3D Trumps 2D For Localizing IUD's

In the August issue of OBG Management, NYU's Dr.Steven R. Goldstein penned an article suggesting that we stop relying on the standard 2D ultrasound for localizing an IUD. The reason: that 3D or volume ultrasound allows visualization of planes, specifically a coronal plane, not often seen on the standard sonogram. Why is this important? Read on.

Dr. Goldstein's article demonstrates several images from studies in which the IUD's location doesn't look unusual on the 2D image. However, in the coronal plane of 3D imaging, a problem is demonstrated. Benacerraf et al found that 75% of patients with abnormally situated IUD's presented with either pain or bleeding - more than twice the rate of women whose IUD's were found normally situated. We recently saw a young woman who had been in the Emergency Department complaining of pelvic pain for whom the diagnosis of her problem was far from clear. Visualization of the IUD in the coronal plane of her 3D sonogram clearly showed that not only was the device malpositioned in the lower uterus but one of the lateral arms penetrated the wall as well.

So now that you know a 3D study is superior, where should it be done? My answer would be more shameless self-promotion. For more information or to schedule a 3D ultrasound, please call (718) 925-6277.

Shameless Self-Promotion

Many patients, colleagues, friends and family have all asked me: "Who's the most qualified to perform Ob-Gyn ultrasounds?" So here is my unvarnished and completely biased opinion.

An ultrasound study can be performed by either a sonographer or a sonologist (a doctor who performs or supervises ultrasounds.) However, a doctor will have a more extensive background in both health and disease processes than someone who is not a physician as a general rule. A physician will have spent far more time on the clinical side of the equation so will be more able to formulate a better differential diagnosis.

Now while a radiologist and gynecologist can both perform a decent pelvic ultrasound study, a gynecologist is generally far more familiar with female pelvic physiology and pathophysiology than a general radiologist. When it comes to a vaginal ultrasound, this shouldn't even be a question. An old friend once remarked that if radiologists performed vaginal sonography, the transducer handle would be long enough to reach into the reading room. Instead, most if not all radiologists read the studies performed by sonographers. A gynecologist performs a vaginal sonogram in much the same way an old-fashioned pelvic exam is performed, even down to occasionally using the abdominal hand.

Also, when a sonographer performs a sonogram in the standard radiology practice, the patient usually has to leave without knowing the result. When a gynecologist performs the exam, the result, at least preliminarily, is available right away. This eliminates a great deal of anziety.

OK, so now we've agreed your pelvic sonogram is best performed by an Ob-Gyn, why should it be performed by THIS "Recovering Obstetrician?" The short answer is Experience. I have been performing Ob-Gyn sonography since the late 1970's and exclusively since 1986. Since that time, when I decided to limit my practice to consultative ultrasound, I have had a chance to learn what works, what doesn't work, and have climbed to the summit of a rather steep learning curve. I've also learned a great deal about how to deal with both anxious patients and concerned referring clinicians. Do keep all this in mind if and when you need an ultrasound.

Thanks for reading. This concludes my infomercial.

For more information or to schedule an ultrasound, please call 718-925-6277.

Pelvic Exam for the 21st Century

The American College of Physicians (ACP) certainly stirred up a hornets' nest with their pronouncement on the value of pelvic exams.

...“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost,” said Dr. Linda Humphrey, a co-author of the guideline and a member of ACP’s Clinical Practice Guidelines Committee.

As I have posted previously, perhaps it's time to think about replacing the pelvic exam with ultrasound.

...So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

When it comes to the issue of screening for ovarian cancer, the pelvic exam has failed miserably. Dr. Nick Summerton writes in the Spectator :

In seeking to pick up ovarian cancer at an early stage — with an improved chance of cure — much better alternatives to the vaginal examination are trans-vaginal ultrasound and CA125 testing. CA125 is a chemical given off by cancer cells that circulates in the bloodstream and women with ovarian cancer tend to have higher levels.

In 2015, the UKCTOCS screening trial for ovarian cancer will publish its results. Preliminary findings look very promising but, of course, "it ain't over 'til it's over."

Stay tuned.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Where's Waldo?

We've all seen Waldo, the guy with the striped shirt and matching cap.

Seems pretty easy to spot, right?

But what if Waldo is in a large, busy crowd - is he still easy to spot?

Sometimes, an early pregnancy is harder to spot than Waldo. Because pregnancy tests are so sensitive, women are getting that first ultrasound quite early on in gestation. There is a window of about 2 - 3 weeks after conception when an early intrauterine pregnancy might not be visualized. This creates a quandary - is she really pregnant, is there a problem with the pregnancy or a problem with the dates, and, worst case scenario, is the pregnancy ectopic. Doctors refer to this clinical situation as "Pregnancy of Uncertain Location" or PUL. The usual management consists of serial measurements of the blood pregnancy hormone or Beta HCG and repeating the ultrasound until the situation is resolved. The protocol had been that failure to see a normally-situated pregnancy on ultrasound at a critical level of Beta HCG was highly suspicious for an ectopic pregnancy or a failed intrauterine pregnancy. Unfortunately, as we all are aware, life is not always so neat.

Doubilet et al, writing in the New England Journal of Medicine reviewed the diagnostic criteria of pregnancy of uncertain location and failed pregnancy and found that previously utilized criteria were a set up for diagnostic error, resulting in administration of a powerful teratogenic drug, Methotrexate, in cases subsequently found to be normal pregnancy. Nurmohamed et al found 8 cases of intrauterine pregnancy in which methotrexate was administered for suspected ectopic. None of these cases had a happy outcome.

Doubilet's review offered new consensus guidelines for the diagnosis of both early pregnancy failure and pregnancy of uncertain location, nicely summarized Here.

So if you find yourself in this situation, please review this post again and perhaps ask your doctor to review it as well.

For more information or to schedule an ultrasound, please call (718) 925-6277.

It Ain't Over 'Til It's Over

This morning, I found this disturbing story from India.

A man upon finding his first born baby deformed created a ruckus in government women's hospital on Wednesday alleging that the administration had changed his baby after delivery. Dozens of villagers gathered in his support in the hospital and shouted slogans against the doctors. The man stated that he had twice got the sonography of his unborn baby done from a privated doctor who claimed that the baby was perfectly normal.

According to sources, Farhan of nearby Gagwana village, was very excited about his first child and he took his wife for sonography in her third and seventh months. "The doctor told me that the baby was perfectly alright and we were happy with it," said Farhan.

On Sunday, Farhan's wife delivered the baby in a government hospital and afterwards the baby was brought to the couple. "The child was deformed and we were shocked to see that. When I enquired the doctors, they said that the baby was born deformed," added Farhan.

Farhan again went to the same private doctor who had conducted the sonography of his wife, "The doctor claimed that it is not possible after looking at the sonography report that the baby would be born deformed," Farhan said.

Farhan on Wednesday came back to the hospital and returned the baby to the hospital administration demanding to return his real child, "They changed my baby with another and I demanded DNA test before taking the baby," said Farhan.

Dozens of villagers from Gagwana also gathered in the hospital and created ruckus. They shouted slogans against the hospital administration. Police was also called on the spot to control the situation.

Having a child with a birth defect is obviously difficult but when it's unexpected, it literally gut-wrenching for all concerned. At issue is the question: what are the reasonable expectations after an apparently normal 20 week scan?

In the Netherlands, Baardman et al reported on the introduction of a routine 20 week scan increased the detection rate for serious congenital heart defects. However, at best, 15% of the defects went undetected before birth.

Magriples and Copel analyzed a series of 901 patients who underwent ultrasound screening with referral for a targeted exam if an abnormality were suspected. The babies were then examined at birth. There were 28 abnormalities in total. Of these, 5 or 17.8% were missed. In general, the more severe were detected while some of those missed were more subtle.

So what's the take home message? Trying to perform a physical exam on someone who is inside someone else is often exceedingly difficult. Moreover, prenatally, the sonographer is not looking at the finished product.

As Yogi Berra once said in 1973, "It ain't over 'til it's over." To contact me or to schedule an ultrasound, call (718) 925-6277.

Polycystic Ovarian Syndrome: A Silent Misery

From The Daily Star:

A young girl, 15 years old, struggles with acne ever since her periods started. And not too long ago, she noticed dark thick facial hair around her chin and over her cheeks, something that can be socially crippling in school. No amount of waxing, threading and bleaching helps and this 15-year-old is miserable.

A couple has been trying to conceive for nine months with no positive result. In a country with an over-population problem and a serious lack of understanding of infertility and sexual health, there are usually misunderstandings on the varied number of reasons as to why a couple may not be able to conceive. There are grumbling in-laws, a lot of finger-pointing and blaming, usually the women, which does little to help the situation.

A 27-year-old woman has very irregular periods. She has gained a lot of weight over a year or two. She feels bloated and uncomfortable with friends and family being rather insensitive to her recent weight gains. Not having periods regularly also makes her scared about her future, especially when she thinks about marriage and children.

A 22-year-old woman feels extreme pain in her lower abdomen. When she is rushed to hospital, the doctors suspect appendicitis but ultrasounds show that her appendix is fine. However, because she has a sexually active relationship with her boyfriend and does not want her family or even her doctor to find out, she provides limited information on her symptoms which leads to inconclusive diagnosis.

What do these women have in common? They have Polycystic Ovarian Syndrome.

For reasons that are not well understood, in PCOS the hormones get out of balance. One hormone change triggers another, which changes another. For example:

The sex hormones get out of balance. Normally, the ovaries make a tiny amount of male sex hormones (androgens). In PCOS, they start making slightly more androgens. This may cause you to stop ovulating, get acne, and grow extra facial and body hair.

The body may have a problem using insulin, called insulin resistance. When the body doesn't use insulin well, blood sugar levels go up. Over time, this increases your chance of getting diabetes.

The cause of PCOS is not fully understood, but genetics may be a factor. PCOS seems to run in families, so your chance of having it is higher if other women in your family have it or have irregular periods or diabetes. PCOS can be passed down from either your mother's or father's side.

For more information or to schedule an ultrasound, please call: (718)925-6277.

Can Ovarian Cancer Be Found Early?

Ovarian cancer is the deadliest of all pelvic cancers for a woman. Overall, about one in seventy-two women will develop this disease. Of these, over half will have died within five years of diagnosis. If ever a disease cried out for a screening test, this would be it. Unlike the breasts, for example, the ovaries lie deep within the body and are therefore less accessible to physical exam. The bimanual pelvic exam is also uncomfortable and the discomfort causes women to tighten the abdominal muscles, making detection that much more difficult. If you add factors such as obesity and scars from Cesareans, you find the examiner's ability to feel the ovaries decreases exponentially.

Ultrasound has been suggested as a screening technique since the 1980's. In the US, the leading proponent of transvaginal ultrasound for ovarian cancer screening has been Dr. Van Nagell's group at the University of Kentucky.

Some have tried utilizing blood markers such as CA-125. Most recently, the group at MD Anderson found that evaluating changes in the level of CA-125 over time and combining that with transvaginal ultrasound yielded promising results in finding more early ovarian cancers.

Others, however, have not met with similar success. The US Preventive Services Task Force, in fact, recommends not screening for ovarian cancer.

Later this year, The UKCTOCS,the largest randomized trial of screening will publish its results, hopefully shedding more light on this issue.

In the meantime, there are some women at significantly higher risk for ovarian cancer, those whose strong family history or genetic tests place in a high risk group. For this group of women, screening, with all its foibles, should be considered. For more information or to schedule an ultrasound, please call: (718) 925-6277.

Dad's Magic Moment

Everyone knows that the prenatal ultrasound provides the opportunity for mom to bond with her baby to be. Even before she first feels movement, seeing that tiny heart's beating, watching those movements, makes it all real. There is ample literature to describe the maternal bonding experience. But what about dad? Few have studied his reactions to the process - that is until now. Dr. Tova Walsh and colleagues at the University of Michigan interviewed 22 expectant fathers after they viewed a midtrimester ultrasound.

They found that the ultrasound experience was an important moment for men, establishing the reality of the coming child, and reassuring them that all was going well with the pregnancy.

It also caused the men to reflect on their roles in the life of mother and child, making it an important practical and psychological preparation for parenthood. The study noted that the men’s “plans and dreams alike extended beyond the immediate future of infancy and across the child’s lifespan.”

One man told the researchers, “Now that we know that it’s a girl, you know, now I’m thinking about ... walking her down the aisle someday, you know, (I’m) thinking that far ahead ... which is crazy, but I mean, it’s like my brain went from bringing her into the world and taking care of her and making sure she is taken care of (as) to her future and everything ...”

Another had more immediate worries: “I need to make sure I have a steady job because my child eating depends on me. If I don’t work, he don’t eat. And I’d rather my child eat before I do.”

Dads have magic moments too.

Walsh is a Robert Wood Johnson Foundation Health & Society Scholar at the UW School of Medicine and Public Health. Her study, “Moving up the Magic Moment: Fathers’ Experience of Prenatal Ultrasound,” is being published in the winter 2014 edition of the journal "Fathering".

For more information, or to schedule an appointment for an ultrasound, call: (718) 925 - 6277.

My Placenta Is Low-Lying. Now What?

Now that most pregnant women have a midpregnancy ultrasound, they are often alerted to findings of uncertain significance. One of the most common of these involves the placenta. A placenta is low-lying when the lower edge extends to within 2 centimeters of the internal cervical opening or os. This is different from a placenta previa which actually covers the internal os. A group of investigators at the Brigham and Women's Hospital in Boston reported on their experience with the eventual outcome of pregnancies complicated by these low placentas.

Here's the short answer: Most of these situations resolve by the end of the pregnancy.

In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks.

A small minority were not so lucky.

Twenty patients (1.6%) had persistent sonographic placenta previa or a low-lying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries.

So, about 98/100 times all turns out well. In about 2/100 cases, the situation persists. Moreover, a very few unfortunate women were found to have vasa previa, a condition in which fetal blood vessels actually cross that internal os in front of the baby. Think about that for a moment. If the baby descends toward the birth canal and puts pressure on these blood vessels, those vessels can tear, resulting in a fetal hemorrhage, often severe.

So what should be the plan if they do find a low-lying placenta during your ultrasound? The authors suggest a repeat sonogram after 28-30 weeks to confirm resolution, repeating again at 34-36 weeks if the situation remains the same. During those studies, a search for vasa previa can also be conducted.

So if you're told you have a low-lying placenta, you should be optimistic but should follow up. The late Ronald Reagan said it best: "Trust but verify."

For more information or to schedule an ultrasound, please call: (718) 925-6277.

New UK Project To Improve Prenatal Detection of Birth Defects

Presently, most if not all pregnant women undergo at least two sonograms during pregnancy for the purpose of screening for serious birth defects - the first at 11.5 - 14 weeks and the second at about 20 weeks. While some abnormalities are virtually always detected, many still are missed for a variety of reasons. For one thing, mom's with increased weight gain pose a technical imaging problem as the ultrasound frequency necessary for sufficient penetration may not yield the optimal resolution. Another factor is the fetal position - "if the baby has his back to the camera, you don't get a good picture." For these reasons and more, a groups of investigators at Kings College London are trying to see if technology can solve these issues.

Professor Reza Razavi and colleagues at King's College London, as part of King's Health Partners Academic Health Sciences Centre, have been awarded funding under the joint Wellcome Trust and EPSRC Innovative Engineering for Health scheme to develop a fully automated and computer-guided ultrasound system, which will allow midwives to acquire three-dimensional images of a whole baby in a much higher resolution than is currently possible. The team are also aiming to develop computer software that will be able to automatically analyse the images acquired. These techniques should substantially improve detection rates of congenital abnormalities.

Professor Razavi, who is Head of Imaging Sciences at King's College London and Director of Research at King's Health Partners, said: "Identifying birth defects at an early stage is essential both for medical professionals and for the parents themselves. Current ultrasound scans are relatively crude and many serious abnormalities are not detected, leading to these babies becoming very ill soon after birth, and substantial delay before a diagnosis is made and they can be transferred to a specialist centre for appropriate treatment.

"We are developing a radically new approach to fetal screening, largely removing the need for experts to acquire and interpret the images. It will allow the initial screening scans to be done in a few minutes, and provide a consistently higher detection rate for major abnormalities."

I wish them well.

For more information or to schedule an appointment for an ultrasound, call: (718) 925-6277.

Maternal Weight And Stillbirth

This past week in the Journal of the American Medical Association, a statistical analysis of 38 studies of moms' weight either prior to pregnancy or in early pregnancy showed a relationship between maternal BMI and risk of stillbirth. The loss of a wanted pregnancy at any gestational age is tragic but the worst has to be a fetal death in the few weeks prior to birth. The nursery has been set up. The birth announcements prepared. Often, the room is packed with gifts from the baby shower. All this adds to the immense suffering of the loss of a child.

So how is maternal weight linked to stillbirth? The authors suggest the possibility that the increased amount of adipose tissue may exert metabolic effects which affect placental function. We already know the effect of weight, fat, and type 2 diabetes, for example. A similar altered biology may be at work here as well. Another possibility is that heavier women become less sensitive to fetal movement and are thus less apt to pick up on the signals of decreasing fetal movement. The lack of this alarm mechanism may miss that narrow window for life-saving intervention.

So what should a woman considering having a baby do in light of this information? The best, obviously, is to get as close to ideal body weight as possible prior to conception. When this is not possible, early prenatal care would be essential, with a special emphasis to nutritional counseling. As pregnancy enters the "home stretch," certain tests of fetal well-being can be considered - monitoring or non-stress tests, serial ultrasounds for fetal growth, and biophysical profiles. Additionally, fetal kick counts can be done at home which require no sophisticated equipment.

Moms to be should voice any concerns with their Obstetricians. For more information, or to schedule an appointment for an ultrasound, you can call my office at: (718) 925 - 6277.

JWoww's Pregnancy Scare

Jenni Farley aka JWoww of "Jersey Shore" fame (or infamy) described the impact of learning about a minor abnormality in her prenatal ultrasound.

Jenni reported on her blog recently that a routine ultrasound turned into a moment of pure terror when her doctor informed her that he identified what may be a cyst on the fetus' brain. "At this point I honestly can't tell you what he's saying because I go numb and tears are just flowing," Jenni wrote of the incident. A scary diagnosis, to be sure, but using her trademark tenacity, Jenni secured an appointment with a specialist who delivered some good news: Jenni writes that the new doc informed her: "It's called choroid plexus cyst and over time the cyst should go away." She added, "Honestly I was happy but still my heart felt heavy. And even though I know I did nothing to cause it, I felt guilty and so helpless." Well, apparently Jenni has developed a skill for suspenseful storytelling during her months of sobriety because she ends the blog post by revealing that this all happened several weeks ago: "Fast forward to this check-up which brings me to 25 weeks aka 6 months," JWoww writes. "My daughter's cyst went away!"

There are a variety of findings whose significance seems relatively minor to obstetricians and sonographers yet strike fear in the hearts of moms to be. Choroid plexus cyst is one of these findings. Choroid plexus cyst or CPC is a small fluid-filled structure found in the choroid tissue in the ventricle of the developing fetal brain. CPC's are found in about 1 - 2% of all fetuses so these are quite common. While earlier descriptions found an association between CPC and Trisomy 18 (an extra copy of chromosome 18,) this association has not panned out in further investigations. CPC's do not cause swelling on the brain or hydrocephaly. They are not in and of themselves a major abnormality and have no effect on mental development. In the absence of other risk factors for chromosome problems, eg. age, family history, previously affected children, or other malformations, these should not warrant either worry or further investigation. In fact, most, as in Ms. Farley's case, resolve spontaneously.

For more information, or to schedule an appointment, please call my office: (718)-925-6277.

Disruptive

There are many disruptions in the flow of care these days, especially in the Emergency Department. However, Disruptive has taken on a whole meaning lately, what with the proliferation of mobile and even wearable tech. Today, I cam across this post by Dr. Teresa Wu..

...As you are supervising two of your residents putting in bilateral chest tubes, your eager medical student runs up to the trauma bay with a pair of Google Glass. You are researching ways to incorporate wearable technology like Google Glass into your clinical practice and medical education so you and your medical student have a few pairs of Glass with you at work. You put on Glass and ask your medical student, “What can I help you with?” He informs you that your senior resident wants you to take a look at an ocular ultrasound of a patient he staffed with you a little while ago. He knows you are going to be tied up in the trauma bays for quite some time and wants to know if he can discharge the patient with ophthalmology follow up.

...You turn on Google Glass and link to your senior resident who is also wearing Google Glass while performing the bedside ocular ultrasound (Image 1). Through Glass you can see the ultrasound screen as he views it. What does the B-mode ocular ultrasound demonstrate? What’s the patient’s diagnosis?

Bedside Ultrasound meets Google Glass. Read the whole thing.

Just Wow!

Should Ultrasound Replace The Bimanual Pelvic Exam?

For complete disclosure, let me point out that my practice is limited to consultative ultrasound, having ceased the practice of clinical gynecology in 1986. When I trained at Bellevue in the late 1970's, even asking such a question would have outted you as a heretic punishable by intense re-education. But medicine swings like a pendulum do and today, this is a fair question. What's changed? The dual developments of portable real-time ultrasound followed by the vaginal transducer have swung that pendulum toward the imaging side. While sonograms have been thought of as the stethoscope for the obstetrician, the vaginal probe has greatly facilitated the pelvic exam. Further, there is now accumulated evidence to highlight the superiority of sonography to evaluate the female pelvis. One eye-opening study was by Padilla et al in 2000, assessing the predictive value of pelvic exam under anesthesia. Conclusion?

Bimanual pelvic examination has marked limitations for evaluating adnexa, even with ideal circumstances. Experience during postgraduate training in gynecology did not seem to improve examination accuracy. Patient characteristics such as obesity, uterine size, and abdominal scars limit the accurate palpation of the adnexa.

Now one reason why the pelvic exam is decidedly unpopular with patients is that, setting aside its invasiveness, it's uncomfortable. The more discomfort felt results in more patient's tensing the abdomen, causing the examiner to press harder and causing more discomfort. In this particular study, anesthesia removed the pain - pressure cycle from the equation and still found the bimanual examination lacking.

So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

Similarly, sonography has been shown to be superior to bimanual exam in assessing gestational age in the first trimester and facilitating the management of inflammatory disease. In the assessment of uterine fibroids, an experienced examiner fared as well as sonography except in obese patients. As more and more Americans are dealing with obesity, the pendulum here again favors sonography.

My colleague from NYU Dr. Steven R. Goldstein suggested incorporating endovaginal sonography into routine gynecologic examinations. That time is long overdue.

To contact me or to schedule an appointment, please call my office:(718) 925-6277

Transvaginal Ultrasound - The Rest of the Story

Recently, an incredibly useful diagnostic tool for women's health has become embroiled in the firestorm of abortion politics. I'm speaking of transvaginal ultrasound and I'm here to try to set the record straight. Transvaginal sonography, or TVS, has been around for longer than you think, having come a long way from the first use by the Japanese in 1971. The technique was popularized in the late 1980's as a logical extention of women's healthcare. Rather than have a woman fill her bladder to point of significantt pain and disttress, a small, high frequency transducer is simply placed close to the organs of interest, resulting in images usually far more detailed than those obtained from the transabdominal route.

During this introductory phase of TVS, I was a practicing gynecologist and it seemed a natural extension of my pelvic examination. I was initially using a small standard pediatric transducer which was easily introduced, but switched over to the standard long-handled probe when I got the chance. As a shameless plug, I'd like to say I was, at least in my neck of the woods, a pioneer in this regard. I found quickly that I could evaluate potential difficulties in early pregnancy for those women who thought they were miscarrying and usually reassuring them that things were OK. I could also confirm the location of an early pregnancy, often a week earlier than transabdominally. This came in handy in those cases of suspected tubal pregnancy, which previously wasn't diagnosed until the woman presented to the emergency room in significant distress.

TVS also was able to characterize ovarian cysts, with endometriomas and dermoids usually exhibiting such a distinctive appearance that a definitive diagnosis became possible. Now, when coupled with sensitive color and power doppler, vascular signatures can be determined, facilitating the diagnosis of ovarian cancer, often at an earlier stage than before.

Today, TVS has many uses in both obstetrics and gynecology. Monitoring cervical length in patients at risk for preterm delivery is routine. TVS is often useful in evaluating fetuses for certain abnormalities such as anencephaly. In women undergoing IVF, monitoring of follicles and obtaining eggs via the transvaginal route is standard of care. TVS, especially with 3D probes, facilitates the monitoring of the location of possibly malpositioned IUD's. Three dimensional multiplanar transvaginal sonography produces images of the uterus which can rival an MRI, allowing cost-effective diagnosis of uterine malformations and location of fibroids and polyps. Instillation of saline into the uterus in patients with abnormal bleeding is now a standard technique for triaging therapy for these women.

So, once the political smoke is allowed to clear, we're left with one impression. Transvaginal ultrasound is an impressive advance in women's healthcare. It's truly frustrating that this diagnostic modality has become such a political football. I truly hope that the dust settles sooner rather than later.

If you have any questions, feel free to leave a comment or tweet me @sonodoc99 on Twitter.