- Email: [email protected]
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Abstracts monly used views and the step-by-step conduct of the examination. Many drawings, animations, video-clips and 3D rendering support the concepts.
CRITICAL CARE IN OBSTETRICS 1043 Emergency obstetrical ultrasound I and II Doubilet P, Brigham and Women’s Hospital, United States of America Major indications for emergency obstetrical ultrasounds are, a. vaginal bleeding and/or pain in the first trimester: ectopic pregnancy is the main emergency diagnostic consideration; b. vaginal bleeding in the third trimester: placenta previa and abruption are the main emergency diagnostic considerations. Ectopic pregnancy The primary modality for diagnosing ectopic pregnancy is transvaginal ultrasound, with lesser roles for transabdominal ultrasound, HCG (serum or urine) and possibly Doppler ultrasound (spectral and/or color). Based on the predictive values of sonographic criteria for ectopic pregnancy, the basic approach to diagnosing tubal ectopic pregnancy will be presented. We will also discuss unusual ectopic pregnancies, including heterotopic, cervical, cornual, abdominal, and Cesarean section scar pregnancies. Diagnostic criteria for these ectopic pregnancies will be presented. Placenta previa The sonographic diagnosis on transabdominal sonography is best made with the bladder partially full, as an empty bladder can make visualization of the relevant area difficult, and an overly full bladder can simulate a previa (“pseudo previa”) by apposing the anterior and posterior walls of the lower uterine segment. If the lower segment posteriorly is obscured by the presenting fetal part, manual elevation of the fetus by abdominal palpation is often helpful. If manual elevation is unsuccessful or the transabdominal scan is nondiagnostic, transvaginal and translabial scanning are useful for diagnosing or excluding previa, as these techniques provide accurate visualization of the internal os. Most marginal previas diagnosed prior to the third trimester do not turn out to be previas at term. This discrepancy can result from technical errors (e.g., bladder overdistention) at the time of the initial scan or from elongation of the lower uterine segment as pregnancy proceeds. Placental abruption Placental abruption, or separation of the placenta from the uterine wall prior to delivery, can be diagnosed sonographically by demonstrating a retroplacental and/or extramembranous hematoma. A placental separation in which there is no retroplacental or extramembranous hematoma may be associated with a normal sonogram, so that a normal scan does not rule out abruption. If an abruption is demonstrated, the prognosis depends upon the estimated percentage of placental detachment and the size of the hemorrhage. 1044
II) Ideal for: a. Uterine fibroid embolization b. Post-partum hemorrhage III) Uterine fibroid embolization: a. First performed in France in early 1990s to reduce intraoperative blood loss during myomectomy. b. Introduced in 1997 as minimally invasive treatment for symptomatic uterine fibroids. c. Abnormal bleeding d. Bulk-related symptoms e. Technique i. Arterial access ii. Selective catheterization & arteriography iii. Embolization iv. Post-embolization arteriography v. Sheath removal f. Results i. Two ways to assess results 1. Symptomatic improvement: Does the patient feel better after UFE? 2. Volume reduction: Are the fibroids and uterus smaller after UFE? ii. Bottom line 1. UFE works to address the symptoms associated with uterine fibroids and does reduce uterine and fibroid volume 2. Results remain consistent when compared with older single-center, retrospective studies 3. Long-term follow-up and comparative data with other GYN procedures will be needed for this procedure to be universally accepted. iii. In one study: UFE demonstrated the following: 1. Better improvement of menorrhagia (92% vs. 64%) 2. Fewer days of narcotic use (5.1 days vs. 8.7 days) 3. Fewer complications (11% vs. 25%) 4. Quicker return to normal activity (8 days vs. 36 days) iv. In another study 1. Compared long-term outcomes of UFE and abdominal myomectomy (f/u 3-5 years) 2. UFE patients more likely to require further invasive treatment (29% vs. 3%) 3. No significant differences in symptomatic improvement in the remaining patients although UFE patients were more satisfied with their choice (94% vs. 79%) v. Pregnancy after embolization 1. UAE performed for indications other than fibroids seems compatible with future pregnancy. 2. UFE does not prevent women from getting pregnant or carrying a pregnancy to term. IV) Post-Partum Hemorrhage y a) Differential diagnosis y Retained products of conception y Uterine atony y Vaginal/cervical laceration y Placenta previa y Placenta accreta/increta/percreta y Placental abruption y Uterine fibroids y b) Embolization indications y Severe postpartum hemorrhage, irrespective of the etiology of bleeding or the type of delivery y Timing • As soon as primary management measures undertaken for hemorrhage are seen to be not working y System must be in place for IR to be here quickly y Results y Embolization effectively controls post-partum bleeding y Embolization does not appear to interfere with subsequent menstruation and fertility y Prophylactic balloon catheter placement y Place balloon catheters (e.g. angioplasty balloons) into both internal iliac arteries and leave them there. y Following delivery, inflate the balloons and limit blood flow into the pelvis. y The catheter access makes embolization quick and easy to do if necessary. Embolization in obstetrics & gynecology: Venous embolization I) Application a. Ovarian vein embolization b. Saphenous vein ablation II) Varicose veins are more than a cosmetic problem III) Conservative therapy should always be tried before invasive therapy IV) Minimally invasive therapy is now available to treat varicose veins (including sclerotherapy, ambulatory phlebectomy, and laser ablation) Conclusions: I) Embolization can play a significant role in the care of your patients II) Uterine fibroid embolization III) Post-partum hemorrhage IV) Ovarian vein embolization V) Saphenous vein ablation
Embolization in obstetrics and gynecology: Arterial embolization Veille J-C, Siskin G, Albany Medical College, United States of America The learning objectives of this talk are three folds: I) To understand the indications for embolization in obstetrics and gynecology II) To understand the methodology of arterial and venous embolization III) To understand the immediate and late beneficial outcomes of embolization I) Applications: a. Get in (vascular access) b. Find the abnormality (diagnostic angiography) c. Occlude the abnormal vessel (embolization)
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ECHOCARDIOGRAPHY FOR CORONARY ARTERY DISEASE 1045 New echocardiographic methods to assess ventricular mechanics: Torsion, strain and intraventricular pressure gradients Thomas JD, Cleveland Clinic Foundation, United States of America Echocardiography has the potential to provide a comprehensive assessment of cardiac systolic and diastolic function. To do this we must
CRITICAL CARE IN OBSTETRICS 1043 Emergency obstetrical ultrasound I and II Doubilet P, Brigham and Women’s Hospital, United States of America Major indications for emergency obstetrical ultrasounds are, a. vaginal bleeding and/or pain in the first trimester: ectopic pregnancy is the main emergency diagnostic consideration; b. vaginal bleeding in the third trimester: placenta previa and abruption are the main emergency diagnostic considerations. Ectopic pregnancy The primary modality for diagnosing ectopic pregnancy is transvaginal ultrasound, with lesser roles for transabdominal ultrasound, HCG (serum or urine) and possibly Doppler ultrasound (spectral and/or color). Based on the predictive values of sonographic criteria for ectopic pregnancy, the basic approach to diagnosing tubal ectopic pregnancy will be presented. We will also discuss unusual ectopic pregnancies, including heterotopic, cervical, cornual, abdominal, and Cesarean section scar pregnancies. Diagnostic criteria for these ectopic pregnancies will be presented. Placenta previa The sonographic diagnosis on transabdominal sonography is best made with the bladder partially full, as an empty bladder can make visualization of the relevant area difficult, and an overly full bladder can simulate a previa (“pseudo previa”) by apposing the anterior and posterior walls of the lower uterine segment. If the lower segment posteriorly is obscured by the presenting fetal part, manual elevation of the fetus by abdominal palpation is often helpful. If manual elevation is unsuccessful or the transabdominal scan is nondiagnostic, transvaginal and translabial scanning are useful for diagnosing or excluding previa, as these techniques provide accurate visualization of the internal os. Most marginal previas diagnosed prior to the third trimester do not turn out to be previas at term. This discrepancy can result from technical errors (e.g., bladder overdistention) at the time of the initial scan or from elongation of the lower uterine segment as pregnancy proceeds. Placental abruption Placental abruption, or separation of the placenta from the uterine wall prior to delivery, can be diagnosed sonographically by demonstrating a retroplacental and/or extramembranous hematoma. A placental separation in which there is no retroplacental or extramembranous hematoma may be associated with a normal sonogram, so that a normal scan does not rule out abruption. If an abruption is demonstrated, the prognosis depends upon the estimated percentage of placental detachment and the size of the hemorrhage. 1044
II) Ideal for: a. Uterine fibroid embolization b. Post-partum hemorrhage III) Uterine fibroid embolization: a. First performed in France in early 1990s to reduce intraoperative blood loss during myomectomy. b. Introduced in 1997 as minimally invasive treatment for symptomatic uterine fibroids. c. Abnormal bleeding d. Bulk-related symptoms e. Technique i. Arterial access ii. Selective catheterization & arteriography iii. Embolization iv. Post-embolization arteriography v. Sheath removal f. Results i. Two ways to assess results 1. Symptomatic improvement: Does the patient feel better after UFE? 2. Volume reduction: Are the fibroids and uterus smaller after UFE? ii. Bottom line 1. UFE works to address the symptoms associated with uterine fibroids and does reduce uterine and fibroid volume 2. Results remain consistent when compared with older single-center, retrospective studies 3. Long-term follow-up and comparative data with other GYN procedures will be needed for this procedure to be universally accepted. iii. In one study: UFE demonstrated the following: 1. Better improvement of menorrhagia (92% vs. 64%) 2. Fewer days of narcotic use (5.1 days vs. 8.7 days) 3. Fewer complications (11% vs. 25%) 4. Quicker return to normal activity (8 days vs. 36 days) iv. In another study 1. Compared long-term outcomes of UFE and abdominal myomectomy (f/u 3-5 years) 2. UFE patients more likely to require further invasive treatment (29% vs. 3%) 3. No significant differences in symptomatic improvement in the remaining patients although UFE patients were more satisfied with their choice (94% vs. 79%) v. Pregnancy after embolization 1. UAE performed for indications other than fibroids seems compatible with future pregnancy. 2. UFE does not prevent women from getting pregnant or carrying a pregnancy to term. IV) Post-Partum Hemorrhage y a) Differential diagnosis y Retained products of conception y Uterine atony y Vaginal/cervical laceration y Placenta previa y Placenta accreta/increta/percreta y Placental abruption y Uterine fibroids y b) Embolization indications y Severe postpartum hemorrhage, irrespective of the etiology of bleeding or the type of delivery y Timing • As soon as primary management measures undertaken for hemorrhage are seen to be not working y System must be in place for IR to be here quickly y Results y Embolization effectively controls post-partum bleeding y Embolization does not appear to interfere with subsequent menstruation and fertility y Prophylactic balloon catheter placement y Place balloon catheters (e.g. angioplasty balloons) into both internal iliac arteries and leave them there. y Following delivery, inflate the balloons and limit blood flow into the pelvis. y The catheter access makes embolization quick and easy to do if necessary. Embolization in obstetrics & gynecology: Venous embolization I) Application a. Ovarian vein embolization b. Saphenous vein ablation II) Varicose veins are more than a cosmetic problem III) Conservative therapy should always be tried before invasive therapy IV) Minimally invasive therapy is now available to treat varicose veins (including sclerotherapy, ambulatory phlebectomy, and laser ablation) Conclusions: I) Embolization can play a significant role in the care of your patients II) Uterine fibroid embolization III) Post-partum hemorrhage IV) Ovarian vein embolization V) Saphenous vein ablation
Embolization in obstetrics and gynecology: Arterial embolization Veille J-C, Siskin G, Albany Medical College, United States of America The learning objectives of this talk are three folds: I) To understand the indications for embolization in obstetrics and gynecology II) To understand the methodology of arterial and venous embolization III) To understand the immediate and late beneficial outcomes of embolization I) Applications: a. Get in (vascular access) b. Find the abnormality (diagnostic angiography) c. Occlude the abnormal vessel (embolization)
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ECHOCARDIOGRAPHY FOR CORONARY ARTERY DISEASE 1045 New echocardiographic methods to assess ventricular mechanics: Torsion, strain and intraventricular pressure gradients Thomas JD, Cleveland Clinic Foundation, United States of America Echocardiography has the potential to provide a comprehensive assessment of cardiac systolic and diastolic function. To do this we must