Biomedical subjects
Publications and source records attributed to Z Weinraub.
Early and accurate prenatal diagnosis of conjoined twins is still a challenge, and is important when planning a favorable outcome for the mother and infants. We present a case diagnosed with transvaginal and three-dimensional ultrasound at 10 weeks of gestation, and discuss the contribution of this relatively new scanning modality.
OBJECTIVE: The aim of this study was to evaluate the feasibility and reproducibility of a novel image-scoring method of first-trimester nuchal translucency measurement as an objective tool of ongoing audit and training. DESIGN: This was an independent evaluation of nuchal translucency images by three separate reviewers unaware of the examiner. SUBJECTS: There were 105 consecutive singleton pregnancies undergoing first-trimester screening. METHODS: Each image was scored according to the following criteria: section (oblique, 0; mid-sagittal, 2), caliper placing (misplaced, 0; proper, 2), skin line (nuchal only, 0; nuchal and back, 2), image size (unsatisfactory, 0; satisfactory, 1), amnion (not visualized, 0; visualized, 1) and head position (flexion/hyperextension, 0; straight, 1). The final score was categorized into one of four quality groups: excellent (8-9), reasonable (4-7), intermediate (2-3), unacceptable (0-1). RESULTS: The distributions of the four quality groups were similar between the three reviewers: 11.4% were classified as excellent, 57.1% as reasonable, 25.7% as intermediate and 5.7% as unacceptable. Inter-reviewer agreement showed identical classification, by each pair of reviewers, from 65.7% to 74.3%, and partial agreement to neighboring quality groups from 25.7% to 34.3% of the cases. In none of the cases did the reviewers differ in categorizing cases to remarkably different quality groups. Application of the auditing method to the examiners showed similar distribution to the various quality groups and similar mean final score of 4.69 (0.39, SE), 4.54 (0.15, SE) and 4.65 (0.15, SE). CONCLUSIONS: The described image-scoring method represents a new approach towards the evaluation of ultrasound performance as a whole and nuchal translucency measurement in particular. It may be employed by every center in an independent manner with minimal resources and regardless of the method of risk assessment. More studies will be needed to determine the standards required from the examiners and to elucidate the contribution of the proposed auditing method to the examination's quality and the process of training.
Trisomy 18 is a chromosomal disorder giving multiple anomalies. Its frequency depends on maternal age. We report a 28-year-old woman in her first pregnancy, who underwent first trimester scanning for screening. Due to increased nuchal translucency and exomphalos, chorionic villous sampling was performed. Cytogenetic diagnosis was trisomy 18 and termination of pregnancy was carried out immediately.
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Correct detection of premature contractions and incompetent uterine cervix is still a challenging obstetrical problem since these factors remain a major cause of perinatal loss. Ultrasonography offers additional important data for the prediction of these pathologies which have common sonographic patterns; shortening of the cervical length, funneling of the membranes and dilatation of the endocervical canal. The first section of this review highlights sonography of normal cervical anatomy, while the second section focuses on recent advances in sonographic detection of premature contractions and incompetent cervix. It is believed that due to its accuracy and reproducibility, this noninvasive technique should become more integrated into this aspect of antenatal care.
A new technique that combines saline contrast hysterosonography with three-dimensional surface rendering for the visualization of uterine intracavitary pathologies is described. A total of 32 patients suspected of having uterine cavity pathologies on the basis of previous ultrasonography, hysterosalpingography or hysteroscopy were involved in the study. They were examined by three-dimensional high-frequency endovaginal probes (Combison 530, Kretztechnik, Zipf, Austria), with normal saline used as an expander and contrast medium. Three perpendicular planes could be evaluated simultaneous, and surface renderings were readily available. Following the instillation of normal saline, the uterine cavity appears as an echo-free, well-defined structure, and the endometrium appears as an echogenic homogeneous lining around the cavity. Data acquisition time is short and images can be stored for later evaluation. Surface rendering of polypoid structures shows echogenic masses on a pedicle protruding into the uterine cavity. Submucous fibroids appear as mixed echogenic sites bulging into the cavity. Intrauterine synechiae appear as bands of varying thickness traversing the uterine cavity. Simultaneous display of the zone of interest in three perpendicular planes enhances imaging capabilities, while surface rendering provides a comprehensive overview of the surface area of the findings and their topographical orientation. Further research using this new technique is required to document its real contribution to ultrasonographic imaging.
OBJECTIVE: To evaluate the outcome of late selective fetal termination based on combined data from eight tertiary perinatal centres. DESIGN: Israeli law requires institutional committee approval for pregnancy termination. Moreover, after 24 weeks only a district superior committee can approve the termination. A total of 36 bichorionic twin pregnancies who underwent selective fetal termination after 24 complete gestational weeks were identified in eight Israeli centres. RESULTS: In 23 women (63.9%) the indication for selective termination was structural anomaly, and in 13 (36.1%) the indication was chromosomal abnormality. The mean gestational age at the time of diagnosis was 24.1 +/- 1.9 weeks. The termination procedure was performed at a mean gestational age of 25.5 +/- 2.0 weeks (median 25, range 24-33 weeks). There was one case of immediate procedure-related complication (i.e. amnionitis) and the unaffected infant died, which was the only perinatal death in this series. No evidence of coagulopathy was reported. Only five women (13.8%) delivered before 34 completed weeks. The mean gestational age at delivery was 36.9 +/- 2.9 weeks (28-41 weeks), and the mean procedure-to-delivery interval was 11.8 +/- 3.2 weeks (median 13, range 3-17 weeks). CONCLUSIONS: Late (> 24 weeks) selective termination in twin pregnancies is associated with favourable perinatal outcome of the healthy twin. In countries where the law permits late pregnancy termination, the parents should be informed of that possibility.
Weekly serum beta-hCG measurements and transvaginal ultrasound scans coupled with color Doppler flow were performed on 8 patients with hydatidiform mole. Two patients later developed persistent trophoblastic disease, necessitating chemotherapy. The correlation coefficients between Doppler flow indices, systolic-diastolic (S/D) ratio and pulsatility index (PI) with log beta-hCG were -0.96 and -0.97, respectively. The weekly S/D and PI indices were plotted on an individual curve. Only the 2 patients who developed persistent gestational trophoblastic disease had PI index levels of < or = 1.5 as early as 2 weeks after molar evacuation. At that stage their serum beta-hCG levels were not different from some of the other patients. In this preliminary report, the regression of the disease could be reliably assessed by observing the changes in low resistance flow which paralleled the gradual decrements in serial beta-hCG levels. Thus, the contribution of this noninvasive imaging technique encourages the authors to further investigate Doppler flow monitoring among a larger sample of patients suffering from various gestational trophoblastic diseases.
Serum placental isoferritin levels (PLF) levels were measured in 33 patients admitted for routine scanning of a first trimester normal singleton pregnancy and six patients who were hospitalized for uterine evacuation of a complete molar gestation. Venous blood was obtained upon admission and before curettage, when necessary. Serum was separated into glass tubes, immediately frozen and stored at -20 degrees C until analysed. The mean serum PLF levels were 18.1 (+/- 14) U/ml and 5.5 (+/- 2) U/ml for normal and molar gestations, respectively, with a significant difference between the two groups (P = 0.001). Sixty-seven per cent of normal pregnancies had serum PLF levels > or = 10 U/ml, whereas none of the molar gestation group reached this threshold level. Furthermore, the molar gestation group's low serum PLF levels remained unchanged throughout the entire follow-up period and until their beta-human chorionic gonadotrophin levels were undetectable. Unlike normal pregnancies, the molar trophoblast does not seem to secrete or synthesize PLF, suggesting that the complete molar placenta has different protein-producing capabilities when compared with those found in normal pregnancies. Further studies, including serum PLF among other categories of gestational trophoblastic neoplasms, are recommended before this data can be integrated into routine clinical work.
The incidence of multiple pregnancies is increasing, mainly as a consequence of the widespread use of various infertility protocols. Since such gestations present a high risk of feto-maternal morbidity and mortality, selective first trimester fetocide remains one of the few reasonable options. We reviewed the literature dealing with the outcome of 804 multiple pregnancies following the use of transcervical, transvaginal or transabdominal approaches. Questions relating to dealing with technical failure, method of fetocide and procedural improvements are examined. In a comparison of the variables: miscarriage, preterm delivery, perinatal and neonatal loss rates, the transvaginal approach fares better, but statistical significance (P < 0.001) is achieved only for preterm delivery. We speculated that this might be attributable to the very early gestational age at which the procedure is usually performed. However, the transabdominal approach offers better results when post-manipulation maternal morbidity is considered, i.e. infection and vaginal bleeding. Since each option offers different advantages and disadvantages, additional experience and larger population samples are required to further clarify this important issue.
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Transabdominal Doppler velocity waveform measurements of the uterine arteries during the third stage of labor were performed upon 25 patients with uncomplicated vaginal deliveries and 5 with prolonged third stage in order to further assess third-stage mechanisms. Based on Doppler flow measurements, three phases of the third stage of labor were observed: (1) a latent phase with a systolic/diastolic ratio (S/D) and a pulsatility index (PI) of 2.14 +/- 0.49 and 0.89 +/- 0.17, respectively; (2) a contraction and detachment phase with an S/D and PI of 2.53 +/- 0.53 and 1.28 +/- 0.37, respectively, and (3) an expulsion phase with an S/D and PI of 2.20 +/- 0.34 and 0.91 +/- 0.20, respectively (p < 0.05). During the third stage of labor, it was shown that uterine contractions squeezed the uterine vessels as they traversed the myometrium, leading to an increase in the extrinsic resistance, which was reflected by high resistance flow. Following placental separation and changes in the placental-site wall, there was slight uterine relaxation resulting in decreased uterine vessel resistance. This observation encourages the authors to continue investigating the contribution of ultrasound and Doppler flow for studies of the postpartum period.
Simultaneous transabdominal injection of potassium chloride (KCl) assisted by transvaginal ultrasonographic guidance was evaluated in 5 patients who conceived due to various assisted reproductive techniques and ovarian stimulation. All 5 underwent first-trimester fetal reduction for multiplicity of high-order pregnancies. Four sets of triplets were reduced to twin, and 1 twin pregnancy was reduced to a singleton. Less than 2 ml of 2 mEq/ml KCl per fetus was needed for each case. No fetal or maternal complications nor technical failure attributable to the procedure were recorded. All pregnancies were delivered > or = 35 weeks of gestation. Transabdominal fetal reduction using simultaneous transvaginal ultrasonographic guidance for selective feticide combines the benefits of both the transabdominal and transvaginal approaches, mainly in selected cases in which some experts prefer the abdominal route, but find it technically difficult to practice. Further experience is needed to confirm our encouraging preliminary results before drawing any definitive conclusions.
Prior classic incision through the uterine corpus carries the most significant risk of catastrophic uterine rupture and subsequent maternal and fetal morbidity or mortality. A trial of labor is not carried out in this group of patients, but the risk of uterine rupture exists during the antepartum period. An accurate and prospective method for diagnosing the presence of uterine defects or documenting their absence would be clinically useful. Our unusual case emphasizes the obvious need for antepartum sonographic scans of the classic uterine scar, starting from the third trimester to term, using the high-frequency (> 5 MHz) transducer.
PROBLEM: Effectiveness of early administered low-dose aspirin in prevention of pregnancy-induced hypertension (PIH) and fetal growth retardation in twin pregnancies was investigated in a randomized placebo controlled, double-blind trial in 47 twin pregnancies. METHOD: Twenty-four women received 100 mg of aspirin daily from mean gestational age of 17.7 wk, and 23 women ingested placebo from a mean gestational age of 18 wk until delivery. The placebo and aspirin group were similar in age, weight gain, zygosity, gravidity, parity, and obstetrical antecedents. Treatment lasted for a mean period of 16.8 wk and 18.3 wk in the placebo and aspirin groups, respectively. The mean gestational age at birth was 35.0 wk and 36.4 wk in the placebo and aspirin groups, respectively. RESULTS: PIH was noted in six women (26%) in the placebo group, but in only one woman (4%) in the aspirin treated patients (P < .05). The mean combined fetal weights of both twins, and the mean weight of the second twin at delivery were significantly higher in the aspirin treated mothers than in the placebo treated gravidas (mean difference of 781 g, P < .02 and mean difference of 488 g, P < .005, respectively). Intrauterine growth retardation (< 10th percentile) concerned 11 (24%) and six (13%) fetuses in the placebo and aspirin groups, respectively. No adverse effects of treatment to either the mothers or the infants were noted. CONCLUSION: Low-dose aspirin reduces the incidence of PIH and has a beneficial effect on fetal growth in twin pregnancies. Additional clinical trials are needed in order to define and select subgroups of twins where aspirin treatment is recommended.
The success of transvaginal aspiration of ovarian cysts in terms of cyst dimensions, location, and content and the age of the women was evaluated in 35 women aged 17 to 76 years old. Three parameters proved important in predicting the outcome of aspiration: age of the woman (higher age = poorer prognosis for cure), maximum diameter of the cyst (larger diameter = poorer prognosis), and location (left-sided cysts have a poorer prognosis). Prognosis based on outcome indicates aspiration of large cysts should be avoided in older women.
The intracellular accumulation of adriamycin (ADR) by Doppler flow sonication was investigated in a human ovarian carcinoma line. Cytofluorometry was performed on cells treated by ADR (0.5, 1 and 2 micrograms/mL) alone, or in conjunction with Doppler flow sonication for 5, 10, and 15 minutes. Increased intracellular accumulation of ADR was observed in cells treated at each of these test intervals. Statistically significant increases in high permeability, due to Doppler sonication, were around 1.5 fold at each of the test intervals, with a maximum observed at 10 minutes of treatment. Examination of ADR dose effect showed that the most vigorous to Doppler sonication occurred at 1 micrograms/mL ADR. Although statistically non-significant, a trend towards the most prominent egect of 91.6% cell validity was noticed after 15 minutes of treatment. Our findings demonstrate that an improvement of ADR penetration into malignant cells can be obtained in this bioultrasound model. Wowever, caution is advised when extrapolating in vitro experimental results to in vivo phenomena.
OBJECTIVE: Dynamic ultrasonographic imaging of the third stage of labor was performed to document ultrasonographic findings and to present new perspectives into third-stage mechanisms. STUDY DESIGN: Twenty-five normal deliveries and five with prolonged third-stage labor were studied. RESULTS: Normal third-stage labor could be divided into four phases: (1) latent phase, characterized by thick, placenta-free wall and thin, placenta-site wall; (2) contraction phase, with thickening of placenta-site wall (from < 1 cm to > 2 cm); (3) detachment phase, in which the placenta completes its separation and detaches; and (4) expulsion phase, with a sliding movement of the placenta. Although oxytocic agents were routinely used, they do not seem to influence the findings. In five cases with retained placenta the placenta-site wall was initially thin. In four of them it became thick, and the placenta was removed by traction of the cord, whereas in the fifth case the placenta-site wall remained thin and the placenta had to be removed manually. CONCLUSION: Shearing forces seem to tear the decidual septae and thereby separate the placenta. This process is completed only when the placenta-site wall attains full thickness. In cases of prolonged third-stage labor, traction of the cord should be applied only when this phase is completed and the actual sliding movement of the placenta is observed.