The use of ultrasound in the prediction of endometrial cancer in women with postmenopausal bleeding

The aim of the work presented in this thesis was to identify the ultrasound methods and ultrasound features that are most useful for the prediction of endometrial cancer in patients with postmenopausal bleeding and sonographic endometrial thickness 4.5 mm or more. The grey-scale ultrasound variable that best predicted malignancy was heterogeneous endometrial echogenicity (area under the receiver operating characteristics curve, AUC, 0.83), and the power Doppler ultrasound variable that best predicted malignancy was irregular branching of endometrial blood vessels (AUC 0.77). Mathematical models for evaluation of the individual risk of endometrial malignancy were constructed using clinical data, sonographic endometrial thickness, grey-scale ultrasound morphology of the endometrium, and power Doppler ultrasound findings. The model with the largest AUC (0.91) and the highest specificity at 90% sensitivity included the variables endometrial thickness, Vascularity index (reflecting the vascularization of the endometrium when using power Doppler ultrasound), age, and use of hormone replacement therapy. The endometrial volume as measured by three-dimensional (3D) ultrasound was larger and the 3D power Doppler flow indices (reflecting endometrial vascularization) were higher in both the endometrium and in the subendometrium in women with malignant endometrium than in those with benign endometrium, but there was substantial overlap between the two categories. The saline contrast sonohysterography (SCSH) variable that best discriminated between benignity and malignancy for both two-dimensional (2D) and 3D SCSH was the presence of at least one focal lesion with an irregular surface (for 2D SCSH the AUC was 0.84, for 3D SCSH the AUC was 0.70). The mathematical models to estimate the individual risk of endometrial malignancy constructed in this thesis are likely to be useful for individualizing the management of women with postmenopausal bleeding and sonographic endometrial thickness 4.5 mm or more, but they need to be prospectively validated before they can be introduced into clinical practice

The impact of Ureaplasma infections on pregnancy complications

The aim of this study was to assess if ureaplasmas are associated with pregnancy complications and diseases in newborns. Pregnant women with complaints and threatening signs of preterm delivery were included. A sample, taken from the endocervical canal and from the surface of the cervical portion, was sent to the local microbiology laboratory for DNA detection of seven pathogens: Chlamydia trachomatis, Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma parvum, Ureaplasma urealyticum, Neisseria gonorrhoeae, and Trichomonas vaginalis. The Pearson Chi-Square test was used to determine the difference in unpaired categorical data. A two-sided p value <0.05 was considered to be statistically significant. In all, 50 pregnant women with complaints and threatening signs of preterm delivery were included. Premature rupture of uterine membranes was found in 23 (46%) of the patients and 38 women (76%) had preterm delivery. Ureaplasma infections were associated with a premature rupture of membranes (p < 0.004), the placental inflammation (p < 0.025), a newborn respiratory distress syndrome (p < 0.019). Ureaplasmas could have affected the preterm leakage of fetal amniotic fluid and are associated with the placental inflammation and a newborn respiratory distress syndrome

The comparison of umbilical cord arterial blood lactate and pH values for predicting short-term neonatal outcomes

Objective: Current clinical practice of assessing neonatal condition is based on evaluation of umbilical cord arterial blood pH value rather than lactate. However, evidence shows that lactate is direct and more predictive measurement than pH or at least of equal importance. This study is to assess and compare umbilical cord arterial lactate and pH values for predicting short-term neonatal outcomes. Materials and methods: A retrospective cohort study was conducted at the tertiary level hospital, were arterial umbilical cord blood sampling was collected according to the standard procedures. Neonatal morbidity was registered if at least one of the following conditions was noted: Apgar score at 1 min after delivery was 6 or lower, resuscitation performed, including assisted ventilation and requirement of admission to neonatal intensive care unit. Mothers–newborns pairs were allocated into two groups: newborns exposed to perinatal hypoxia (group 1) and observed as healthy newborns (group 2). Receiver operating characteristics curves (ROC) were generated to assess the predictive ability of pH and lactate for the short-term neonatal outcomes. Results: 901 neonates born at ≥37 weeks of gestation were included. Newborns exposed to perinatal hypoxia (group 1) encompassed 39 (4.3%) patients, and observed as healthy (group 2) – 862 (95.7%). Arterial umbilical cord blood pH in group 1 was 7.160 ± 0.126 as compared to 7.314 ± 0.083 in group 2; p < 0.001. Mean arterial lactate was significantly higher in group 1 than group 2 (6.423 ± 2.335 as compared to 3.600 ± 1.833; p < 0.001). The difference between areas under ROC curves representing pH and lactate was not significant (0.848 and 0.831 respectively; p = 0.6132). Conclusion: Umbilical cord arterial lactate and pH predicted short-term neonatal outcomes with similar efficacies

Clinical and Ultrasound Characteristics of the Microcystic Elongated and Fragmented (MELF) Pattern in Endometrial Cancer According to the International Endometrial Tumor Analysis (IETA) criteria

OBJECTIVES: To describe sonographic features of the microcystic elongated and fragmented (MELF) pattern of myometrial invasion (MI) using the International Endometrial Tumor Analysis (IETA) criteria; to assess the effect of the MELF pattern on preoperative ultrasound evaluation of MI; and to determine the relationship of the MELF pattern to more advanced stage ( 65 IB) and lymph node metastases (LNM) in women with endometrioid endometrial cancer (EEC). METHODS/MATERIALS: We included 850 women with EEC from the prospective IETA 4 study. Ultrasound experts performed all ultrasound examinations, accordingto the IETA protocol. Reference pathologists assessed the presence orabsence of the MELF pattern. Sonographic features and accuracy of ultrasound assessment of MI were compared in cases with the presence and the absence of the MELF pattern. The MELF pattern was correlated to more advanced stage ( 65IB) and LNM. RESULTS: The MELF pattern was present in 197 (23.2%) women. On preoperative ultrasound imaging the endometrium was thicker (p = 0.031), more richly vascularized (p = 0.003) with the multiple multifocal vessel pattern (p < 0.001) and the assessment of adenomyosis was more often uncertain (p < 0.001). The presence or the absence of the MELF pattern did not affect the accuracy of the assessment of MI. The MELF pattern was associated with MI 65 50% (p < 0.001), cervical stromal invasion (CSI) (p = 0.037), more advanced stage ( 65 IB) (p < 0.001) and LNM (p = 0.011). CONCLUSIONS: Tumors with the MELF pattern were slightly larger, more richly vascularized with multiple multifocal vessels and assessment of adenomyosis was more uncertain on ultrasound imaging. The MELF pattern did not increase the risk of underestimating MI in preoperative ultrasound staging. Tumors with the MELF pattern were more than twice as likely to have more advanced stage ( 65 IB) and LNM