The latest medical research on Radiology

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Comparison of two fetoscopic open neural tube defect (ONTD) repair techniques: Single-layer vs three-layer closure.

Ultrasound in Obstetrics and Gynecology

We previously reported on a fetoscopic repair for open neural tube defect (ONTD) using a single layer closure (SLC). Because of a high rate of cerebrospinal fluid (CSF) leak at birth we developed a 3 layer closure (3LC) comprising a bovine collagen patch, a myofascial layer and a skin layer, using the same exteriorized uterus, fetoscopic technique.

Prospective cohort study: 32 consecutive SLC controls were compared with 18 consecutive 3LC cases. All patients satisfied Management of Myelomeningocele Study (MOMS) criteria. Obstetric, maternal, fetal, and early neonatal outcomes were compared.

Maternal demographics and gestational age at fetal surgery (24.9 ± 0.7 vs. 25.0 ± 0.5 weeks; p = NS) and at delivery (36.5 ± 3.5 vs. 37.6 ± 3.1 weeks; p = 0.14) were similar for SLC vs. 3LC, respectively. PPROM < 37 weeks (28% vs. 29%; p = NS), timing of PPROM (32.3 ± 3.4 vs. 32.7 ± 1.9 weeks; p = NS), and vaginal delivery (50% vs. 47%; p = 0.8) were similar for SLC vs. 3LC respectively. SLC showed a significantly higher rate of CSF leak (8/32 (25%) vs. 3LC (0/17 (0%); p = 0.02), and a lower rate of reversal of hind brain herniation at 6 weeks postoperatively (SLC = 18/30 (60%) vs. 3LC = 14/15 (93%); p 0.02). The rates of meeting MOMS criteria for hydrocephalus (SLC = 23/31 (74%) vs. 3LC = 7/12 (58%); p = 0.31) and requiring treatment for hydrocephalus at 12 months (15/32 (47%) SLC controls vs. 4/12 (33%) 3LC; p=0.14) were similar.

Compared to SLC, 3LC preserves the fetal and obstetric benefits of fetoscopic repair, and shows improved rates of CSF leakage and reversal of hindbrain herniation at 6 weeks postoperatively. ClinicalTrials.gov NCT02230072 and NCT03794011 This article is protected by copyright. All rights reserved.

Maternal cardiovascular function and risk of intrapartum fetal compromise in women undergoing induction of labor: a pilot study.

Ultrasound in Obstetrics and Gynecology

Identification of the fetus at risk of intrapartum compromise has many benefits. Impaired maternal cardiovascular function is associated with placental hypoperfusion intrapartum fetal distress. The main aim of this study was to assess the predictive accuracy of maternal hemodynamics for the risk of operative delivery due to presumed fetal compromise in women undergoing induction of labour (IOL).

In this prospective cohort study patients were recruited between November 2018 and January 2019. Women undergoing IOL were invited to participate in the study. A non-invasive ultrasonic cardiac output monitor (USCOM-1A) was used for the cardiovascular evaluation. The study outcome was operative delivery due to presumed fetal compromise, which included cesarean or instrumental delivery for abnormal fetal heart monitoring. Regression analysis was used to test the association between cardivascular markers, as well as the maternal characteristics and the risk of operative delivery for presumed fetal compromise. The ROC curve analysis was used to assess the predictive accuracy of the cardivascular markers for the risk of operative delivery for presumed fetal compromise.

A total of 99 women were recruited and four women were later excluded from the analysis due to semi-elective cesarean section (n=2) and failed IOL (n=2). The rate of operative delivery due to presumed fetal compromise was 28.4% (27/95). Women who delivered without suspected fetal compromise were more likely to be multiparous (52.9% vs 18.5%, p=0.002). Women who underwent operative delivery due to presumed fetal compromise had significantly lower cardiac index (CI) (median: 2.50 L/min/m2 vs. 2.60 L/min/m2 , p=0.039) and higher systemic vascular resistance (SVR) (median: 1480.0 mmHg.min.mL-1 /m2 vs. 1325.0 mmHg.min.mL-1 /m2 , p=0.044) compared to controls. The baseline model (multiparity only) showed poor predictive accuracy with an area under the curve (AUC) value of 0.67 (95% CI: 0.58-0.77). The addition of stroke volume index (SVI) <36 ml/m2, systemic vascular resistance (SVR) >7.2 logs or SVR index (SVRI) >7.7 logs significantly improved the baseline model (p=0.012, p=0.026 and p=0.012, respectively).

In this pilot study, we demonstrated that pre-labour maternal cardiovascular assessment in women undergoing IOL could be useful for assessing the risk of intrapartum fetal compromise necessitating operative delivery. The addition of SV, SVR and SVRI significantly improved the predictive accuracy of the baseline antenatal model. This article is protected by copyright. All rights reserved.

First-trimester screening for trisomies in pregnancies with a vanishing twin.

Ultrasound in Obstetrics and Gynecology

To examine multiple of the median (MoM) levels of serum free β-hCG and PAPP-A in a large series of pregnancies with a vanishing twin, determine the association of these levels with the interval between embryonic death and blood sampling and develop a model that would allow incorporation of these metabolites in first-trimester combined screening for trisomies.

This was a retrospective study comparing maternal serum free β-hCG and PAPP-A levels at 11-13 weeks' gestation in 528 dichorionic pregnancies with vanishing twins, including 194 (36.7%) with an empty gestational sac and 334 (63.3%) with a dead embryo, with levels in 5,280 normal singleton pregnancies matched for method of conception and date of examination. In the vanishing twins marker levels were examined in relation to the estimated time between embryonic death and maternal blood sampling.

The main findings were: first, in vanishing twins the median free ß-hCG MoM was not significantly different from that of normal singleton pregnancies (1.000, 95% CI 0.985 - 1.0156, versus 0.995, 95% CI 0.948 - 1.044; p= 0.849), second, PAPP-A MoM was higher in vanishing twins than in normal singleton pregnancies (1.000, 95% CI 0.985 - 1.015), both in the group with an empty gestational sac (1.165, 95% CI 1.080 - 1.256; p=0.0001), and in those with a dead embryo (1.175, 95%CI 1.105 -1.249; p<0.0001), third, in vanishing twins with a dead embryo PAPP-A MoM was inversely related to the interval between estimated gestational age at embryonic demise and blood sampling (p<0001), fourth, in first-trimester screening for trisomy 21 in singleton pregnancies the estimated detection rate, at 5% false positive rate, was 82% in screening by a combination of maternal age and fetal NT and this increased to 86% with the addition of serum free ß-hCG and then to 91% with the addition of serum PAPP-A, and fifth, similar performance of screening can be achieved in vanishing twins, provided the appropriate adjustments are made in the level of PAPP-A for the interval between estimated gestational age at embryonic demise and blood sampling.

First-trimester screening for trisomies in vanishing twins should rely on a combination of maternal age, fetal nuchal translucency thickness and serum free β-hCG, as in a singleton pregnancy, without the use of serum PAPP-A. Alternatively, PAPP-A can be included but only after appropriate adjustment for the interval between the estimated gestational age at fetal demise and blood sampling. This article is protected by copyright. All rights reserved.

Cardiac hemodynamics in fetuses with transposition of the great arteries and intact ventricular septum from diagnosis to end of pregnancy: a longitudinal follow-up.

Ultrasound in Obstetrics and Gynecology

Little is known about cardiac hemodynamics in the fetus with transposition of the great arteries and intact ventricular septum (TGA-IVS). A better understanding of the fetal physiology in TGA-IVS would help to provide insights in specific clinical complications observed after birth, in particular neonatal hypoxia and pulmonary hypertension.

To assess cardiac hemodynamics in fetuses with TGA-IVS through a systematic longitudinal echocardiographic follow-up from diagnosis to delivery.

A longitudinal retrospective study of fetuses referred from 2010 to 2018 at CHU Sainte-Justine Hospital University Center was performed. Complete assessment of cardiac hemodynamics was performed in 59 fetuses with TGA-IVS at 18-22, 28-32 and 35-38 weeks of gestation, and compared with 160 normal fetuses matched for gestational age. Also, the maximal diameter of the foramen ovale was measured using 2D echocardiography under the guidance of color Doppler echocardiography. Then, fetal cardiac hemodynamics were analyzed as a function of postnatal pre-ductal transcutaneous oxygen saturation (tcSO2 ) as a neonatal outcome.

Compared to controls, global cardiac output was significantly increased in TGA-IVS, mainly due to higher global pulmonary output, while the systemic cardiac output was not different to controls throughout pregnancy. The aortic flow (right ventricular output in fetuses with TGA-IVS) was significantly higher than the aortic flow in normal fetuses. The ductal flow was significantly lower in fetuses with TGA-IVS at every timepoint, and this difference increased dramatically after 28-32 weeks of gestation. In parallel, the diameter of the foramen ovale was significantly smaller in TGA-IVS, with a stagnation after 28 weeks compared to continuous growth in normal fetuses. Most of these cardiac hemodynamic anomalies in TGA-IVS were already present at 18-22 weeks and became more significant at 28-32 weeks of gestation. Neonates with tcSO2 lower than 65% had lower fetal LV output, higher diastolic ductal retrograde flow and smaller foramen ovale diameter at 28-32 weeks of gestation, compared to fetal values in neonates with tcSO2 higher or equal to 65%.

Compared to normal, fetuses with TGA-IVS undergo a complex redistribution of flow during the second half of the pregnancy with higher global pulmonary flow, lower ductal flow (with a negative diastolic flow at the end of pregnancy), and a smaller foramen ovale. In addition, fetal cardiac hemodynamic anomalies observed at 28-32 weeks of gestation were associated to lower postnatal tcSO2 . These observations may provide a better understanding of a premature closure of the foramen ovale and postnatal hypoxia that are specific to the physiology in TGA-IVS. This article is protected by copyright. All rights reserved.

Intertwin discordance in fetal size at 11-13 weeks' gestation and pregnancy outcome.

Ultrasound in Obstetrics and Gynecology

To investigate the value of inter-twin discordance in fetal crown-rump length (CRL) at the 11-13 weeks scan in the prediction of adverse outcome in dichorionic (DC), monochorionic diamniotic (MCDA) and monochorionic monoamniotic (MCMA) twin pregnancies.

This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. In pregnancies with no major abnormalities we examined the value of inter-twin discordance in fetal CRL in DC, MCDA and MCMA twins in the prediction of fetal loss at <20 and <24 weeks' gestation, perinatal death at ≥24 weeks, preterm delivery at <32 and <37 weeks, birth of at least one small for gestational age (SGA) neonate with birth weight <5th percentile and inter-twin birth weight discordance of ≥20% and ≥25%.

First, the study population of 6,225 twin pregnancies included 4,896 (78.7%) DC, 1,274 (20.4%) MCDA and 55 (0.9%) MCMA twins. Second, the median CRL discordance in DC twin pregnancies (3.2, IQR 1.4 - 5.8) was lower than in MCDA twins (3.6, IQR 1.6 - 6.2; P=0.0008), but not significantly different from that in MCMA twins (2.9, IQR 1.2 - 5.1; P=0.269). Third, compared to CRL discordance in DC twin pregnancies with two non-SGA live births at ≥37 weeks' gestation, there was a significantly higher CRL discordance in both DC and MCDA twin pregnancies complicated by fetal death at <20 and <24 weeks' gestation, perinatal death at ≥24 weeks, preterm birth at <32 and <37 weeks, birth of at least one SGA neonate and birth weight discordance ≥20% and ≥25% and in MCDA twin pregnancies undergoing endoscopic laser surgery. Fourth, the predictive performance of CRL discordance for each adverse pregnancy outcome was poor with areas under the receiver-operating characteristics curve ranging from 0.533 to 0.624. However, in both DC and MCDA twin pregnancies with large CRL discordance there was a high risk of fetal loss. Fifth, in DC twin pregnancies the overall rate of fetal loss at <20 weeks' gestation was 1.3%, but in the small subgroup with CRL discordance of ≥15%, which constituted 1.9% of the total, the rate increased to 5.3%. Sixth, in MCDA twin pregnancies the rate of fetal loss or endoscopic laser surgery at <20 weeks was about 11%, but in the small subgroups with CRL discordance of ≥10%, ≥15% and ≥20%, which constituted 9%, <3% and <1% of the total, the risk was increased to about 32%, 49% and 70%. Seventh, in MCMA twin pregnancies there were no significant differences in CRL discordance for any of the adverse outcome measures, but this may be the consequence of the small number of cases in the study population.

In both DC and MCDA twin pregnancies increased CRL discordance is associated with increased risk of fetal death at <20 and <24 weeks' gestation, perinatal death at ≥24 weeks, preterm birth at <37 and <32 weeks, birth of at least one SGA neonate and birth weight discordance ≥20% and ≥25%, but CRL discordance is a poor screening test for adverse pregnancy outcome. However, in DC twins CRL discordance of ≥15% is associated with increased risk of fetal loss at <20 weeks' gestation and in MCDA twins CRL discordance of ≥10%, and more so discordance of ≥15% and ≥20%, is associated with a very high risk of fetal loss or endoscopic laser surgery at <20 weeks and this information is useful in counselling women and defining the timing for subsequent assessment and possible intervention. This article is protected by copyright. All rights reserved.

Analysis of 270 fetuses with non-visualisation of the cavum septi pellucidi and vergae on in-utero MR imaging.

Ultrasound in Obstetrics and Gynecology

The primary aim of this paper is to present a retrospective analysis of fetuses in which the cavum septi pellucidi and vergae (CSPV) was not present, or was not in its expected position on in utero MR (iuMR) imaging. We will use this information to describe the possible causes of that finding and provide a diagnostic approach using iuMR imaging.

This is a retrospective study from a single institution using data from an 18 year period (2000-2017) and it includes fetuses in which the CSPV was not visualised on iuMR. Those studies were reviewed and classified as CSPV 'not present', 'disrupted' or 'mal-positioned' and we describe the neuropathologies present in each of the groups.

270 fetuses met the entrance criteria and the CSPV was described as 'mal-positioned' in 56% of fetuses, 'disrupted' in 26% and 'not present' in 18%. Mal-positioned CSPV were present only in cases of agenesis of the corpus callosum and three specific patterns of mal-positioning are described. Disrupted CSPV was present in fetuses with hydrocephalus or pathologies causing extensive brain parenchymal injury. 'Not present' CSPV was found in cases with holoprosencephaly or when absence of the CSPV appeared to be an isolated finding.

We have described a large cohort of fetuses with non-visualisation of a normal CSPV on iuMR imaging and present a categorical classification system based on the CSPV being 'not present', 'disrupted' and 'mal-positioned'. This approach should help in the diagnosis of the underlying cause of a CSPV abnormality. This article is protected by copyright. All rights reserved.

Impact of biometric measurement error on identification of small- and large-for-gestational-age fetuses.

Ultrasound in Obstetrics and Gynecology

First, to obtain measurement error models for biometric measurements of fetal head circumference (HC), abdominal circumference (AC) and femur length (FL), and second, to examine the impact of biometric measurement error on sonographic estimated fetal weight (EFW) and its effects on the prediction of small for gestational age (SGA) and large for gestational age (LGA) fetuses with EFW <10th and >90th percentile, respectively.

Measurement error standard deviations for fetal HC, AC and FL were obtained from a previous large study on fetal biometry utilising a standardized measurement protocol and both qualitative and quantitative quality control monitoring. A typical combination of HC, AC and FL that gave an EFW on the 10th and 90th percentiles was determined. A Monte-Carlo simulation study was carried out to examine the effect of measurement error on the classification of EFW above and below the 10th and 90th percentiles.

Errors were assumed to follow Gaussian distributions with means of 0 mm and SDs obtained from a previous well conducted study of 6.93 mm for AC, 5.15 mm for HC and 1.38 mm for FL. Assuming errors according to such distributions, when the 10th and 90th percentiles are used to screen for SGA and LGA fetuses, respectively, the detection rates would be 78%, at false positive rates of 5%. If the cut-offs were relaxed to the 30th and 70th percentile the detection rates would increase to 98%, but at false positive rates of 24%. Assuming half of the spread in the error distribution, using the 10th and 90th percentiles to screen for SGA and LGA fetuses, respectively, the detection rates would be 86.6%, at false positive rates of 2.3%. If the cut-offs were relaxed to the 15th and 85th percentile, respectively, the detection rates would increase to 97% and the false positive rates would increase to 6.3%.

Measurement error in fetal biometry causes substantial error in EFW, resulting in misclassification of SGA and LGA fetuses. The extent to which improvement can be achieved through effective quality assurance remains to be seen but, as a first step, it is important for practitioners to understand how biometric measurement error impacts on prediction of SGA and LGA fetuses. This article is protected by copyright. All rights reserved.

Fetal ventricular strain in uncomplicated and selective growth restricted monochorionic diamniotic pregnancies, with cardiovascular responses in pre-TTTS.

Ultrasound in Obstetrics and Gynecology

The primary aim of this prospective, blinded study was to confirm whether inter-twin pair discordance in ventricular strain and ductus venosus time intervals predicts twin-twin transfusion syndrome (TTTS). Secondary aims using uncomplicated monochorionic diamniotic (MCDA) pregnancies were the creation of gestational age ranges for ventricular strain in those without selective intrauterine growth restriction (sIUGR) and the characterization of the relationship of ventricular strain with those with sIUGR.

We enrolled 150 MCDAs consecutively into a prospective study of left and right ventricular global longitudinal strain (2015-2018). Four-chamber clips recorded at ultrasound surveillance were blinded to twin-pair and outcome for offline strain measurement, between the usual development of TTTS (16 to 26 completed gestational weeks). Uncomplicated MCDAs, without sIUGR, were used as controls to test the association between strain, gestational age and estimated fetal weight using mixed-effects multilevel regression. Inter-rater correlation was tested in 208 strain measurements and within-fetus variation in 16 controls, where multiple 4-chamber views were taken on the same day. The effect of sIUGR on strain in otherwise uncomplicated MCDAs was analyzed. "Pre-TTTS" was defined as MCDA pregnancies referred for TTTS evaluation, who did not satisfy Quintero staging criteria, but subsequently developed TTTS requiring laser treatment. Cardiovascular parameters measured in "pre-TTTS" included tissue Doppler and ductus venosus early filling time as a percentage of cardiac cycle (DVeT%). Inter-twin pair strain and DVeT% discordance was compared between controls and "pre-TTTS", matched for gestational age.

Paired strain data were available for inter-twin comparison in 128/150 MCDAs, comprising 14 "pre-TTTS" and 113 controls after exclusions. Scans were collected at a median frame rate of 97 Hz (range 28-220). Laser was performed at median of 20.6 (range 17.2-26.6) weeks' gestation. There were no group differences in right or left ventricular (RV or LV) strain discordance between 68/127 MCDA controls and 13/14 "pre-TTTS" pregnancies below 20 completed gestational weeks (RV: p=0.338, LV: p=0.932). DVeT% discordance >3.6% was found in 8/13 "pre-TTTS". In controls, the estimated variability in ventricular strain within each twin during the day was high (19.7 RV, 12.9 LV). However, within each pair (between fetus variation) variability was low (5.5 RV, 2.9 LV). Interclass correlation reflecting the proportion of total variability represented by the variability between twin pairs was low (0.22 RV, 0.18 LV). Both RV (p<0.001) and LV (p=0.025) strain showed a negative association with gestational age. LV strain was on average 1.83 higher in sIUGR compared to normally grown fetuses (p = 0.023) in MCDA controls with no statistically significant difference in RV strain (p=0.271).

Although we have previously reported ventricular strain as a possible predictor of developing TTTS, we found no significant inter-group differences in "pre-TTTS", compared with age-matched MCDA controls in this blinded prospective study. We recommend DVeT% discordance may be a more practical screening tool in MCDA pregnancies. This study also provides new information on the gestational change, biological and technical variation of global longitudinal ventricular strain in uncomplicated MCDAs and those with isolated sIUGR. This article is protected by copyright. All rights reserved.

The effect of race on longitudinal maternal central hemodynamics.

Ultrasound in Obstetrics and Gynecology

To compare maternal central hemodynamics between White, Black and Asian women.

This was a prospective, longitudinal study of maternal central hemodynamics by a bioreactance method at 11+0 -13+6 , 19+0 -24+0 , 30+0 -34+0 and 35+0 -37+0 weeks' gestation, in White (n=1165), Black (n=247) and Asian (n=116) women. Multilevel linear mixed-effects analysis was performed to compare the repeated measures of the cardiac variables controlling for maternal characteristics and medical history.

Cardiac output (CO) increased with gestational age to a peak at 32 weeks; the highest CO was in White women and the lowest in Asian women. Stroke volume (SV) increased with gestation in White women, decreased in Black women and remained static in Asian women. Heart rate (HR) increased with gestation to 32 weeks and then remained constant; HR was highest in Black women and lowest in White women. Peripheral vascular resistance (PVR) showed a reversed pattern to CO; the highest values were in Asian women and the lowest in White women. The least favourable hemodynamic profile in Black and Asian, compared to White women was reflected in the higher rates of small for gestational age infants.

There are race-specific differences in maternal cardiac adaptation in pregnancy. White women have the most favourable cardiac adaptation by increasing SV and HR, achieving the highest CO and lowest PVR. In contrast, Black and Asian, compared to White women, have lower CO and higher PVR, increasing their CO through a rise in HR due to a declining or static SV. This article is protected by copyright. All rights reserved.

Comparison of different methods of measuring angle of progression in the prediction of labor outcome.

Ultrasound in Obstetrics and Gynecology

First, to compare the manual sagittal and para-sagittal and automated para-sagittal methods of measuring the angle of progression (AOP) by transperineal ultrasound during labor, and second, to develop models for the prediction of time-to-delivery and need for cesarean section (CS) for failure to progress (FTP) in a population of patients undergoing induction of labor.

This was a prospective observational study of transperineal ultrasound on a cohort of 512 women with singleton pregnancies undergiong induction of labor. A random selection of 50 stored images was assessed for inter- and intra-observer reliability between methods. In the cases of vaginal delivery univariate linear, multivariate linear and quantile regression were performed to predict time-to-delivery. Univariate and multivariate binomial logistic regression were performed to predict CS for FTP in the first stage of labor.

The intra correlation coefficients (ICC) for the manual para-sagittal method for a single observer was 0.97 (CI 0.95-0.98) and for two observers was 0.96 (CI 0.93-0.98) indicating good reliability. The ICC for the sagittal method for a single observer was 0.93 (0.88-0.96) and for two observers was 0.74 (0.58-0.84) indicating moderate reliabilty for a single observer and poor reliability between two observers. Bland-Altman analysis demonstrated narrower limits of agreement for the manual para-saggittal approach than for the sagittal approach for both single and two observers. The automated para-sagittal method failed to capture an image in 19% of cases. The mean difference between sagittal and para-sagittal methods was 110 . In pregnancies resulting in vaginal delivery, 54% of the variation in time-to-delivery was explained in a model combining parity, epidural and syntocinon use during labour and the sonographic findings of fetal head position and AOP. In the prediction of CS for FTP in the first stage of labour a model which combined maternal factors with the sonographic measurements of AOP and estimated fetal weight was superior to one utilising maternal factors alone (area under the curve 0.80 vs 0.76).

First, the method of measuring AOP with greatest reliability is the manual para-sagittal technique and future research should focus on this technique, second, over half of the variation in time to vaginal delivery can be explained by a model that combines maternal factors, pregnancy characteristics and ultrasound findings, and third, the ability of AOP to provide clinically useful prediction CS for FTP in the first stage of labour is limited. This article is protected by copyright. All rights reserved.

Can dynamic contrast-enhanced ultrasound (DCE-US) improve diagnostic performance in endometrial cancer staging? A proof of concept.

Ultrasound in Obstetrics and Gynecology

To compare the sensitivity and specificity of conventional two-dimensional transvaginal ultrasound/power Doppler (2D-TVU/PD) alone to 2D-TVU/PD combined with dynamic contrast-enhanced ultrasound (DCE-US) in diagnosing deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer (EC) and to correlate DCE-US and 2D-TVU/PD quantitative and qualitative variables to FIGO stage ≥IB and to 'high' risk cancer (stage ≥IB and/or grade 3 endometrioid and/or non-endometrioid histology).

A prospective study including 101 consecutive women with biopsy-confirmed EC, undergoing expert ultrasound examination at Karolinska University Hospital, Stockholm, Sweden, a tertiary referral center. All consenting women underwent DCE-US (using a 1.5-2.5 ml intravenous bolus of Sonovue® contrast agent) and conventional 2D-TVU/PD examination. DCE-US video clips were analyzed with regard to filling pattern, wash-in pattern and wash-out pattern and semi-quantitative DCE-US parameters (wash-in slope, time-to-peak, peak intensity and area-under-the-time-intensity-curve) obtained from a time-intensity curve. The study cohort was compared to a control cohort examined with 2D-TVU/PD only, matched 3:1 on FIGO stage and grade, using cases from our center examined according to the IETA (International Endometrial Tumor Analysis) protocol. Pathological evaluation after hysterectomy served as 'gold standard'.

After exclusions, 93 women remained in the study cohort and matched to 279 women in the control cohort. The prevalence of stage IA, grade 1-2 were 51% in both cohorts. The sensitivity was higher in the study cohort than in the control cohort in diagnosing both deep MI and CSI (MI: 0.74 vs. 0.62, p=0.036, CSI: 0.75 vs. 0.51, p<0.001) whereas specificity was not significantly different (MI: 0.87 vs. 0.85, CSI: 0.96 vs. 0.95). Specificity was higher in detecting 'high' risk cancer in the study cohort (0.94 vs. 0.85, p=0.024) but sensitivity did not differ. 'High' risk cancer and FIGO stage ≥IB was characterized by a 'focal' filling pattern, with wash-in 'prior' and a 'focal' wash-out pattern on subjective assessment of DCE-US. All quantitative DCE-US parameters were significantly predictive of FIGO stage ≥IB, but not to 'high' risk cancer despite a clear trend.

Combining DCE-US with 2D-TVU/PD can significantly improve the detection of deep MI and CSI without increasing the false positive rate compared to using 2D-TVU alone. It can also improve the correct classification of high-risk disease mainly by increasing the specificity and thereby possibly avoid unnecessary surgeries by almost ten percent. Quantitative DCE-US parameters, as well as a 'focal' filling pattern, endometrial wash-in 'prior' to the myometrium and a 'focal' wash-out pattern, all correlate to more advanced disease. This article is protected by copyright. All rights reserved.

The effect of prophylactic antibiotics for preterm prelabor rupture of membranes on perinatal outcomes: a network meta-analysis of randomized controlled trials.

Ultrasound in Obstetrics and Gynecology

Prophylactic antibiotics are routinely recommended in preterm prelabour rupture of membranes (PPROM), but there is an abundance of potential treatments and a paucity of comparative information. The aim of this network meta-analysis was (i) to compare the efficiency of different antibiotic regimens on perinatal outcomes, and ii) to assess the quality of the current evidence.

We performed a network meta-analysis of randomized trials comparing prophylactic antibiotics, or regimens of antibiotics, to each other or to placebo, in women with PPROM. We searched MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (Central), US Registry of clinical trials (www.clinicaltrials.gov) and grey literature sources. The primary outcomes were neonatal mortality and chorioamnionitis; secondary outcomes included other measures of perinatal morbidity. We estimated the relative effect sizes using risk ratios (RRs) and we obtained the relative ranking of the interventions using cumulative ranking curves. We assessed the quality of evidence for the primary outcomes according to GRADE guidelines, adapted for network meta-analysis. .

The analysis included 20 studies (7169 participants randomized in 15 therapeutic regimens). For the outcome of chorioamnionitis, clindamycin plus gentamycin (network relative risk [RR] 0.19, 95% confidence interval [CI] 0.05-0.83), penicillin (RR 0.31, 95%CI, 0.16-0.6), ampicillin-sulbactam plus amoxicillin-clavulanic acid (0.32; 95%CI 0.12-0.92), ampicillin (RR 0.52, 95% confidence interval [CI] 0.34-0.81), and erythromycin plus ampicillin plus amoxicillin (RR 0.71, 95%CI 0.55-0.92), were superior to placebo/no treatment. Erythromycin was the only affective drug for neonatal sepsis (RR 0.74, 95%CI 0.56-0.97). Clindamycin plus gentamicin (RR 0.32, 95%CI 0.11-0.89) and erythromycin plus ampicillin plus amoxicillin (RR 0.83; 95%CI, 0.69-0.99) were the only effective regimens for respiratory distress syndrome, whereas ampicillin (RR 0.42, 95%CI 0.20-0.92) and penicillin (RR 0.49, 95%CI 0.25-0.96) were effective in reducing the rates of IVH. None of the antibiotics appeared significantly more effective than placebo in reducing the rates of neonatal death, perinatal death, and necrotizing enterocolitis. No network risk ratios could be estimated for NICU admission. The overall quality of the evidence per GRADE was moderate to very low, depending on the outcome and comparison.

Several antibiotics appear to be more effective than placebo in reducing the rate of chorioamnionitis after PPROM. However, none of them is clearly and consistently superior compared to other antibiotics, and most are not superior to placebo for outcomes other than chorioamnionitis. The overall quality of the evidence is low and needs to be updated, as microbial resistance may have emerged for some antibiotics, while some other are underrepresented in the existing evidence. This article is protected by copyright. All rights reserved.