An ultrasound examination is undoubtedly one of the most commonly performed procedures in Obstetrics and Gynecology. This technology has been an important development in the diagnosis and management of many common disorders in obstetrics and gynecology. By reviewing its history, we appreciate how much it has revolutionized our clinical practice.
Gynecology ; Pregnancy ; Technology ; Female

This paper documents the first reported cases of patients in the country who underwent transvaginal ultrasound‑guided Tru‑cut biopsy of pelvic tumors in a tertiary level health institution in 2019. Different indications for Tru‑cut biopsy were demonstrated highlighting its clinical utility in the diagnosis and management of malignant pelvic tumors. All patients warranted histologic diagnosis for further planning of the most appropriate management. Adequate tissue samples were obtained from all three patients with no procedure‑related complications.

Objectives: Pseudomyxoma peritonei (PMP) in women arises from an appendiceal or ovarian pathology and presents either of two histological subtypes of differing prognosis, disseminated peritoneal adenomucinosis (DPAM), or peritoneal mucinous carcinomatosis (PMCA). This study aimed to evaluate the demographic, clinical, and sonographic features among affected women and the differences between the two histological subtypes. Methods: A retrospective study was conducted involving 36 women with histopathological diagnosis of PMP who had preoperative ultrasound and underwent surgery at the department of obstetrics and gynecology in a tertiary hospital. Demographic and clinical data, ultrasound images and reports, and final histopathology were reviewed. To compare the subtypes, one‑way analysis of variance for continuous data and Chi‑square/Fisher exact test for categorical data were used, with P < 0.05 indicating statistical significance. Results: Patients were mostly >50 years of age, multigravid, and presented with abdominal distention. Ultrasound examinations consistently showed amorphous, mixed echo or echogenic ascites, peritoneal thickening, and omental caking. Adnexal/ovarian masses were detected in 66.7% of cases. Omental caking was significantly more prevalent in PMCA (83.3%; P = 0.0002), whereas larger ovarian tumors (>20 cm) and papillarities were more common in DPAM (both 92.9%; P = 0.0005). Most patients underwent gynecologic surgery (n = 31; 86.1%), and 14 (38.9%) required readmission due to recurrence. The final histopathology revealed largest tumor involvement of the appendix (n = 13; 36.1%), the ovaries (n = 11; 30.5%), or undetermined (n = 12; 33.3%). Conclusions Preoperative diagnosis of PMP is possible based on its clinical and ultrasound features. Although the subtypes are similar in most of these features, certain ultrasound findings may aid in distinguishing them.
Pseudomyxoma Peritonei

Context: Endometrial cancer is the third most common malignancy of the female genital tract in the Philippines, following cervical and ovarian cancer. Ultrasound as the first line in imaging has a major role in preoperative treatment and planning. Aims: To compare the diagnostic accuracy of subjective versus objective ultrasound measurement techniques in detecting cervical stromal invasion (CSI) and deep myometrial invasion (MI). Materials and Methods: Fifty‑seven patients were enrolled in this cross‑sectional study. Deep MI and CSI were evaluated both subjectively and objectively by measuring tumor‑free distance (TFD), distance from the outer cervical os to lowest edge of the tumor border (Dist‑OCO), and distance from the internal cervical os to caudal tumor border (Dist‑ICO). Histopathological result used as the gold standard. Results: Subjective assessment for deep (MI) had 79.3% sensitivity, 82.1% specificity, 82.1% positive predictive value (PPV), 82.1% negative predictive value (NPV), and 80.7%. Subjective assessment for CSI had a sensitivity, specificity, PPV, NPV, and overall accuracy of 80%, 90.4%, 44.4%, 97.9%, and 89.5%. Objective measurement (TFD ≤0.8 cm) to detect deep MI had 86.2% sensitivity, 57.1% specificity, 67.4% PPV, 80% NPV, and 71.9% overall accuracy. Adjusting TFD cutoff to 0.65 increased to 71.4% specificity, making it comparable with subjective assessment. Dist‑OCO (≤2.1 cm) yielded 100% sensitivity, 86.3% specificity, 30% PPV, 100% NPV, and 87% overall accuracy. Dist‑ICO was first used in this study, hence no cutoff yet. By using receiver operating characteristics, cutoff was 0.45 cm, which yielded a 60% sensitivity and 92% specificity (area under the curve 0.731, P = 0.09). Conclusions Subjective assessment of CSI and deep MI performs better than objective measurement techniques. TFD and Dist‑OCO as the objective measurements showed clinically comparable accuracy to subjective assessment by an expert. Dist‑ICO needs to be validated to a larger population to determine its clinical value in predicting CSI.
Endometrial Neoplasms

Background: The International Endometrial Tumor Analysis (IETA) group developed a catalog of standardized terms to describe findings that may be associated with uterine pathology. However, there is a lack of reliability studies for these descriptors in the literature. Objective: The objective of this study was to estimate interobserver and intraobserver reliability with regard to the IETA group descriptors for endometrial vascular characteristics in women with abnormal uterine bleeding. Materials and Methods: Five nonexpert and five expert raters assessed stored still images of transvaginal ultrasound examinations obtained from 68 women with abnormal uterine bleeding and endometrial thickening. Endometrial vascularity was evaluated using the IETA group descriptors for color flow and vascular pattern. Interobserver agreement was estimated by comparing the assessments of the nonexpert and expert raters. Intraobserver agreement was estimated by repeating the raters’ assessment after 4 weeks. Interrater agreement to the subjective assessment of an expert investigator was also computed. Results and Conclusion The reproducibility of assigning IETA color score is good regardless of the degree of expertise of the rater, although the experts displayed better interobserver reliability (κ = 0.74 vs. 0.57) and intraobserver reliability (κ = 0.84 vs. 0.63). However, the reproducibility of describing IETA vascular patterns is significantly worse for both expert and nonexpert raters in both interobserver reliability (experts κ = 0.49 vs. 0.34) and intraobserver reliability (experts κ = 0.65 vs. 0.42). Both expert and nonexpert raters exhibited acceptable agreement with the reference standard, with experts performing better for both color score (κ = 0.79 vs. 0.70) and vascular pattern (κ = 0.63 vs. 0.44).
Endometrium

Context: Vulvar cancers are rare gynecologic tumors. Ultrasound can characterize primary tumors and guide the biopsy of suspicious nodes. Currently, there are no studies on the sonologic features of different vulvar cancer types. Aims: The aim is to determine the sonologic features of different vulvar malignancies. To compare the accuracy of ultrasound in identifying lymph node status. Settings and Design: This is a retrospective descriptive study. Subjects and Methods: Patient records, ultrasound images, and reports of vulvar cancer with long‑ and short‑axis (L/S) ratio of inguinal nodes were reviewed from the year 2010 to 2019. Statistical Analysis Used: The accuracy of ultrasound to detect lymph nodes and the correlation of L/S ratio to histopathology were done. Results: The study included 49 patients. The most common histopathologies were squamous cell carcinoma (SCCA), vulvar melanoma (VM), and adenocarcinoma (ADCA). Most tumors were > 4 cm, unifocal, and lateral in location. SCCA, verrucous carcinoma, VM, ADCA, adenosquamous carcinoma (ASCA), eccrine carcinoma (ECCA), and carcinosarcoma (CS) were irregular heterogeneous masses. Leiomyosarcoma (LMS) and proximal‑type epithelioid sarcoma (PES) were regular, heterogeneous masses. Paget’s disease of the vulva (PDV) was hypoechogenic with regular borders. Vascularities were absent in PDV and LMS, minimal in ECCA, moderate in ASCA and PES, moderate to abundant in CS, and variable in VM. The accuracy of ultrasound in detecting lymph nodes was 78%; the accuracy of the L/S ratio was 75%. Tumor border and FIGO stage showed significant association with histopathologic type. Conclusions Sonologic features and accuracy of ultrasound in predicting lymph node status help prognostication in vulvar cancer. Nodal morphometric studies are recommended for future researches.
Vulvar Neoplasms

Background: Pelvic arteriovenous malformations (AVMs) are rare but carries life-threatening consequences. Case Report: A 47-year-old multipara who had previously undergone four cesarean sections came for re-evaluation of a malignant ovarian new growth. She was asymptomatic. Repeat ultrasound revealed normal ovaries, and a cystic structure at the left adnexa with abundant mixing of colors, turbulent flow and pulsative waveforms on spectral Doppler. It arises from serpentine tubular structures from the uterine isthmus. Uterine artery aneurysm was considered. Magnetic resonance angiography confirmed the findings of aneurysm and pelvic arteriovenous malformation. The patient underwent a hysterectomy with ligation and excision of aneurysm. Histopathologic findings showed pelvic AVM and a true aneurysm of the uterine artery. Conclusion Ultrasound with color Doppler is a low-cost and readily available tool for gynecologists for the diagnosis and management of pelvic AVM.
Ultrasonography, Doppler

The objective of this clinical report is to present the first local case of rare cavernous uterine hemangioma. This is a case of a 28‑year‑old G2P1 (1001) during her first trimester of pregnancy who was admitted to our institution for the second time due to profuse vaginal bleeding and severe anemia. The transvaginal scan revealed an embryonic demise of 8 weeks age of gestation noted at the endocervical canal. There is a posterofundal heterogeneous mass measuring 6.3 cm × 5.7 cm × 5.0 cm (volume: 94.2 ml) with multiple cystic spaces, which on Doppler studies showed abundant vascularity suggestive of uterine hemangioma. Antifibrinolytics were administered. The patient underwent emergency hysterectomy with bilateral salpingectomy due to profuse vaginal bleeding with histopathology result of cavernous hemangioma of the uterus. Cavernous uterine hemangioma is a rare vascular lesion that poses a great challenge in the diagnosis and management. There were limited published articles regarding cavernous hemangioma of the uterus. There were conservative treatment options such as uterine artery embolization, the use of hormonal oral contraception, intralesional glucocorticoid therapy, the use of interferon‑α, laser therapy, and surgical excision. Hysterectomy is the definitive treatment for intractable bleeding. It is recommended to establish an international registry for this rare case. The experts in different specialties such as obstetrician‑gynecologists, interventional radiologists, and vascular surgeons, can also formulate an algorithm for its diagnosis and treatment.
Case Reports ; Hemangioma ; Vascular Malformations

Urogynecology and Reconstructive Pelvic Surgery has long been recognized specialty in the field of obstetrics and gynecology and it is not new to any of us. In 1979, the American College of Obstetrics and Gynecology officially recognized this field as a subspecialty. In the Philippines, however, urogynecology is still in its infancy stage. Urogynecology concerns problems of the female genital tract and lower urinary and lower intestinal tract disorders. More commonly, we provide care to women with various pelvic floor disorders such as pelvic organ prolapse, fecal incontinence, and bladder control problems, specifically urinary incontinence. They are, at present, aspects of women’s health that are frequently neglected or ignored. With the recent emphasis on women’s health and quality of life, caring for women with various pelvic floor disorders would become an increasingly important aspect of women’s healthcare. Moreover, for a rapidly growing and aging population, the demand for such care will inevitably escalate.
Pelvic Floor Disorders

Introduction: Although it is likely that outcomes in pregnancy differ between regions due to differences in health‑care delivery, resources, and health protocols, the rampant increase in COVID‑19 cases has proven its effects on the maternal and fetal outcomes. But to what extent does COVID‑19 in pregnancy affect adverse maternal and neonatal outcomes compared to non‑COVID‑19 pregnant patients? Objectives: This study aims to compare maternal outcomes (morbidity, mortality, intensive care unit [ICU] admissions, and cesarean section [CS] rate) and fetal outcomes (prematurity, APGAR score, neonatal ICU [NICU] admission, and mortality) between COVID‑19 and non‑COVID‑19 cases. Methodology: A retrospective cohort study was done through chart review of 240 patients, 120 for the COVID‑19 group and 120 for the non‑COVID‑19 group. Demographic data, as well as maternal outcomes (i.e., morbidity, mortality, ICU admissions, and emergency CS), and adverse fetal outcomes (i.e., prematurity, low APGAR, NICU admission, and mortality) were gathered. These outcomes were also classified according to disease severity for the COVID‑19 group. The effect of using investigational drugs to outcomes was also determined. Results: This study shows that adverse maternal outcomes were significantly increased with COVID‑19 infection. Mortality was increased by 10% while morbidities (acute respiratory distress syndrome, disseminated intravascular coagulation, hemorrhage, and sepsis) were increased by 35%. ICU admission for COVID‑19 patients was 10.8% higher, and the emergency CS rate was also increased by 10% in the COVID‑19 group. Results also showed increased adverse fetal outcomes for the COVID‑19 group, with a 10.8% increase in neonates being born prematurely, an 11.67% increase in low APGAR score, a 9.16% increase in mortality, and a 10% increase in NICU admission. The use of investigational drugs in cases of severe and critical COVID‑19 did not have any significant benefits to the outcomes. Conclusion COVID‑19 infection significantly increases both maternal and fetal outcomes, and these adverse effects correspond to the severity of the disease. The use of investigational drugs in severe and critical COVID‑19 cases has no significant benefit to maternal and fetal outcomes.