Publications by authors named "Ilan E Timor-Tritsch"

98 Publications

Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity.

J Matern Fetal Neonatal Med 2021 Mar 17:1-12. Epub 2021 Mar 17.

Department of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.

Objective: To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases.

Material And Methods: This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded.

Results: Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy.

Conclusion: The EMV developing in the background of retained placental tissue associated with differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.
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http://dx.doi.org/10.1080/14767058.2021.1897564DOI Listing
March 2021

Special Report of the Society for Maternal-Fetal Medicine Placenta Accreta Spectrum Ultrasound Marker Task Force: Consensus on definition of markers and approach to the ultrasound examination in pregnancies at risk for placenta accreta spectrum.

Am J Obstet Gynecol 2021 01;224(1):B2-B14

Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and their screening performance, inconsistencies in the literature persist. In response to the need for standardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound examination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides information on the Placenta Accreta Spectrum Task Force process and findings.
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http://dx.doi.org/10.1016/j.ajog.2020.09.001DOI Listing
January 2021

Three-Dimensional Coronal Plane of the Uterus: A Critical View for Diagnostic Accuracy.

J Ultrasound Med 2021 Mar 22;40(3):607-619. Epub 2020 Aug 22.

Department of Obstetrics and Gynecology, Division of Obstetric and Gynecologic Ultrasound, New York University Grossman School of Medicine, New York, New York, USA.

Two-dimensional transvaginal and transabdominal ultrasound (US) examinations are the suggested methods for examining the uterus. Three-dimensional (3D) US, which is not compulsory by society guidelines, provides additional uterine views, reassuring users of pathologic conditions not evident on customary sagittal and transverse views. The 3D coronal plane is rarely seen by 2-dimensional US transducers, let alone in extremely retroverted or axial uteri. Ultrasound machines nowadays feature 3D US capability. Our experience is that the coronal uterine view is a problem solver, helping diagnostic abilities of pelvic imaging. We advocate its liberal use and its acquisition in every pelvic scan. In this Pictorial Essay we present examples to demonstrate its use.
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http://dx.doi.org/10.1002/jum.15432DOI Listing
March 2021

Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy.

Am J Obstet Gynecol 2020 05 21;222(5):B2-B14. Epub 2020 Jan 21.

The American College of Obstetricians and Gynecologists (ACOG), the American Institute of Ultrasound in Medicine (AIUM), and the Society of Family Planning (SFP) endorse this document.

Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).
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http://dx.doi.org/10.1016/j.ajog.2020.01.030DOI Listing
May 2020

Cesarean Scar Pregnancy: Patient Counseling and Management.

Obstet Gynecol Clin North Am 2019 Dec;46(4):813-828

Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.

There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.
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http://dx.doi.org/10.1016/j.ogc.2019.07.010DOI Listing
December 2019

Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.

Obstet Gynecol Clin North Am 2019 Dec;46(4):797-811

Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.

Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.
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http://dx.doi.org/10.1016/j.ogc.2019.07.009DOI Listing
December 2019

Ultrasound and Histopathologic Correlation of Ovarian Cystadenofibromas: Diagnostic Value of the "Shadow Sign".

J Ultrasound Med 2019 Nov 29;38(11):2973-2978. Epub 2019 Mar 29.

Departments of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA.

Objectives: Cystadenofibromas (CAFs) are rare benign ovarian tumors without a widely accepted ultrasound (US) pattern. They are usually described by as thin-walled, unilocular or multilocular, and at times septated cysts with scant blood flow and no solid components. We describe a unique US feature, the "shadow sign," seen in prospectively diagnosed benign CAFs. We also provide the histopathologic basis for this typical US appearance.

Methods: Ultrasound (US) examinations were performed in our obstetric and gynecologic US unit. Pathologic examinations were performed by a dedicated gynecologic pathology team. The US and pathology department's database was searched for the diagnosis of a CAF between 2010 and 2017.

Results: We identified 20 patients who underwent transvaginal US examinations with a sole US diagnosis of a CAF, and the tumors were surgically removed. The common US feature across the 20 cases was the presence of hyperechoic avascular shadowing nodules. The correlating histologic features were unilocular or multilocular cysts with a smooth internal wall surface lined by a simple epithelium and occasional robust polypoid fibrous stroma.

Conclusions: This US marker helps in differentiating CAFs from borderline ovarian tumors, which do not show this US feature. We hope that recognizing the suggested shadow sign as an additional descriptor of CAFs will lead to minimizing their unnecessary removal and eliminating additional and unnecessary imaging by computed tomography and magnetic resonance imaging.
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http://dx.doi.org/10.1002/jum.15003DOI Listing
November 2019

Minimally Invasive Treatment of Cesarean Scar and Cervical Pregnancies Using a Cervical Ripening Double Balloon Catheter: Expanding the Clinical Series.

J Ultrasound Med 2019 Mar 12;38(3):785-793. Epub 2018 Aug 12.

New York University Langone Health, New York, New York, USA.

The efficacy of treating cesarean scar pregnancies and cervical pregnancies with the Cook® cervical ripening balloon catheter, in a multicenter office-based setting is reported. Thirty-eight women were treated. Insertion of the catheter was performed under real-time ultrasound guidance. Patients received adjuvant systemic methotrexate, prophylactic oral antibiotics, and oral pain medication. Serum human chorionic gonadotropin and ultrasound scans were followed serially until resolution. Thirty-seven patients were successfully treated, requiring no further procedures. We found that the Cook cervical ripening balloon technique is a simple, effective, outpatient, minimally invasive treatment with few complications noted in this expanded series.
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http://dx.doi.org/10.1002/jum.14736DOI Listing
March 2019

Cesarean Delivery Changes the Natural Position of the Uterus on Transvaginal Ultrasonography.

J Ultrasound Med 2018 May 27;37(5):1179-1183. Epub 2017 Oct 27.

Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA.

Objectives: To assess whether cesarean delivery changes the natural position of the uterus.

Methods: In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery.

Results: We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans ± SD was 18 ± 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P < .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8° ± 45.7°) versus vaginal delivery (145.8° ± 43.7°; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4° ± 51.2°) versus vaginal delivery (152.8° ± 47.7°; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6° versus 7.0°; P = .027).

Conclusions: Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.
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http://dx.doi.org/10.1002/jum.14461DOI Listing
May 2018

Recap-Minimally invasive treatment for cesarean scar pregnancy using a double-balloon catheter: additional suggestions to the technique.

Am J Obstet Gynecol 2017 10 23;217(4):496-497. Epub 2017 Jul 23.

Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY.

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http://dx.doi.org/10.1016/j.ajog.2017.07.031DOI Listing
October 2017

Pregnancy in an Abnormal Location.

Clin Obstet Gynecol 2017 09;60(3):586-595

*Carnegie Imaging for Women, Icahn School of Medicine at Mount Sinai †New York University School of Medicine, New York, New York.

Cesarean scar pregnancy and cervical pregnancy are 2 relatively rare types of abnormally implanted pregnancies. Both if unrecognized can result in significant morbidity to the patient. The most important issue regarding cesarean scar pregnancy and cervical pregnancy is to establish the diagnosis early in order for the patient to be adequately counseled and appropriate management carried out. For both of these conditions early detection and treatment can result in preservation of fertility.
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http://dx.doi.org/10.1097/GRF.0000000000000306DOI Listing
September 2017

Rambam Hospital is the Birthplace of the Modern Version of Transvaginal Ultrasound.

Rambam Maimonides Med J 2017 Apr 28;8(2). Epub 2017 Apr 28.

Director of Obstetrics and Gynecology Ultrasound, Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA.

The worldwide use of the transvaginal scanning route has revolutionized obstetrical and gynecologic imaging. The long, slow, and at times challenging aspects of its acceptance by the obstetrical and gynecologic community are the subject of this article. From its inception to its recent use, the dedicated doctors in the Department of Obstetrics and Gynecology at Rambam Medical Center, Haifa, Israel, were instrumental in conceiving and then collaborating with an Israeli manufacturer in the construction and worldwide use of the transvaginal ultrasound probe, resulting in the now well-known field of transvaginal sonography.
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http://dx.doi.org/10.5041/RMMJ.10301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5415370PMC
April 2017

Tubal Disease and Impersonators/Masqueraders.

Clin Obstet Gynecol 2017 03;60(1):46-57

Department of Obstetrics/Gynecology, New York University School of Medicine, New York.

Ultrasound is considered the first-line imaging modality in the evaluation of the fallopian tubes. This chapter reviews both the physiologic and pathologic sonographic findings of the fallopian tubes and how to recognize characteristic entities. Specifically, it describes how to use ultrasound techniques to distinguish between pathologic processes including chronic versus acute pelvic inflammatory disease, as well as infertility, torsion, and malignancy. It also describes how to employ modern ultrasound techniques, such as color Doppler, three-dimensional imaging, and salpingocentesis in clinical practice.
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http://dx.doi.org/10.1097/GRF.0000000000000262DOI Listing
March 2017

Standardization of peak systolic velocity measurement in enhanced myometrial vascularity.

Am J Obstet Gynecol 2016 Dec 18;215(6):802-803. Epub 2016 Aug 18.

Maternal Fetal Medicine Associates, Carnegie Hill Imaging for Women, New York, NY; Department of Obstetrics and Gynecology, NYU School of Medicine, New York, NY.

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http://dx.doi.org/10.1016/j.ajog.2016.08.013DOI Listing
December 2016

Ultrasound Detection of Bladder-Uterovaginal Anastomoses in Morbidly Adherent Placenta.

Fetal Diagn Ther 2017 5;41(3):239-240. Epub 2016 May 5.

Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy.

Vascular control is a fundamental step in the surgical management of morbidly adherent placenta (MAP), and this implies a precise knowledge of the vascular supply in the lower part of the genital tract. High degrees of MAP are sometimes characterised by the presence of a rich vascular anastomotic system between the bladder, uterus, and vagina involving the superior, medial, and inferior vaginal and the lower vesical arteries. This brief report shows that prenatal ultrasound assessment of bladder-uterovaginal anastomoses in MAP is feasible.
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http://dx.doi.org/10.1159/000445055DOI Listing
February 2018

A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy.

Am J Obstet Gynecol 2016 09 12;215(3):351.e1-8. Epub 2016 Mar 12.

Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY.

Background: Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10% to 62%. At times, life-saving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single-balloon catheter for the treatment of cesarean scar pregnancy after local injection of methotrexate, we evaluated the use of a double-balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This was a retrospective study.

Objectives: The objective of the study was to describe the placement of a cervical ripening double-balloon catheter as a novel, minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac.

Study Design: Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office-based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days, a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum human chorionic gonadotropin were followed weekly or as needed.

Results: Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 through 7 4/7 weeks). Patients' acceptance for the double-balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but 1 patient noted vaginal spotting at the follow-up appointment. Only 1 patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range, 1-5 days). Median time from treatment to the total drop of human chorionic gonadotropin was 49 days (range, 28-97 days).

Conclusion: The double balloon is a successful, minimally invasive and well-tolerated single treatment for cervical pregnancy and cesarean scar pregnancy. This simple treatment method has 4 main advantages: it effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies, and is familiar to obstetricians-gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.
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http://dx.doi.org/10.1016/j.ajog.2016.03.010DOI Listing
September 2016

Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester.

Am J Obstet Gynecol 2016 08 17;215(2):225.e1-7. Epub 2016 Feb 17.

New York University School of Medicine, New York, NY.

Background: Cesarean scar pregnancy (CSP) is a serious complication of pregnancy, which consists of implantation of the gestational sac in the hysterotomy scar. This condition is increasing in frequency and often poses a diagnostic challenge. Its diagnosis is dependent on visual assessment of the uterus on the longitudinal sagittal ultrasound plane. Misdiagnosing a low intrauterine chorionic sac as a CSP, or a true scar pregnancy as an intrauterine pregnancy (IUP), may lead to adverse outcomes including hysterectomy.

Objective: The objective of the study is to describe a sonographic method for the differential diagnosis of CSP vs IUP in early gestation. The current study tests the hypothesis that on a first-trimester ultrasound performed between 5-10 weeks of gestation, the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus can be used for early detection of CSPs.

Study Design: This is a retrospective review of electronically archived ultrasound images of IUP and CSP between 5-10 weeks of gestation. A total of 242 ultrasound images were analyzed: 185 cases of normal IUPs (including 128 in anteverted uteri, 31 in retroverted uteri, and 26 IUPs with history of cesarean delivery) and 57 cases of CSPs diagnosed from 2004 through 2015 in a single institution. The following measurements were made for each case: distance from the external cervical os to the uterine fundus, the midpoint axis of the uterus, the distance from the external cervical os to the center of gestational sacs, and the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix.

Results: The location of the center of the gestational sac relative to the midpoint axis of the uterus between 5-10 weeks of gestation differentiated between IUP and CSP (mean 17.8 vs -10.6 mm, respectively, P = .0001), indicating that most CSPs are located proximally to the midpoint axis of the uterus whereas most normal IUPs are located distally from the midpoint of the uterus. Using location of the center of the gestational sac as a marker of CSPs between 5-10 weeks of gestation yielded the following characteristics of diagnostic accuracy: sensitivity 93.0% and specificity 98.9%. The likelihood ratio of the positive test was 84.5. The likelihood ratio of the negative test was 0.07.

Conclusion: The location of the center of the gestational sac relative to the midpoint axis of the uterus can be used as an easy method for sonographic differentiation of IUP and CSP between 5-10 weeks of gestation.
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http://dx.doi.org/10.1016/j.ajog.2016.02.028DOI Listing
August 2016

Ultrasound diagnosis and management of acquired uterine enhanced myometrial vascularity/arteriovenous malformations.

Am J Obstet Gynecol 2016 06 9;214(6):731.e1-731.e10. Epub 2016 Feb 9.

Department of Obstetrics & Gynecology and Radiology, New York University School of Medicine and Langone Medical Center, New York, NY.

Background: Arteriovenous malformation is a short circuit between an organ's arterial and venous circulation. Arteriovenous malformations are classified as congenital and acquired. In the uterus, they may appear after curettage, cesarean delivery, and myomectomy among others. Their clinical feature is usually vaginal bleeding, which may be severe, if curettage is performed in unrecognized cases. Sonographically on 2-dimensional grayscale ultrasound scanning, the pathologic evidence appears as irregular, anechoic, tortuous, tubular structures that show evidence of increased vascularity when color Doppler is applied. Most of the time they resolve spontaneously; however, if left untreated, they may require involved treatments such as uterine artery embolization or hysterectomy. In the past, uterine artery angiography was the gold standard for the diagnosis; however, ultrasound scanning has diagnosed successfully and helped in the clinical management. Recently, arteriovenous malformations have been referred to as enhanced myometrial vascularities.

Objectives: The purpose of this study was to evaluate the role of transvaginal ultrasound scanning in the diagnosis and treatment of acquired enhanced myometrial vascularity/arteriovenous malformations to outline the natural history of conservatively followed vs treated lesions.

Methods: This was a retrospective study to assess the presentation, treatment, and clinical pictures of patients with uterine Enhanced myometrial vascularity/arteriovenous malformations that were diagnosed with transvaginal ultrasound scanning. We reviewed both (1) ultrasound data (images, measured dimensions, and Doppler blood flow that were defined by its peak systolic velocity and (2) clinical data (age, reproductive status, clinical presentation, inciting event or procedure, surgical history, clinical course, time intervals that included detection to resolution or detection to treatment, and treatment rendered). The diagnostic criteria were "subjective" with a rich vascular network in the myometrium with the use of color Doppler images and "objective" with a high peak systolic velocity of ≥20 cm/sec in the vascular web. Statistical analysis was performed and coded with statistical software where necessary.

Results: Twenty-seven patients met the diagnostic criteria of uterine enhanced myometrial vascularity/arteriovenous malformation. Mean age was 31.8 years (range, 18-42 years). Clinical diagnoses of the patients included 10 incomplete abortions, 6 missed abortions, 5 spontaneous complete abortions, 5 cesarean scar pregnancies, and 1 molar pregnancy. Eighty-nine percent of patients had bleeding (n = 24/27), although 1 patient was febrile, and 2 patients were asymptomatic. Recent surgical procedures were performed in 55.5% patients (15/27) that included curettage (n = 10), cesarean deliveries (n = 5), or both (n = 1); 4 patients had a remote history of uterine surgery that included myomectomy. Treatment was varied and included expectant treatment alone in 48% of the patients with serial ultrasound scans and serum human chorionic gonadotropin until resolution (n = 13/27 patients), uterine artery embolization (29.6%; 8/27 patients), methotrexate administration (22.2%; 6/27 patients), hysterectomy (7.4%; 2/27 patients), and curettage (3.7%; 1/27 patients). Three patients required a blood transfusion. Of the 9 patients whose condition required embolization, the conditions of 7 patients resolved after the procedure although 1 patient's condition required operative hysteroscopy and 1 patient's condition required hysterectomy for intractable bleeding. Average peak systolic velocity after embolization in the 9 patients was 85.2 cm/sec (range, 35-170 cm/sec); the average peak systolic velocity of the 16 patients with spontaneous resolution was 58.5 cm/sec (range, 23-90 cm/sec).

Conclusions: Acquired enhanced myometrial vascularity/arteriovenous malformations occurred after unsuccessful pregnancies or treatment procedures that included uterine curettage, cesarean delivery, or cesarean scar pregnancy. Triage of patients for expectant treatment vs intervention with uterine artery embolization based on their clinical status, which was supplemented by objective measurements of blood velocity measurement in the arteriovenous malformation, appears to be a good predictor of outcome. Ultrasound evaluation of patients with early pregnancy failure and persistent bleeding should be considered for evaluation of a possible enhanced myometrial vascularity/arteriovenous malformation.
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http://dx.doi.org/10.1016/j.ajog.2015.12.024DOI Listing
June 2016

Consider ultrasound first for imaging the female pelvis.

Am J Obstet Gynecol 2015 Apr;212(4):450-5

Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY.

Ultrasound technology has evolved dramatically in recent years and now includes applications such as 3-dimensional volume imaging, real-time evaluation of pelvic organs (simultaneous with the physical examination), and Doppler blood flow mapping without the need for contrast, which makes ultrasound imaging unique for imaging the female pelvis. Among the many cross-sectional imaging techniques, we should use the most informative, less invasive, and less expensive modality to avoid radiation when possible. Hence, ultrasound imaging should be the first imaging modality used in women with pelvic symptoms.
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http://dx.doi.org/10.1016/j.ajog.2015.02.015DOI Listing
April 2015

Cesarean scar pregnancies: experience of 60 cases.

J Ultrasound Med 2015 Apr;34(4):601-10

Departments of Obstetrics and Gynecology (I.E.T.-T., N.K., A.M., J.R., R.B.) and Radiology (S.K.), New York University School of Medicine, New York, New York USA.

Objectives: To evaluate the management, clinical courses, and outcomes of cesarean scar pregnancies diagnosed in the first trimester.

Methods: We identified 60 cases of cesarean scar pregnancies diagnosed between 5 and 14 weeks. Group A contained 48 patients with fetal/embryonic cardiac activity; group B comprised 12 patients without cardiac activity; and group C included 11 patients with cardiac activity who chose expectant management.

Results: Five of the 48 patients (10.4%) in group A were successfully treated for vaginal bleeding. Thirty-three (68.7%) received methotrexate injections, and all had full resolution. Three (6.3%) required uterine artery embolization for late-developing arteriovenous malformations. Ten of the 12 patients (83.3%) in group B were managed expectantly and had full recovery. Two of the 10 (20.0%) had arteriovenous malformations; 1 had unsuccessful uterine artery embolization followed by a hysterectomy, and the second requested a hysterectomy. Ten of the 11 patients (90.9%) in group C continued the pregnancies. One declined local injection. Four of the 10 (40.0%) delivered live offspring by successive elective cesarean deliveries. Three (30.0%) had hysterectomies for placenta percreta, and 1 did not have a hysterectomy after delivery. Five (50%) had second-trimester complications, all leading to hysterectomies. Of the 60 patients, 20 (33.3%) had serious complications: 5 had arteriovenous malformations; 4 had uterine artery embolization; and 11 had hysterectomies.

Conclusions: A cesarean scar pregnancy is a serious complication for patients who have had cesarean deliveries. Counseling, treatment, and follow-up are challenging for patients and caregivers. However, emerging data from different management approaches confirm that a cesarean scar pregnancy may progress and result in a live neonate at the expense of further fertility. This study confirmed that expectant management of a cesarean scar pregnancy is associated with a high risk of hysterectomy due to morbidly adherent placenta.
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http://dx.doi.org/10.7863/ultra.34.4.601DOI Listing
April 2015

Cystadenofibromas: Can transvaginal ultrasound appearance reduce some surgical interventions?

J Clin Ultrasound 2015 Jul-Aug;43(6):393-6. Epub 2014 Oct 1.

Department of Pathology, New York University School of Medicine, 530 First Ave, Suite 10 N, New York, NY, 10016.

Purpose: Cystadenofibromas are benign ovarian neoplasms. Their most typical features on sonography (US) are unilocular cysts with small, shadowing hyperechoic, solid papillae without internal vascularity. In the past, they were virtually always surgically removed to exclude malignancy. This study was undertaken to review the sonographic appearances of benign cystadenomas.

Methods: We retrospectively reviewed the transvaginal US studies of 32 cases of pathologically proven ovarian cystadenofibromas.

Results: Twenty-two of the tumors presented as unilocular cystic structures with one or more solid, hyperechoic, shadowing, mural nodules with no discernible blood flow projecting from the inner cyst wall. Ten lesions were multiloculated with multiple small solid areas, with scant or no blood vessels.

Conclusions: Cystadenofibromas do not always have a classic appearance on transvaginal US and color Doppler imaging. In our series, however, the majority (69%) presented as unilocular cysts with one or more small solid, avascular projections from the inner cyst wall. These features had 100% reliability for a diagnosis of benign cystadenofibroma in this small series. Further study is necessary to confirm the reliability of this finding for benign cystadenofibroma, thus possibly avoiding or minimizing any surgical exploration.
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http://dx.doi.org/10.1002/jcu.22241DOI Listing
March 2016

Early second-trimester sonography to improve the fetal anatomic survey in obese patients.

J Ultrasound Med 2014 Sep;33(9):1579-83

From Maternal-Fetal Medicine Associates, PLLC, New York, New York USA (S.G.); and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York USA (S.G., I.E.T.-T., C.O., J.C., A.M.).

Objectives: Fetal anatomic surveys are difficult to perform on obese patients. However, there are limited data available on methods to improve the rate of complete anatomy scans in these patients. The objective of this study was to determine whether the addition of an early second-trimester fetal anatomy scan improves the rate of complete anatomy scans in obese patients.

Methods: We conducted a prospective cohort study of 100 obese patients at a city hospital who were scheduled for a fetal anatomy scan using transvaginal and transabdominal sonography at 14 to 16 weeks (early anatomy scan) and an anatomy scan at 18 to 22 weeks ("routine" anatomy scan). Inclusion criteria were a body mass index of 30 kg/m(2) or higher, singleton pregnancy, and presentation for prenatal care before 16 weeks. Data for the routine anatomy scan alone versus a combination of early and routine anatomy scans was calculated by the McNemar χ(2) test for categorical variables and the Wilcoxon signed ranks test for continuous variables.

Results: The addition of the early anatomy scan significantly increased the rate of complete anatomy scans from 42% to 51% (P < .01). It also significantly improved visualization of the head, thorax, and abdomen and significantly increased the mean number of items seen (P < .05).

Conclusions: The addition of an early second-trimester fetal anatomy scan to a routine anatomy scan performed later in the second trimester significantly improves the rate of complete anatomy scans in obese patients.
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http://dx.doi.org/10.7863/ultra.33.9.1579DOI Listing
September 2014

Reply: To PMID 22516620.

Am J Obstet Gynecol 2014 Apr 29;210(4):380-381. Epub 2014 Jan 29.

NYU School of Medicine, Obstetrics and Gynecology, 550 First Ave., NBV-9N1, New York, NY 10016.

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http://dx.doi.org/10.1016/j.ajog.2014.01.028DOI Listing
April 2014

Hyperosmolar glucose injection for the treatment of heterotopic ovarian pregnancy.

Obstet Gynecol 2012 Nov;120(5):1212; author reply 1212-3

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http://dx.doi.org/10.1097/aog.0b013e3182721a3aDOI Listing
November 2012

The diagnosis, treatment, and follow-up of cesarean scar pregnancy.

Am J Obstet Gynecol 2012 Jul 16;207(1):44.e1-13. Epub 2012 Apr 16.

Department of Obstetrics and Gynecology, NYU School of Medicine, New York, NY 10016, USA.

Objective: The diagnosis and treatment of cesarean scar pregnancy (CSP) is challenging. The objective of this study was to evaluate the diagnostic method, treatments, and long-term follow-up of CSP.

Study Design: This is a retrospective case series of 26 patients between 6-14 postmenstrual weeks suspected to have CSP who were referred for diagnosis and treatment. The diagnosis was confirmed with transvaginal ultrasound. In 19 of the 26 patients the gestational sac was injected with 50 mg of methotrexate: 25 mg into the area of the embryo/fetus and 25 mg into the placental area; and an additional 25 mg was administered intramuscularly. Serial serum human chorionic gonadotropin determinations were obtained. Gestational sac volumes and vascularization were assessed by 3-dimensional ultrasound and used to monitor resolution of the injected site and outcome.

Results: The 19 treated pregnancies were followed for 24-177 days. No complications were observed. After the treatment, typically, there was an initial increase in the human chorionic gonadotropin serum concentrations as well as in the volume of the gestational sac and their vascularization. After a variable time period mentioned elsewhere the values decreased, as expected.

Conclusion: Combined intramuscular and intragestational methotrexate injection treatment was successful in treating these CSP.
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http://dx.doi.org/10.1016/j.ajog.2012.04.018DOI Listing
July 2012

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review.

Am J Obstet Gynecol 2012 Jul 10;207(1):14-29. Epub 2012 Mar 10.

Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY 10016, USA.

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.
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http://dx.doi.org/10.1016/j.ajog.2012.03.007DOI Listing
July 2012

Fetal CNS scanning--less of a headache than you think.

Clin Obstet Gynecol 2012 Mar;55(1):249-65

Department of Obstetrics and Gynecology, Division of Maternal-Fetal-Medicine, NYU School of Medicine, New York, New York, USA.

Anatomy, pathology, and developmental changes of the fetal central nervous system (brain and spine) can be studied by prenatal sonography, using a transabdominal, or, and preferably, later in pregnancy in a cephalic presenting fetus, a transvaginal approach, with the possibility of obtaining coronal and sagittal views through the acoustic window provided by the fontanels and sutures of the skull. In a 3-dimensional sonography, both approaches may generate images in all 3 classic scanning planes (longitudinal, sagittal, and coronal). Guidelines exist concerning standard fetal anatomical survey, which includes fetal brain and spine as well as specific central nervous system examination, both basic and advanced. Normal anatomy of the fetal brain and spine in their various planes will be described with only few details on congenital anomalies.
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http://dx.doi.org/10.1097/GRF.0b013e3182446d65DOI Listing
March 2012