Simple sonographic marker helps predicts the risk of intra-abdominal adhesions in patients with previous Cesarean section

A simple sonographic marker ‘sliding sign’ of the uterus during the last trimester of pregnancy can help physicians to distinguish between patients who have a high probability of intraabdominal adhesions during repeat cesarean section reports the results of an observational study published in the Journal of Ultrasound in Obstetrics & Gynecology (UOG). 

Presence of Intra-abdominal adhesions complicate the repeat surgical procedure and increase the chances of bladder and bowel trauma and bleeding. About 24% to 46% of patients will develop adhesions after one cesarean and the rate increases to 43% to 75% at the third, and up to 83% at the fourth cesarean delivery.

Italian researcher Baron and colleagues selected 59 patients who had a history of one or more previous cesarean section and evaluated them during the third trimester of ongoing pregnancy by abdominal ultrasound. To know about the risk of the presence of adhesions, the researcher looked at the sliding of gravid uterus under the inner part of the fascia of abdominal muscles.

Women who demonstrated easy and obvious sliding during deep breathing were predicted to be at low to moderate risk of the presence of intraabdominal adhesions (positive sliding sign), while in women whom the sliding was very little or absent (negative sliding sign), were at high risk of severe adhesions.

The prediction was confirmed at surgery, 16 out of 19 women who displayed a negative ‘sliding sign’ had severe intra-abdominal adhesions while 35 out of 40 women with positive ‘sliding sign’ had very few adhesions.

The sensitivity and specificity of the sliding sign in predicting the presence of intra‐abdominal adhesions in women undergoing repeat CS were 76.2% and 92.1%, respectively.

Thus, a simple sonographic sign can help physicians to know about the patient’s risk of having adhesions and be prepared for adhesions related complications during the repeat cesarean delivery.

Here is UOGJournal video clip illustrating the simple sonographic marker ‘sliding sign.’

Abstract 

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Innovative combination of light and ultrasound could help catch ovarian malignancy early

https://yourmedicalsource.com

A team of physicians and researchers from the Washington University School of Medicine in St. Louis has recently developed a ‘hopeful technique’ that combines ultrasound and photoacoustic technology to evaluate and diagnose malignant ovarian tumors at an early stage.

Ovarian malignancies are often diagnosed at a late stage because there are no specific signs and symptoms and no specific screening test for diagnosing ovarian cancer. Only 15% of ovarian cancers are detected at early stages.

The American Cancer Society estimates that about 22,240 women will receive a new diagnosis of ovarian cancer and about 14,070 women will die from ovarian cancer in the year 2018.

The researchers recently conducted a pilot study using co-registered photoacoustic tomography with ultrasound to evaluate ovarian masses in 16 patients at the School of Medicine and Barnes-Jewish Hospital. The results were recently published in the journal Radiology.

The team involving Quing Zhu, professor of biomedical engineering in the School of Engineering & Applied Science created a sheath using optical fibers that encases the standard transvaginal ultrasound probe. The optical fibers are connected with a laser source.

As the sheath is introduced in the vagina, the laser light penetrates the vaginal wall to get absorbed by the tumor to generate sound waves to reveal information about tumor vasculature and sO2 inside the ultrasound visible ovaries.

A normal ovary is not highly vascular and contains a lot of collagen tissue, but a malignant tissue is highly vascular because of neoangiogenesis. Using this multispectral photoacoustic imaging, the team looked at 26 ovarian masses from 16 participants that included nine invasive epithelial ovarian cancers (six serous carcinomas and three endometroid adenocarcinomas), three other tumors (two borderline serous tumors and one sex cord-stromal tumor), and 14 benign and normal (hereafter referred to as benign/normal) ovaries.

The researchers used two biomarkers to study the ovaries: relative total hemoglobin concentration (rHbT), which is directly dependent on the tumor angiogenesis, and mean oxygen saturation (sO2). The rHbT was almost two times higher for invasive epithelial cancerous ovaries as compared to normal ovaries P = .01) and the mean sO2 of invasive epithelial cancers, and the borderline and stromal tumors, was 8.2% lower than that of benign/normal ovaries (P = .003).

“Physicians are very excited about this because it might bring significant change into current clinical practice,” Zhu said. “It is very valuable to detect and diagnose ovarian cancers at early stages. It is also important to provide information and assurance to patients that there is no worry about their ovaries, instead of removing a patient’s ovaries. This technology can also be valuable to monitor high-risk patients who have increased risk of ovarian and breast cancers due to their genetic mutations. The current standard of care for these women is performing risk reduction surgeries to remove their ovaries at some point, which affects their quality of life and causes other health problems.”

Encouraged by the results of the pilot study, the team is gearing up to validate the findings in larger subjects and has applied for funding.

Here is a short video showing Dr. Zhu explaining the technology

Abstract in Radiology Journal

News Release by Washington University in St. Louis

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GE Healthcare new fetalHQ software streamlines evaluation of congenital heart diseases

The ultrasonologist can now assess the size, shape, and function of the fetal heart in less than 3 minutes with the GE Healthcare new fetalHQ software. Evaluating fetal heart and ruling out congenital heart anomalies is complicated at 18-20 weeks. This condition is not uncommon and affects one out of every 110 babies around the world.

At this gestational age, the fetal heart is exceptionally complex, just the size of a grape and the rate is near twice the adult heart rate. GE new tool – fetalHQ runs on GE Healthcare’s Voluson ultrasound systems and is the first tool to simultaneously examine the size, shape, and function of the fetal heart.

fetalHQ is the brainchild of Greggory DeVore, M.D., a specialist in maternal-fetal medicine at Huntington Hospital, Pasadena, California. He got inspired to develop the software from another software that used speckle tracking analysis to map the motion of tissues in the heart. This software was regularly used by adult and pediatric cardiologist to assess the function of the heart.

Dr. DeVore installed the software and reprogrammed it to visualize the fetal heart in 24 segments and map it in a way that was never done earlier.

“This was the genesis of the creativity behind using this software,” DeVore said. “From this, we made several measurements of the heart’s size, shape, and contractility – or how it’s squeezing. We immediately got to work and published 13 peer-reviewed articles that described the clinical value of this software.”

Here is a video showing the fetalHQ‘s automatic delineation of the fetal heart’s shape

GE Healthcare news release

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New 3-D printed, air-powered, biopsy robot that can collect sample inside MRI unveiled

The University of Twente revealed its latest version of world’s most accurate 3D-printed biopsy robot during the Surgical Robot Challenge at the international Hamlyn Symposium in London. The robot is named Sunram 5 and is faster and accurate than its previous self.

Today, most breast biopsies are performed by handheld needles under sonographic guidance, based on previous radiological films. But, many a time the needle placement is not perfect because what was seen on MRI or mammography may look quite different on sonography. Coupled with human error, this may create serious problems such as a malignant lesion may be reported as benign.

MRI scanners are unparalleled in terms of locating lesions, and it would be perfect if a biopsy is taken under their guidance. This would though require a robot small enough to fit beside the patient under MRI robot that could fit. The robot should also be made of a material not influenced by strong magnetic field created by MRI.

Researchers at the Twente University, Netherlands, have tailor-made a robot to above specification. The robot is very small and easily fit under the breast compression device. It is powered by air pressure maintained through external pumps, which also enables it to be under operator control. It is made up of hard plastic except for the MR-conditional needle itself.

The dual speed motors in the updated model have improved the speed so as the robot can reach its target location in about 10 seconds. In case of any technical mishap, a safety mechanism in the device retracts the needle from the breast.

Here is the video showing how the new robot works.

University of Twente press release

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3D printed fetus to hold and love: Brazilian obstetrician prints ultrasound fetal model for visually impaired couple

Ana Paula and Alvaro with the baby's model

Ana Paula and Alvaro with the baby's model

A team of doctors from Brazil printed a 3D life like model of  baby in utero from images obtained from GE Voluson10 ultrasound  for a legally blind couple, so that they can feel their baby, because they were unable to see the ultrasound images.

Ana Paula Silveira and her husband, Alvaro Zermiani, live in São Paulo, Brazil, and are legally blind. Like other normal couples they also wanted to enjoy the grainy glimpses of their son, Davi Lucas and see him growing and developing well inside the uterus.

They consulted Dr. Heron Werner, a gynecologist and obstetrician working atthe DASA clinic in Rio de Janeiro, who is well into 3D printing and is known for printing 3D fetus models through high-quality ultrasound exams.

So, they printed the first fetus model for the couple at 12 weeks of pregnancy. Ana and Alvaro were thrilled. “Holding the small fetus at 12 weeks is an indescribable feeling,” she says. “Following up on our son’s evolution allowed us to have this feeling of being whole, because we feel with our hands.”

Ana Paula and Alvaro with Dr. Werner (left) in his office in Rio. 

Images credit: Ana Paula and Alvaro Zermiani.

Dr. Werner got the idea of 3D printing babies during a visit to Rio’s National Museum, which was using a tomography machine to digitize its ancient Egyptian exhibits.

“From the moment we got to the high-quality ultrasound exam, through the possibility of 3D printing it, I realized that it could also serve to enhance the prenatal experience of visually impaired pregnant women,” Dr. Werner said.

A second model has also been printed, in which they could feel Davi’s face and appreciate the close resemblance he shared with them. “Thanks to the exams and printing, we were able to not only know that our baby was growing healthy but also to have a very real contact and establish a very strong involvement with our son,” she says.

The ultrasound machine, Voluson E10 is GE’s newest and most advanced Voluson system to date. The Voluson E10’s Radiance System Architecture sets a new standard in imaging technology and gives the more clarity because of 4X ultrasound pathways for spectacular 2D and 3D/4D images with increased penetration, transfer the data at 10x speed providing higher resolution and very fast frame rates and it processes the information 4X times faster to streamline the workflow.

A real-time ultrasound GIF of a baby’s face taken by the GE’s Voluson 10 machine.

 Image credit: GE Healthcare

All images: Courtesy GE

GE Reports

Double layer vs single layer uterine closure in cesarean results in stronger uterine scar and increases chances of vaginal birth in future pregnancies.

Transabdominaluterine scar measurement at 36-38 weeks.

Double layer closure of uterus during previous cesarean section results in thicker third-trimester lower uterine segment and decreases rate of uterine rupture by 3 to 5fold during trial of labor after cesarean (TOLAC) and vaginal birth after cesarean reports results of multicenter prospective cohort study published in July issue of Journal obstetrics and gynecology.

In U.S.A, about 1.3 million babies are delivered by Cesarean every year, which roughly equals to every 1 in every 3 children born in US (33%). Decrease in vaginal births after cesarean and TOLAC has significantly contributed to the rising C-section rates. Significant maternal and neonatal mortality and morbidity because of uterine rupture has increased the rate of elective repeat C-section (ERC).

Lower uterine segment thickness (LUST) as measured by ultrasound is routinely used in clinical practice to estimate the risk of uterine rupture during TOLAC.  A value of <2.0 mm measured between 35 and 38 weeks is significantly associated with greater incidence of uterine rupture or scar dehiscence compared with a measurement >2.0 mm.

The researchers performed a secondary analysis of study conducted at 4 hospitals over a period of 5 years. Out of 1856 women originally recruited, records about uterine closure in previous C-section were available for 1613 patients.

Each of the study participant received transvaginal and transabdominal sonography for measuring LUST between 34 weeks to 38 weeks and 6 days of pregnancy.  Each measurement was confirmed at least 3 times.

Thirty-one percent (495) of patients had undergone a single layer closure, whereas 69% (1118) had undergone a double layer closure at the time of previous C-section.

After adjustment of confounding factors, it was observed that patients with double layer uterine closure had 32% less odds of third-trimester LUST <2.0 mm in the next pregnancy (P<.01).

Type of catgut (Chromic vs synthetic) did not have any effect on thickness of lower uterine segment in next pregnancy. Other factors that resulted in LUST < 2 mm were interdelivery interval <18 months; a body mass index >30 kg/m2; and an elective or planned cesarean delivery.

If previous cesarean was performed in labor than it resulted in thicker lower uterine segment as compared to cesarean performed electively. So, double layer closure becomes all the more important in elective cesarean sections.

Patients were followed up till delivery and it was seen that patients with double layer closure were slightly more likely to undergo TOLAC or vaginal birth. Double layer closure was also significantly less likely to be associated with uterine scar defect and dehiscence.

The authors concluded that, “the current study supports the use of double-layer suture of the uterus at cesarean, especially when it is performed before labor, to optimize uterine scar healing. This technique could lead to a reduction of uterine scar defects during a TOLAC.”

Full text can be accessed here.

Source: Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy

Vachon-Marceau, Chantale et al.

American Journal of Obstetrics & Gynecology , Volume 217 , Issue 1 , 65.e1 - 65.e5