
Detection of endometrial cancer in asymptomatic women has not proved to be a cost-effective procedure. Studies on this matter have shown that ultrasonography as a detecting method presents a high ratio of false-positive results and a negligible effect on the mortality rate. This way, the assistance strategy should be based on earlier diagnosis and appropriate treatment in women who present postmenopause bleeding. Being a non-invasive method, largely available and with high sensitivity, the transvaginal ultrasonography should be the initial investigative method. Though there is no consensus about the echographical endometrial thickness, above which the investigation is to proceed, diagnostic hysteroscopy should be the next step. The risk of neoplasia in endometriums with thickness under or equal to 3 mm is low enough to limit hysteroscopy to exceptional cases. Biopsy must be a necessary part of the hysteroscopy, because the diagnosis, made on visual basis, alone may lead to false results. Outpatient hysteroscopy can be done in more than 95% of the cases, even in menopausal women, rarely with severe complications. The adoption of "non-contact" examination techniques and the progressive reduction of the hysteroscope diameter have decreased the discomfort associated to small outpatient procedures.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2008;30(10):524-530
DOI 10.1590/S0100-72032008001000008
Detection of endometrial cancer in asymptomatic women has not proved to be a cost-effective procedure. Studies on this matter have shown that ultrasonography as a detecting method presents a high ratio of false-positive results and a negligible effect on the mortality rate. This way, the assistance strategy should be based on earlier diagnosis and appropriate treatment in women who present postmenopause bleeding. Being a non-invasive method, largely available and with high sensitivity, the transvaginal ultrasonography should be the initial investigative method. Though there is no consensus about the echographical endometrial thickness, above which the investigation is to proceed, diagnostic hysteroscopy should be the next step. The risk of neoplasia in endometriums with thickness under or equal to 3 mm is low enough to limit hysteroscopy to exceptional cases. Biopsy must be a necessary part of the hysteroscopy, because the diagnosis, made on visual basis, alone may lead to false results. Outpatient hysteroscopy can be done in more than 95% of the cases, even in menopausal women, rarely with severe complications. The adoption of "non-contact" examination techniques and the progressive reduction of the hysteroscope diameter have decreased the discomfort associated to small outpatient procedures.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2008;30(1):5-11
DOI 10.1590/S0100-72032008000100002
PURPOSE: to study the value of Doppler velocimetry of the ductus venosus, between the 11th and 14th weeks of pregnancy, associated to the nuchal translucency thickness measurement, in the detection of adverse fetal outcome. METHODS: a transversal and prospective study in which a total of 1,268 fetuses were studied consecutively. In 56 cases, a cytogenetic study was performed on material obtained from a biopsy of the chorionic villus and, in 1,181 cases, the postnatal phenotype was used as a basis for the result. In addition to the routine ultrasonographic examination, all the fetuses were submitted to measurement of the nuchal translucency thickness and to Doppler velocimetry of the ductus venosus. Aiming at prevalence and accuracy indices, sensitivity, specificity, positive predictive value, negative predictive value, probability of false-positive, probability of false-negative, reason of positive probability and reason of negative probability were calculated and analyzed. RESULTS: from the total of 1,268 fetuses, 1,183 cases were selected for analysis. From this number, 1,170 fetuses were normal (98.9%) and 13 fetuses presented adverse outcome at birth (1.1%), including fetal death (trisomy 21 and 22) in two cases; genetic syndrome (Nooman) in one case; two cases of polymalformed fetuses; cardiopathy in three cases; and other structural defects in five cases. The prevalence of the modified ductus venosus (wave A zero/reverse) in the studied population was of 14 cases (1.2%), with a false-positive rate of 0.7%. CONCLUSIONS: there is a significant correlation between the alteration of the ductus venosus Doppler velocimetry and the thickness of the nuchal translucency as an ultrasonographic marker for the first trimester of gestation, in the detection of adverse fetal outcome, especially serious malformations. The ductus venosus was able to diminish the false-positive result in comparison to the isolated use of the nuchal translucency thickness, improving considerably the positive predictive value of the test.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2008;30(1):5-11
DOI 10.1590/S0100-72032008000100002
PURPOSE: to study the value of Doppler velocimetry of the ductus venosus, between the 11th and 14th weeks of pregnancy, associated to the nuchal translucency thickness measurement, in the detection of adverse fetal outcome. METHODS: a transversal and prospective study in which a total of 1,268 fetuses were studied consecutively. In 56 cases, a cytogenetic study was performed on material obtained from a biopsy of the chorionic villus and, in 1,181 cases, the postnatal phenotype was used as a basis for the result. In addition to the routine ultrasonographic examination, all the fetuses were submitted to measurement of the nuchal translucency thickness and to Doppler velocimetry of the ductus venosus. Aiming at prevalence and accuracy indices, sensitivity, specificity, positive predictive value, negative predictive value, probability of false-positive, probability of false-negative, reason of positive probability and reason of negative probability were calculated and analyzed. RESULTS: from the total of 1,268 fetuses, 1,183 cases were selected for analysis. From this number, 1,170 fetuses were normal (98.9%) and 13 fetuses presented adverse outcome at birth (1.1%), including fetal death (trisomy 21 and 22) in two cases; genetic syndrome (Nooman) in one case; two cases of polymalformed fetuses; cardiopathy in three cases; and other structural defects in five cases. The prevalence of the modified ductus venosus (wave A zero/reverse) in the studied population was of 14 cases (1.2%), with a false-positive rate of 0.7%. CONCLUSIONS: there is a significant correlation between the alteration of the ductus venosus Doppler velocimetry and the thickness of the nuchal translucency as an ultrasonographic marker for the first trimester of gestation, in the detection of adverse fetal outcome, especially serious malformations. The ductus venosus was able to diminish the false-positive result in comparison to the isolated use of the nuchal translucency thickness, improving considerably the positive predictive value of the test.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2007;29(12):647-653
DOI 10.1590/S0100-72032007001200008
Screening for major chromosomal abnormalities can be provided in the first trimester of pregnancy. Screening by a combination of fetal nuchal translucency and maternal serum free human chorionic gonadotropin and pregnancy-associated plasma protein-A can identify 90% of fetuses with trisomy 21 and other major chromosomal abnormalities for a false-positive rate of 5%. This is superior to the 30% detection rate achieved by maternal age and 65% by second-trimester maternal serum biochemistry. A further improvement in the effectiveness of first-trimester screening is likely to be achieved by a risk-orientated two-stage approach. In this approach, the patients are subdivided into a high-risk group, requiring invasive testing; a low-risk group, which can be reassured that an abnormality is unlikely, and an intermediate-risk group (risk of 1 in 101 to 1 in 1000), in which further assessment is performed by first-trimester ultrasound examination (for presence/absence of the nasal bone or presence/absence of tricuspid regurgitation or normal/abnormal Doppler velocity waveform in the ductus venosus), and chorionic villus sampling is performed if their adjusted risk becomes 1 in 100 or more. Those performing first-trimester scans should be appropriately trained and their results subjected to external quality assurance. This process was well established by the Fetal Medical Foundation several years ago and is widely accepted internationally.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2007;29(12):647-653
DOI 10.1590/S0100-72032007001200008
Screening for major chromosomal abnormalities can be provided in the first trimester of pregnancy. Screening by a combination of fetal nuchal translucency and maternal serum free human chorionic gonadotropin and pregnancy-associated plasma protein-A can identify 90% of fetuses with trisomy 21 and other major chromosomal abnormalities for a false-positive rate of 5%. This is superior to the 30% detection rate achieved by maternal age and 65% by second-trimester maternal serum biochemistry. A further improvement in the effectiveness of first-trimester screening is likely to be achieved by a risk-orientated two-stage approach. In this approach, the patients are subdivided into a high-risk group, requiring invasive testing; a low-risk group, which can be reassured that an abnormality is unlikely, and an intermediate-risk group (risk of 1 in 101 to 1 in 1000), in which further assessment is performed by first-trimester ultrasound examination (for presence/absence of the nasal bone or presence/absence of tricuspid regurgitation or normal/abnormal Doppler velocity waveform in the ductus venosus), and chorionic villus sampling is performed if their adjusted risk becomes 1 in 100 or more. Those performing first-trimester scans should be appropriately trained and their results subjected to external quality assurance. This process was well established by the Fetal Medical Foundation several years ago and is widely accepted internationally.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2008;30(3):142-148
DOI 10.1590/S0100-72032008005000004
PURPOSE: to compare the intra and interobserver reproducibility of the total thickness measurement of the inferior uterine segment (IUS), through the abdominal route, and of the muscle layer measurement, through the vaginal route, using bi and tridimensional ultrasonography. METHODS: the IUS thickness measurement of 30 women, between the 36th and 39th weeks of gestation with previous caesarean section, done by two observers, was studied. Abdominal ultrasonography with the patient in both supine and lithotomy position was performed. In the sagittal section, the IUS was identified and four bidimensional images and two tridimensional blocks of the total thickness were collected through the abdominal route, and the same for the muscle layer, through the vaginal route. Tridimensional acquisitions were manipulated in the multiplanar mode. The time was measured with a chronometer. Reproducibility was evaluated by the computation of the absolute difference between measurements, the ratio of differences smaller than 1 mm, the intraclass coefficient (ICC), and the Bland and Altman's concordance limits. RESULTS: the average bidimensional measurement of IUS thickness was 7.4 mm through the abdominal and 2.7 mm through the vaginal route, and the tridimensional measurement was 6.9 mm through the abdominal and 5.1 mm through the vaginal route. Intra- and interobserver reproducibility of vaginal versus abdominal route: smaller absolute difference (0.2-0.4 mm versus 0.8-1.5 mm), greater ratio of differences (85.8-97.8% versus 48.7-72,8%), with p<0,0001, higher ICC (0.8-0.9 versus 0.6-0.8) and lower concordance limits (-0.9 to 1.5 versus -3.8 to 4 mm) for the vaginal route. Tri versus bidimensional ultrasonography: lower absolute difference (0.2-1.4 versus 0.4-1.5 mm), higher ratio of differences (57.7-97.8% versus 48.7-91.7%) with p>0.05[A1] and similar lower concordance limits (-38 to 3.4 versus -3.6 to 4 mm) for tridimensional ultrasonography and ICC (0.6-0.9 versus 0.7-0.9). CONCLUSIONS: from the above, we came to the conclusion that the measurement of the IUS muscle layer, through the vaginal route using tridimensional ultrasonography is more reproducible. Nevertheless, our results do not indicate that this measurement shows any clinical evidence to predict uterine tear, as that was not the aim of this study. The only work that has correlated the UIS thickness with risk of uterine tear, without interfering in the obstetrician behavior or anticipating delivery, was done by bidimensional abdominal measurements of the total thickness.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2008;30(3):142-148
DOI 10.1590/S0100-72032008005000004
PURPOSE: to compare the intra and interobserver reproducibility of the total thickness measurement of the inferior uterine segment (IUS), through the abdominal route, and of the muscle layer measurement, through the vaginal route, using bi and tridimensional ultrasonography. METHODS: the IUS thickness measurement of 30 women, between the 36th and 39th weeks of gestation with previous caesarean section, done by two observers, was studied. Abdominal ultrasonography with the patient in both supine and lithotomy position was performed. In the sagittal section, the IUS was identified and four bidimensional images and two tridimensional blocks of the total thickness were collected through the abdominal route, and the same for the muscle layer, through the vaginal route. Tridimensional acquisitions were manipulated in the multiplanar mode. The time was measured with a chronometer. Reproducibility was evaluated by the computation of the absolute difference between measurements, the ratio of differences smaller than 1 mm, the intraclass coefficient (ICC), and the Bland and Altman's concordance limits. RESULTS: the average bidimensional measurement of IUS thickness was 7.4 mm through the abdominal and 2.7 mm through the vaginal route, and the tridimensional measurement was 6.9 mm through the abdominal and 5.1 mm through the vaginal route. Intra- and interobserver reproducibility of vaginal versus abdominal route: smaller absolute difference (0.2-0.4 mm versus 0.8-1.5 mm), greater ratio of differences (85.8-97.8% versus 48.7-72,8%), with p<0,0001, higher ICC (0.8-0.9 versus 0.6-0.8) and lower concordance limits (-0.9 to 1.5 versus -3.8 to 4 mm) for the vaginal route. Tri versus bidimensional ultrasonography: lower absolute difference (0.2-1.4 versus 0.4-1.5 mm), higher ratio of differences (57.7-97.8% versus 48.7-91.7%) with p>0.05[A1] and similar lower concordance limits (-38 to 3.4 versus -3.6 to 4 mm) for tridimensional ultrasonography and ICC (0.6-0.9 versus 0.7-0.9). CONCLUSIONS: from the above, we came to the conclusion that the measurement of the IUS muscle layer, through the vaginal route using tridimensional ultrasonography is more reproducible. Nevertheless, our results do not indicate that this measurement shows any clinical evidence to predict uterine tear, as that was not the aim of this study. The only work that has correlated the UIS thickness with risk of uterine tear, without interfering in the obstetrician behavior or anticipating delivery, was done by bidimensional abdominal measurements of the total thickness.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2007;29(11):588-592
DOI 10.1590/S0100-72032007001100007
This report describes an unusual case of spontaneous pregnancy in a patient with Müllerian anomaly. The patient was a 34-years old, white, nulligravida, with regular menstrual cycles, and suspected uterine septum observed during a routine ultrasonographic examination. The gynecological examination revealed a complete longitudinal vaginal septum and two uterine cervices. Three-dimensional pelvic ultrasonography showed cervix duplication, uterine septum from isthmus to endometrial cavity and absence of uterine body division, compatible with complete uterine septum and true dual cervices. She returned after one month and reported unprotected sexual intercourse and delayed menstrual period. She was pregnant, had a good pregnancy evolution, and delivered a healthy term baby girl, by cesarean section, at 37 weeks of pregnancy. This report describes a case of normal-term pregnancy in a patient with a rare anomaly (vaginal septum and two cervices) who became spontaneously pregnant without treatment.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2007;29(11):588-592
DOI 10.1590/S0100-72032007001100007
This report describes an unusual case of spontaneous pregnancy in a patient with Müllerian anomaly. The patient was a 34-years old, white, nulligravida, with regular menstrual cycles, and suspected uterine septum observed during a routine ultrasonographic examination. The gynecological examination revealed a complete longitudinal vaginal septum and two uterine cervices. Three-dimensional pelvic ultrasonography showed cervix duplication, uterine septum from isthmus to endometrial cavity and absence of uterine body division, compatible with complete uterine septum and true dual cervices. She returned after one month and reported unprotected sexual intercourse and delayed menstrual period. She was pregnant, had a good pregnancy evolution, and delivered a healthy term baby girl, by cesarean section, at 37 weeks of pregnancy. This report describes a case of normal-term pregnancy in a patient with a rare anomaly (vaginal septum and two cervices) who became spontaneously pregnant without treatment.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2007;29(7):352-357
DOI 10.1590/S0100-72032007000700005
PURPOSE: to analyze the pattern of fetal breathing movements (FBM) in diabetic pregnant women in the third trimester of pregnancy. METHODS: sixteen pregestational diabetic and 16 nondiabetic (control group) pregnant subjects were included fulfilling the following criteria: singleton, between 36-40 weeks of gestation, absence of other maternal diseases and absence of fetal anomalies. The fetal biophysical profile (FBP) was performed to evaluate the following parameters: fetal heart rate, FBM, fetal body movements, fetal tone and amniotic fluid index. The FBM was evaluated for 30 minutes, period when the examination was integrally recorded in VHS video for posterior analysis of the number of FBM episodes, the duration of each episode and the fetal breathing movements index (BMI). The BMI was calculated by the formula: (interval of time with FBM/total time of observation) x 100. At the beginning and in the end of the FBP maternal glucose levels were checked. The results were analyzed by the Mann-Whitney U-test and the Fisher exact test, adopting a level of significance of 5%. RESULTS: the glucose levels demonstrated significantly superior average in the diabetic group (113.3±35.3 g/dL) in relation to the normal group (78.2±14.8 g/dL, p<0.001). The average of the amniotic fluid index was higher in the group of the diabetic cases (15.5±6.4 cm) when compared with controls (10.6±2.0 cm; p=0.01). The average of the number of FBM episodes was superior in the diabetic ones (22.6±4.4) in relation to controls (14.8±2.3; p<0.0001). The average of the BMI in the diabetic patients (54.6±14.8%) was significantly higher than that in the control group (30.5±7.4%, p<0.0001). CONCLUSIONS: the elevated blood glucose levels can be associated with a different pattern in the FBM of diabetic mothers. The use of this parameter of the FBP, in the obstetric practice, must be considered with concern in diabetic pregnancies.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2007;29(7):352-357
DOI 10.1590/S0100-72032007000700005
PURPOSE: to analyze the pattern of fetal breathing movements (FBM) in diabetic pregnant women in the third trimester of pregnancy. METHODS: sixteen pregestational diabetic and 16 nondiabetic (control group) pregnant subjects were included fulfilling the following criteria: singleton, between 36-40 weeks of gestation, absence of other maternal diseases and absence of fetal anomalies. The fetal biophysical profile (FBP) was performed to evaluate the following parameters: fetal heart rate, FBM, fetal body movements, fetal tone and amniotic fluid index. The FBM was evaluated for 30 minutes, period when the examination was integrally recorded in VHS video for posterior analysis of the number of FBM episodes, the duration of each episode and the fetal breathing movements index (BMI). The BMI was calculated by the formula: (interval of time with FBM/total time of observation) x 100. At the beginning and in the end of the FBP maternal glucose levels were checked. The results were analyzed by the Mann-Whitney U-test and the Fisher exact test, adopting a level of significance of 5%. RESULTS: the glucose levels demonstrated significantly superior average in the diabetic group (113.3±35.3 g/dL) in relation to the normal group (78.2±14.8 g/dL, p<0.001). The average of the amniotic fluid index was higher in the group of the diabetic cases (15.5±6.4 cm) when compared with controls (10.6±2.0 cm; p=0.01). The average of the number of FBM episodes was superior in the diabetic ones (22.6±4.4) in relation to controls (14.8±2.3; p<0.0001). The average of the BMI in the diabetic patients (54.6±14.8%) was significantly higher than that in the control group (30.5±7.4%, p<0.0001). CONCLUSIONS: the elevated blood glucose levels can be associated with a different pattern in the FBM of diabetic mothers. The use of this parameter of the FBP, in the obstetric practice, must be considered with concern in diabetic pregnancies.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 1998;20(2):111-113
DOI 10.1590/S0100-72031998000200009
The acardius syndrome is a rare complication of monozygotic twin pregnancies, occurring once in 35.000 births. The outcome is invariably fatal for the acardiac twin and for 50-75% of the normal twins. We report a case of partial (pseudo)acardia in twin pregnancy. The diagnosis was made using ultrasonography, fetal echocardiography and confirmed after delivery.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 1998;20(2):111-113
DOI 10.1590/S0100-72031998000200009
The acardius syndrome is a rare complication of monozygotic twin pregnancies, occurring once in 35.000 births. The outcome is invariably fatal for the acardiac twin and for 50-75% of the normal twins. We report a case of partial (pseudo)acardia in twin pregnancy. The diagnosis was made using ultrasonography, fetal echocardiography and confirmed after delivery.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 1998;20(5):237-243
DOI 10.1590/S0100-72031998000500002
We analyze prospectively the existence of a relationship between the mother's glycemic control, in the first half of pregnancy, and the occurrence of abnormal fetal cardiac abnormalities, in pregnant women with diabetes mellitus. In 127 pregnant women, the level of glycosylated hemoglobin was determined on the first visit during prenatal care. Nine patients had type I diabetes, 77 type II and 41 gestational diabetes mellitus (GDM). All mothers were submitted to detailed fetal echocardiography, during the 28th ± 4.127 week of gestation. In 31 (24.4%) of the 127 fetuses cardiac anomalies were detected. In 10 (7.87%) an isolated cardiac anomaly was identified. Mean HbA1c in the group of pregnant women without cardiac anomalies (5.64%) was statistically different from the group with anomalies (10.14%) (p<0.0001). The receiver-operator characteristic, representing the balance between sensitivity (92.83%) and specificity (98.92%) in the diagnosis of structural cardiac abnormalities, showed a cut-off point at the 7.5% HbA1c level. In nine of ten fetuses with structural cardiac anomalies, the maternal level of HbA1c was higher than 7.5%. The difference between means of the groups with and without myocardial hypertrophy diagnosed as isolated anomaly (MCHP) was not statistically significant, when considering both type II diabetes and GDM subgroups. In conclusion, levels of HbA1c higher than 7.5% were associated with most cases of echocardiographycally diagnosed structural cardiac anomalies. On the other hand, this test was not useful to discriminate conceptus with MCHP.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 1998;20(5):237-243
DOI 10.1590/S0100-72031998000500002
We analyze prospectively the existence of a relationship between the mother's glycemic control, in the first half of pregnancy, and the occurrence of abnormal fetal cardiac abnormalities, in pregnant women with diabetes mellitus. In 127 pregnant women, the level of glycosylated hemoglobin was determined on the first visit during prenatal care. Nine patients had type I diabetes, 77 type II and 41 gestational diabetes mellitus (GDM). All mothers were submitted to detailed fetal echocardiography, during the 28th ± 4.127 week of gestation. In 31 (24.4%) of the 127 fetuses cardiac anomalies were detected. In 10 (7.87%) an isolated cardiac anomaly was identified. Mean HbA1c in the group of pregnant women without cardiac anomalies (5.64%) was statistically different from the group with anomalies (10.14%) (p<0.0001). The receiver-operator characteristic, representing the balance between sensitivity (92.83%) and specificity (98.92%) in the diagnosis of structural cardiac abnormalities, showed a cut-off point at the 7.5% HbA1c level. In nine of ten fetuses with structural cardiac anomalies, the maternal level of HbA1c was higher than 7.5%. The difference between means of the groups with and without myocardial hypertrophy diagnosed as isolated anomaly (MCHP) was not statistically significant, when considering both type II diabetes and GDM subgroups. In conclusion, levels of HbA1c higher than 7.5% were associated with most cases of echocardiographycally diagnosed structural cardiac anomalies. On the other hand, this test was not useful to discriminate conceptus with MCHP.
