DONALD SCHOOL JOURNAL OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY

January-March 2020 Volume 14 Issue 1 ISSN: 0973-614X
eISSN: 0975-1912
January-March2020Volume14Issue1
Bibliographic Listings:
ProQuest, Embase, Scopus, EBSCO, Index Copernicus,
Genamics JournalSeek, Ulrich, HINARI, J Gate,
Google Scholar, CiteFactor, SIS, SJIF, OAJI,
COSMOS, SIF, ESJI, SJR, IIJIF, Journals Factor
The Official Journal of the
Ian Donald Inter-University School of Medical Ultrasound
Jaypee Journals
Special Issue: Reducing Maternal Mortality in Low-income Countries
PICTURE OF THE MONTH
• HDlive Flow with STIC for Assessment of Fetal Goiter
RESEARCH ARTICLE
• A Noninvasive Screening Tool for Abnormal Uterine Bleeding: An Attempt to Reduce
Numbers of Endometrial Biopsies
CASE REPORTS
• Fetal Massive Pericardial Effusion as a Sign of Bilateral Diaphragmatic Agenesis:
A Case Report
• Klippel–Feil Syndrome: A Rare Case Report
PAPERS DEDICATED TO SHOCKING DATA ON MATERNAL MORTALITY IN
DEVELOPING COUNTRIES
REVIEW ARTICLES
• Maternal Mortality: Tragedy for Developing Countries and Shame for Developed World
• How to Increase Resilience of Healthy Newborns in Underdeveloped Countries?
• Health-dedicated Millennium Development Goals: What has been Done Wrong?
• Maternal Mortality in the USA
• Role of Obstetric Ultrasound in Reducing Maternal and Neonatal Mortality in
Developing Countries: From Facts to Acts
• Maternal Mortality: The Indian Story
• Improving the Quality of Training and Service in Obstetrics and Gynecology Practice
• Some Solutions to Reduce Maternal Mortality
• Maternal Mortality among Refugees and in Zones of Conflict
• Maternal Mortality: What are Women Dying from?
• Health System and Markers of Health in Uruguay
COMMENTARY
• From Safe Motherhood to Sustainable Development Goals: Unmet Targets; What Are
We Missing?
DONALD SCHOOL JOURNAL OF ULTRASOUND IN
OBSTETRICS AND GYNECOLOGY
SPECIAL ISSUE: REDUCING MATERNAL MORTALITY IN LOW-INCOME COUNTRIES

Also Available...
For more details log on www.ijifm.com
Infertility & Fetal Medicine
International Journal of
Editor-in-Chief : Kamini A Rao (India)
Presentation: Full Color / Cover Type: Soft Cover / Size: 8.25’’ × 11.75’’
ISSN: 2229-3817 / eISSN: 2229-3833 / Issues: 3
Jaypee Journals
CALL FOR PAPERS
We invite you to
submit your research work
to our journal
Bibliographic Listings:
ProQuest, Embase, Scopus, EBSCO, Genamics JournalSeek, Ulrich,
HINARI, J Gate, Google Scholar, CiteFactor, SIS, Index Copernicus,
SJIF, OAJI, COSMOS, SIF, ESJI, SJR, IIJIF, Journals Factor
We take you global
and increase your
visibility
Also available online at: www.jaypeejournals.com,www.dsjuog.com
email: siddharth.singh@jaypeebrothers.com

Volume 14 Issue 1 January–March 2020
DSJUOG
Donald School Journal of Ultrasound
in Obstetrics and Gynecology
www.jaypeebrothers.com
www.jaypeejournals.com
Special Issue: Reducing Maternal Mortality in Low-income Countries

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)ii
2. Ethical Considerations
Manuscripts submitted for publication must
comply with the following ethical considerations:
Informed Consent
Informed consent of the patients must be taken
before they are considered for participation in
the study. Patient identifying information, such as
names, initials, hospital numbers or photographs
should not be included in the written descriptions.
Patient consent should be obtained in written and
archived with the authors.
Protection of Human Subjects and
Animals in Research
When conducting experiments on human
subjects, appropriate approval must have been
obtained by the relevant ethics committees. All
the procedures must be performed in accordance
with the ethical standards of the responsible
ethics committee both (institutional and national)
on human experimentation and the Helsinki
Declaration of 1964 (as revised in 2008). When
reporting experiments on animals, authors must
follow the institutional and national guidelines for
the care and use of laboratory animals.
Copyright
© 2020 Jaypee Brothers Medical Publishers (P) Ltd.
www.jaypeebrothers.com
1. Aims and Scope
The Donald School Journal of Ultrasound in
Obstetrics and Gynecology publishes quality
review articles of all aspects of ultrasound as it
impacts diagnosis and management in the field.As
the technology and its applications are constantly
improving, there is a need for lifelong learning for
all sonologists so that they can optimize their care
of gynecologic, maternal and fetal patients on an
ongoing basis.
The Ian Donald Inter-University School of
Medical Ultrasound with its 50 active member
nations is proud to support. The Donald School
Journal of Ultrasound in Obstetrics and Gynecology
(DSJUOG) and provide continuing medical
education to sonologists throughout the world.
4. Subscription Information
ISSN 0973-614X
eISSN 0975-1912
• Subscription rates
For information on subscription rates and the other
journal-related enquiries, please contact:
subscriptions@jaypeebrothers.com
• Orders
Journals Department
Jaypee Brothers Medical Publishers (P) Ltd.
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-4357 4357
Fax: +91-11-4357 4314
e-mail: subscriptions@jaypeebrothers.com
• Back volumes. Prices are available on request.
5. Electronic Media
An electronic edition of this journal is available at
Manuscripts can be submitted online at
www.dsjuog.com
For advertisement queries, please contact:
Journals Department
e-mail: ashwani.shukla@jaypeebrothers.com
6. Advertisement
Foranyqueriesregardingonlinesubmission,please
e-mailusat:siddharth.singh@jaypeebrothers.com
For editorial queries, please contact:
geetika.sareen@jaypeebrothers.com
The journal is printed on acid-free paper.
3. Copyright
Following guidelines must be followed before
submission of the manuscript:
The articles must represent original research
material, should not have been published before
and should not be under consideration of publi
cation elsewhere. This, however, does not include
previous publication in form of an abstract or as
part of published literature (review or thesis). It is
the duty of the author to obtain the necessary
permissions for extensive quotations, tables,
illustrations or any other copyrighted material
they are using in the paper before a paper can
be considered for publication. Copyright of
the article gets transferred to Jaypee Brothers
Medical Publishers (P) Ltd., once the article has
been accepted for publication. The author would
be asked to sign the ‘Copyright Transfer Form’
before his/her article is considered for publication.
Once the copyright transfer statement has been
signed by the corresponding author, no change in
authorship or in the order of the authors listed on
the article would be accepted by Jaypee Brothers
Medical Publishers (P) Ltd. Also by signing the
above-mentioned form, the author reassigns the
rights of copublishing or translation if considered
necessary in future to the publisher. In the advent
of occurrence of any dispute, the matter would be
resolved within the jurisdiction of New Delhi court.
While all care has been taken to provide
accurate and correct information in accordance
with the date of publication, neither the authors/
editors and nor the publisher takes any legal
responsibility for any unintentional omission
or error. The publisher makes no expressed or
implied warranty with respect to the information
contained herein. The published material cannot
be photocopied for the following purposes: general
distribution, promotion, new works or resale. If this
is required, specific written permission requires to
be obtained from the publisher. Exclusive rights
to reproduce and distribute the articles in this
journal have been protected by copyright. This
also covers the rights to reproduce or distribute the
article as well as the translation rights. No material
published in this journal can be reproduced in
digital format or stored in form of electronic
databases, video disks, etc.
Both the conflict of interests and financial
disclosure need to be handled well while con
ducting the research study. Disclosure of such
relationships is also important in connection with
all articles submitted for publication. Both of these
have also been included in the copyright transfer
form. Authors should give due acknowledgment
Donald School
Journal of Ultrasound
in Obstetrics and
Gynecology
to the individuals who provide writing or other
assistance while conducting the research study
and also disclose the funding source for the
research study.

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) iii
Editorial Board
Publishing Center
Publisher
Jitendar P Vij
Business Head
Geetika Sareen
Managing Editor
Siddharth Singh
Advertisements/ Subscriptions/ Reprints
Ashwani Shukla
Phone: +91-8447136447
ashwani.shukla@jaypeebrothers.com
For Website Queries
Phone: +91-11-43574357
e-mail: journals.editor@jaypeebrothers.com
Editorial and Production Office
PS Ghuman
Journals Department
4838/24, Ansari Road, Daryaganj
New Delhi-110 002, India
Phone: +91-11-43574357, +91-9717528877
Fax: +91-11-43574314
e-mail: ps.ghuman@jaypeebrothers.com
EDITORS-IN-CHIEF
Asim Kurjak Croatia
Frank A Chervenak USA
EXECUTIVE EDITORS
Sanja Kupesic Plavsic USA
Ritsuko K. Pooh Japan
Ivica Zalud USA
Renato Augusto Moreira de Sa Brazil
Panagiotis Antsaklis Greece
Tuangsit Wataganara Thailand
CO-EDITORS
Kazuo Maeda Japan—History
Ana Bianchi Uruguay—Obstetrics
Giovanni Monni Italy—Invasive diagnostic procedures
Zoltan Papp Hungary—Prenatal diagnosis
Eberhard Merz Germany—3D/4D sonography
Veljko Vlaisavljevic Slovenia—Human reproduction
Miroslaw Wielgos Poland—Education
Radu Vladareanu Romania—Gynecology
Milan Stanojevic Croatia—Neonatology
Narendra Malhotra India—Developing countries
Carmina Comas Gabriel Spain—Non-invasive prenatal diagnostics
Aris Antsaklis Greece—Twins
Ashok Khurana India—Urogynecology
Tamara Illescas (Spain) & Waldo Sepulveda Chile—1st trimester screening
Toshiyuki Hata Japan—Functional studies of the fetus
EDITORIAL BOARD
Abdel Latif Ashmaig Khalifa Sudan
Abdallah Adra Lebanon
Alaa Ebrashy Egypt
Aleksandar Ljubic Serbia
Alexandra Matias Portugal
Aliyu Labaran Dayyabu Nigeria
Anton Mikhailov Russia
Awatif Al Bahar UAE
Azen Salim Indonesia
Cihat Sen Turkey
Corazon Yabes-Almirante Philippines
Elsa Viora Italy
Erasmo Huertas Tacchino Peru
Fida Mahmoud Ahmad Thekrallah Jordan
Gordana Adamova Macedonia
Gwang Jun Kim Korea
Hari Shrestha Nepal
Ha To Nguyen Vietnam
Hisham Ahmad Arab Saudi Arabia
Junichi Hasegawa Japan
Jure Knez Slovenia
Lara Spalldi Barisic Croatia
Liliana Voto Argentina
Marina Degtyareva Russia
Mohamed S Elmahaishi Libya
Nelson Aguilar Colombia
Orion Gliozheni Albania
Salim Daya Canada
Syed Amir Gilani Pakistan
Taib Delic Bosnia and Herzegovina
Tony Duan China
Tze Kin Lau Hong Kong
Ulrich Honemeyer UAE
Vincenzo D’Addario Italy
Yaron Zalel Israel
Young-Nam Kim Korea
Sertaç Esin Turkey
Official Director of Publishing
Jitendar P Vij India
Secretary of the Journal
Jadranka Cerovec
Global Marketing Directors
Raju Menon/Shivkumar Menon
Global Marketing Office
Ian Donald Inter University School of
Medical Ultrasound LLP
Unit no. 5, Ground Floor, Dilkap Chambers
Behind Balaji Telefilms, Veera Desai Road Extension
Andheri (W), Mumbai-400053
Phone: 66990140/50/60
e-mail: shiv@iandonaldschoolindia.com

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)iv
IAN DONALD SCHOOL DIRECTORS
Country Email address
Founder and Director
Asim Kurjak Croatia asim.kurjak@public.carnet.hr
Vice-Director
Ivica Zalud USA Ivica@hawaii.edu
Co-Directors
Frank A. Chervenak USA fchervenak@northwell.edu
Eberhard Merz Germany merz.eberhard@web.de
Executive Director
Milan Stanojevic Croatia mstanoje29@yahoo.com
Regional Directors
Jaideep Malhotra (Indian subcontinent) India jaideepmalhotraagra@gmail.com
Toshiyuki Hata (Asia and Oceania) Japan toshi28@med.kagawa-u.ac.jp
Giovanni Monni (Europe) Italy prenatalgmonni@gmail.com
Ana Bianchi (Latin America) Uruguay abianchi@asesp.com.uy
Abdallah Adra (Arabic World) Lebanon aa107@aub.edu.lb
Syed Amir Gilani (Central Asia) Pakistan profgilani@gmail.com
Miroslaw Wielgos (Eastern Europe) Poland miroslaw.wielgos@wum.edu.pl
Executive Board
Sanja Plavsic Kupesic USA sanja.kupesic@ttuhsc.edu
Ritsuko K. Pooh Japan pooh27ritsuko@fetal-medicine-pooh.com
Panagiotis Antsaklis Greece panosant@gmail.com
Waldo Sepulveda Chile waldosep@yahoo.co.uk
Tuangsit Wataganara Thailand twataganara@yahoo.com
Sonal Panchal India sonalyogesh@yahoo.com
Advisory Board
Giampaolo Mandruzzato Italy mandruzzatogiampaolo@tin.it
Jose Maria Carrera Spain jmcarrera@matres-mundi.org
Joachim Dudenhausen Germany joachim.dudenhausen@charite.de
Toshiyuki Hata Japan toshi28@med.kagawa-u.ac.jp
Kazuo Maeda Japan maedak@mocha.ocn.ne.jp
Permanent Director of Advanced International Courses on Ultrasound and Human Reproduction
Domenico Baldini Italy dbaldini@libero.it
Director of Ian Donald School specialist fellowship programs in Arabic World
Badreldeen Ahmed Qatar profbadreldeen@hotmail.com
Directors of National Branches
Abbas Aflatoonian Iran abbas_aflatoonian@yahoo.com
Ulrich Honemeyer / Amala Khopkar Nazareth UAE (Dubai) dr.ulrich.ho@hotmail.com
dr.amala@hotmail.com
Ghalia Gaber Abd El Mottaleb UAE (Abu Dhabi) ghgaber@gmail.com
Nelson Aguilar Colombia nelsonyesid@gmail.com
Mandy Abushama / Badreldeen Ahmed Qatar mdabushama@hotmail.com / profbadreldeen@
hotmail.com
Saadia Amour Sultan (Al Riyami)/ Kanchana
Rajan
Oman drsaadiaalriyami@gmail.com / raajaan@omantel.net.
om
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) v
Aris Antsaklis / Panos Antsaklis Greece arisants@otenet.gr / panosant@gmail.com
Shahana Afroz Bangladesh nmcdhaka@agni.com
Ana Bianchi Uruguay anabbianchi@gmail.com
Carmina Comas / Bernat Serra Spain (Barcelona) minacomas.germanstrias@gencat.cat/berser@dexeus.
com
Pavel Calda Czech Republic calda@gynstart.cz
Vincenzo D’Addario Italy (Bari) daddariov@alice.it
Giovanni Monni Italy (Cagliari) prenatalgmonni@gmail.com
Tony Duan / Chen Min China tduan@yahoo.com / chenm@cuhk.edu.hk
Alaa Ebrashy Egypt ebrashy3@yahoo.com
Taib Delic Bosnia and Herzegovina
(Sarajevo)
taib.delic@bosna-sunce.ba
Orion Gliozheni Albania gliozheniorion@gmail.com
Erasmo Huertas Tacchino/ Alfredo Guzman Peru erasmohuertas@hotmail.com/alfredoguz@gmail.com
Leung Kwok Yin Hong Kong kyleungog@gmail.com
Aleksandar Ljubic Serbia gakljubic@gmail.com
Ritsuko K. Pooh Japan pooh27ritsuko@fetal-medicine-pooh.com
Abdel Latif Ashmaig Khalifa Sudan profashmaig@hotmail.com
Narendra Malhotra / Jaideep Malhotra India mnmhagra3@gmail.com / jaideepmalhotraagra@
gmail.com
Sonal Panchal / Chaitanya Nagori India (Ahmedabad) sonalyogesh@yahoo.com / cbnagori@yahoo.com
Lara Spalldi Barisic Croatia spalldi@gmail.com
Anton Mikhailov Russia (St. Petersburg) amikhailov@AM2697.spb.edu
Alexander Papitashvili Georgia ampsmpge@hotmail.com
Zoltan Papp Hungary pzorvosihetilap@maternity.hu
Azen Salim Indonesia azen364@msn.com
Cihat Sen / Sertac Esin Turkey csen@perinatal.org.tr / sertacesin@gmail.com
Florin Stamatian Romania (Cluj) lorin_stamatian@yahoo.com
Radu Vladareanu Romania (Bucharest) vladareanu@gmail.com
Inessa Safonova / Maryna Kharchenko / Olena
Susidko
Ukraine inessa7799@gmail.com / marina@poliklinika-veritas.hr
/ elena2910801@gmail.com
Veljko Vlaisavljevic / Jure Knez Slovenia (Maribor) veljko.vlaisavljevic@ivf-adria.com / knez.jure@gmail.
com
Liliana Voto / Jorge Hamer / Ana Marcela
Espinosa
Argentina lvoto@intramed.net / drjorgehamer@hotmail.com /
draanaespinosa@gmail.com
Miroslaw Wielgos Poland miroslaw.wielgos@wum.edu.pl
Ivica Zalud USA, Honolulu ivica.zalud@gmail.com
Roberto Cassis Martinez Ecuador robertocassis@hotmail.com
Hari Kishor Shrestha Nepal harishrestha340@hotmail.com, omhrc@wlink.com.np
Eberhard Merz Germany merz.eberhard@web.de
Farah Sulaiman Youssif Bahrain farahnuaimy@yahoo.com
Alexandra Matias Portugal matiasalexand@gmail.com
Francisco Filho Mauad Brazil fmn@ultra-sonografia.com.br
Syed Amir Gilani Pakistan (Lahore) profgilani@gmail.com
Snezana Crnogorac Montenegro snezanacrnogorac1@gmail.com
Karl Erwin Schweinfurth Alvarado Honduras karlerwin64@gmail.com
Miguel Antonio Ruoti Cosp Paraguay mruoticosp@gmail.com
Corazon Yabes-Almirante Philippines cora313@yahoo.com
Mohammad Hashim Wahaaj Afghanistan wahaajhospital@yahoo.com
Contd…
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)vi
Abdallah Adra Lebanon aa107@aub.edu.lb
Mohamed S. Elmahaishi Libya elmahaishi@elmahaishi.com
Fida Mahmoud Ahmad Thekrallah Jordan fidaaymen@hotmail.com
Ha To Nguyen / Pham Viet Thanh Vietnam hatonguyen@gmail.com/bvtudu@hcm.vnn.vn /
thuky.bgd@tudu.com.vn
Monia Ferchiou Cherif / Mounira Nouri
Chaabane
Tunisia moniaferchiou@yahoo.fr / chaabanem@hotmail.fr
Tuangsit Wataganara Thailand twataganara@yahoo.com
Ruben Quintero USA (Miami) yvrq@aol.com
Jeanne Hortence Fouedjio Cameroon fouedjiojeanne@yahoo.fr
Yaron Zalel Israel zalel1954@gmail.com
Kwabena Appiah-Sakyi Ghana kasak@doctors.org.uk
Abdulfetah Abdulkadir Ethiopia chechera68@gmail.com
Gordana Adamova Macedonia gadamova@hotmail.com
Rodrigo Ayala Yáñez Mexico rayalaabc@gmail.com
Marina Degtyareva/Lali Sichinava Russia (Moscow) mvdegtyareva@gmail.com / lalisichinava@gmail.com
Waldo Sepulveda Chile waldosep@yahoo.co.uk
Jose De Lancer Despradel/Fauzi Bacha Arbaje Dominican Republic josedelancer@yahoo.com, Fauzibacha@hotmail.com
Lira Kalieva Kazakhstan lira_kali@mail.ru
Gwang Jun Kim Korea gjkim@cau.ac.kr
Teuta Daullxhiu Kosovo teutadaullxhiu@gmail.com
Salim Daya Canada dayas@mcmaster.ca
Roumen Gueorguiev Dimitrov Bulgaria roumendim@abv.bg
Mark P. Brincat Malta markpaulbrincat@gmail.com
Fatma Gahramanli Azerbaijan fatigy@yahoo.com
Ruzanna Abrahamyan Armenia r_abrahamyan@mail.ru
Tamara Illescas Molina Spain (Madrid) tamaraillescas@hotmail.com
Freddy Gonzalez Arias Venezuela freddygonarias@gmail.com
Aliyu Labaran Dayyabu Nigeria zainalabidinaliyu@yahoo.com
Mohamed Bayari Morocco mohamed.bayari@gmail.com
Larisa Belotserkovtseva / Tatyana Petrova Russia (Surgut) info@surgut-kpc.ru, lbelotserkovtseva@gmail.com/
shuvaeva66@mail.ru
Firas Jawdat Abdeljawad Palestine dr_firasjawdat@yahoo.com
William Ching Hua Hsiao Taiwan hsiaochh2866@gmail.com
Adolfo Liao Brazil (Sao Paulo) a.liao@proafeto.com.br, liao@usp.br
Natalia Bondarenko Russia (Irkutsk) bondnatasha@mail.ru
Renato Augusto Moreira de Sá Brazil (Rio de Janeiro) renatosa.uff@gmail.com
Hisham Ahmad Arab Saudi Arabia (Jeddah) arab123@gmail.com
Raul Moreira Neto Brazil (Porto Alegre) raul@ecomoinhos.com.br, rmneto@cpovo.net
Valentin Friptu Republic of Moldova friptu@hotbox.ru
Vasilios Tanos Cyprus v.tanos@aretaeio.com
Juan Troyano Luque Spain (Canary Islands) jtroyanol@sego.es
Arkadiy Makogon Russia (Novosibirsk) makogon@ngs.ru
Grigory A. Penzhoyan Russia (Krasnodar) pga05@mail.ru
Ajay Rane Australia ajay.rane@jcu.edu.au
Ousmane Bechir Hassaballah Chad samnna2015@gmail.com
Elsa Viora Italy (Turin) viora.elsa@yahoo.it; eviora@cittadellasalute.to.it
Natalia G. Pavlova Russia (St. Petersburg) ngp05@yandex.ru
Contd…
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) vii
Maurizio Filippini San Marino mfilippini@omniway.sm
Nadezhda Bashmakova Russia (Yekaterinburg) dr@niiomm.ru
Ursula Res Muravec Slovenia (Ljubljana) ursula.res@gmail.com
Suada Tinjic Bosnia and Herzegovina
(Tuzla)
drtinjic@ginekologija.ba
Shama Munim Pakistan (Karachi) smunim1678@hotmail.com
Young Nam Kim Korea (Busan) ob.youngnam@gmail.com
Manzura Khodjaeva/ Nodira Kasimova Uzbekistan menzurka2006@rambler.ru/ nana_65@mail.ru
Dace Matule Latvia matule@parks.lv
Fahmida Banu India (Hyderabad) doctorfahmidabanu@gmail.com
Gigi Selvan India (Palayamkottai) gigi2410@icloud.com
Armen K. Blbulyan / Tatevik Blbulyan Armenia belbulyan@mail.ru / tblbulyan@gmail.com
Mouna Kharmach Morocco kharmach@yahoo.fr
Saulo Molina Giraldo Colombia (Bogota) saulo.molina@urosario.edu.co, smolina@fucsalud.edu.
co, smolina@clinicadelamujer.com.co
Sameer Achyut Umranikar UK sameer.umranikar@uhs.nhs.uk, drsaumranikar@gmail.
com, drsaumranikar@hotmail.com
Tserensambuu Urjindelger / Narmandakh
Suldsuren
Mongolia ts_urjee@yahoo.com / suldsuren@unfpa.org,
narmandaa@yahoo.com
Monica Vanessa Garcia Santacruz Honduras (San Pedro Sula,
Cortes)
mgarciasantacruz@yahoo.com
Evaldo Troyano Brazil (Brasilia) evaldotrajano@gmail.com
Waldemar Amaral Brazil (Goiana) waldemar@sbus.org.br
Apostolos Athanasiadis Greece (Thessaloniki) apostolos3435@gmail.com
Seang Lin Tan Canada seanglin.tan@muhc.mcgill.ca, sltan@originelle.com
Loïc Sentilhes France (Bordeaux) loic.sentilhes@chu-bordeaux.fr
Margaret Huesler Charles Switzerland m.huesler@spitalmaennedorf.ch
Erik Dosedla Slovakia erik.dosedla@nemocnicasaca.sk
K.V. Sridevi India (Visakhapatnam) kvsridevi2000@yahoo.co.in
Audrone Arlauskiene Lithuania audrone.arlauskiene@mf.vu.lt
Ramon T. Reyles Philippines ramonreyles@yahoo.com
Joaquín Bustillos-Villavicencio Costa Rica joaquin.bustillos@gmail.com
François Jacquemard France (Paris) jacquemard@gmail.com, francois.jacquemard@
ahparis.org
Ferenc Szirko Estonia ferenc.szirko@itk.ee
Sanja Sibincic Bosnia and Herzegovina
(Banja Luka)
sanjasibincic@gmail.com
Yasser S. Sabr Saudi Arabia (Riyadh) yasabr@gmail.com
Vincent della Zazzera Canada (Ottawa) o2vince@hotmail.com
Selami Sylejmani / Bajram Syla Kosovo selami.sylejmani@gmail.com / bajsy@hotmail.com
Erich Cosmi Italy (Padua) ecosmi@hotmail.com
Edin Marcial Hidalgo Portillo Guatemala edin.hidalgo@gmail.com
Vedran Stefanovic Finland vedran.stefanovic@hus.fi
Official publisher – Jaypee Brothers - director of publishing
J. P. Vij India jaypee@jaypeebrothers.com
Global marketing partner – Dialog India Services Pvt Ltd
Shivkumar Menon India shiv@dialogindia.com
Raj Menon India raj@dialogindia.com
Administrative Secretary of the School
Jadranka Cerovec Croatia jadranka.cerovec@yahoo.com
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)viii
IAN DONALD SCHOOL COURSES IN 2019
Date City/Country Number of participants
March 1–2 Turin, Italy 280
March 9–10 Osaka, Japan 58
March 21–23 Dubrovnik, Croatia 206
March 26–27 Belitong Island, Indonesia 120
March 29 Budapest, Hungary 120
May 3–5 Tirana, Albania 320
May 18–19 Seoul, Korea 332
May 18 Krasnodar, Russia 520
May 24–25 Moscow, Russia 806
May 27–28 Surgut, Russia 427
June 7 Kathmandu, Nepal 150
June 8 Sarajevo, BIH 40
June 13–15 Cagliari, Italy 520
July 7–9 Kabul, Afghanistan 40
July 10–12 Guatemala City, Guatemala 1000
July 11 Kandahar, Afghanistan 40
July 14–16 Kabul, Afghanistan 40
August 16 Agra, India 150
August 24–29 Global congress, cruise Monarch 420
August 30 Kabul, Afghanistan 250
September 4–6 Bangkok, Thailand 120
September 11–14 Istanbul, Turkey 500
September 21–22 Ahmedabad, India 220
September 26–28 Cluj, Romania 400
October 5 Sarajevo, BIH 50
October 11 Kandahar, Afghanistan 100
October 17–19 Gdansk, Poland 200
October 25–26 Okinawa, Japan 162
November 8 Kandahar, Afghanistan 50
November 9–10 Santo Domingo, Dominican Republic 1080
November 15–17 Skopje, Macedonia 90
November 19 Kabul, Afghanistan 150
November 23–24 Tbilisi, Georgia 105
November30–December1 Athens, Greece 290
Total number of participants 9.356

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) ix
Courses in Afghanistan – Kabul and Kandahar
HERE ARE SOME PHOTOS TAKEN DURING COURSES

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)x

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xi

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xii
October 17–19, 2019
Gdansk, Poland

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xiii
October 25–26, 2019
Okinawa, Japan

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xiv
November 9–10, 2019
Santo Domingo, Dominican Republic
Skopje, North Macedonia

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xv
Tbilisi, Georgia
November 30–December 1, 2019
Athens, Greece

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xvi
IAN DONALD SCHOOL COURSES TO BE HELD IN 2020
Date City/Country
February 1 Sarajevo, Bosnia and Herzegovina
February 20–22 Jeddah, Saudi Arabia
February 29–March 1 Kiev, Ukraine
March 13–14 Turin, Italy
May 7–9 Asuncion, Paraguay
May 8–10 Zagreb, Croatia
May 14–16 Belgrade, Serbia
June 5–7 Prizren, Kosovo
June 11–13 Cagliari, Italy
September 25–27 Bodrum, Turkey

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xvii
NEWS! NEWS!
It is a pleasure to announce that Ian Donald School of Medical Ultrasound (https://iandonaldschools.com) is in the
process of becoming a part of University Sarajevo School of Science and Technology (SSST) (https://ssst.edu.ba)
QSWorldUniversityRankingsreleasedthenewsthatUniversitySarajevoSchoolofScienceandTechnology(SSST)
was ranked as one of the top 600 universities in the World and the best ranked university in the Region for the year
2019.
Our plan is that all future courses are run under umbrella of this university. We are offering following specialized
postgraduate courses leading to Master degree:
• Ultrasound in Obstetrics and Gynecology
• Perinatal Medicine
• Human Reproduction, Reproductive Endocrinology and Infertility
• Minimally Invasive Gynecologic Surgery
• Fetal, Neonatal and Pediatric Echocardiography
Curricula of the Five Courses are Attached
Courses are scheduled as one-year courses on a part-time basis. The unique opportunity is that these courses can
be attended without compromising professional or private commitments because they are organized as modules
overthetimeof12months.Eachmodulelastsoneweek.Modulesarecomposedofthetheoreticalpartandpractical
training.
Uponfulfillingalltherequirementsandpassingprescribedexaminations,attendantsareawardedMasterdegree
issued by Ian Donald School and University Sarajevo School of Science and Technology.
Another great news — last autumn we started PhD course at University SSST where Master diploma and one
year Master study within Donald School is recognized as the first year of otherwise three years long PhD study.
Asim Kurjak, founder and director of Ian Donald School
For more information please contact
Ms. Jadranka Cerovec
e-mail: jadranka.cerovec@yahoo.com

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xviii
Course title Ultrasound in obstetrics and gynecology
Type of the course University specialized Fellowship Program
Duration of the course One academic year, two semesters
Course leaders Asim Kurjak, Professor Emeritus, University Sarajevo School of Science and Technology, Sarajevo, BIH
Frank Chervenak, Professor, New York, USA
Faculty Asim Kurjak, Croatia
Frank Chervenak, USA
Eberhard Merz, Germany
Ritsuko Kimata Pooh, Japan
Sanja Kupesic Plavsic, USA
Milan Stanojevic, Croatia
Ivica Zalud, USA
Aris Antsaklis, Greece
Lara Spalldi Barišić, Croatia
Panagiotis Antsaklis, Greece
Sonal Panchal, India
Aida Salihagić Kadić, Croatia
Srećko Gajović, Croatia
Amir Muzur, Croatia
Ulla Marton, Croatia
Prerequisites Those with a diploma of completed education, residents or specialists of OB/GYN, license
Syllabus outline The program consists of 6 obligatory and 2 elective modules
Obligatory module 1: Ultrasound in gynecology
Obligatory module 2: Ultrasound in the 1st trimester-sonoembryology
Obligatory module 3: Fetal well being (Fetal biometry and fetal growth)
Obligatory module 4: Fetal anatomy – placenta – umbilical cord
Obligatory module 5: Fetal congenital anomalies
Obligatory module 6: 3D/ 4D ultrasound in Obstetrics and gynecology and Doppler in gynecology and infertility
Elective module:
• How to write scientific texts
• KANET diploma
Objectives Postgraduate Fellowship program on Ultrasound in Obstetrics and Gynecology is designed to gain and broaden the
basic knowledge and skills in ultrasound assessment in the field of obstetrics and gynecology.
Learning outcomes • Fundamental Principles of Ultrasound- techniques possibilities and limitations.
• Knowing how to use, acquire and adjust images produced by transabdominal and transvaginal US. Orientation.
• Identifying and differentiating between normal and abnormal gynecological US examination.
• Identifying different pathology on pelvic US.
• Performing complete US examination in all trimesters of pregnancy.
• Learning how to write a comprehensive obstetric US report in the 1st, 2nd and 3rd trimesters of pregnancy.
• Performing a 1st trimester ultrasound scan.
• Transvaginal/ transabdominal cervicometry
• Performing a complete fetal anatomy scan in 2nd trimester of pregnancy.
• Performing a US scan in twin (multiple) pregnancy (early and advanced pregnancy)
• Recognizing fetal dysmorphology and knowing the significance of their presence.
• Assessing fetal well being.
• Knowing how and when to use color/power Doppler in Ob & Gyn Ultrasound.
• Role of all ultrasound modalities (B mode, Doppler, 3D, 3D Color and power Doppler, different render modes,
4D ultrasound)
• Witnessing and being acquainted for the 3D/4D US application in Obstetrics and Gynecology.
• Witnessing and getting acquainted by the invasive procedures in fetal medicine.
• 4D ultrasound- introduction in fetal neurodevelopmental assessment by KANET
• Broaden the knowledge and consciousness of important ethical and legal issues in obstetrics and gynecology
in the decision making process while caring for pregnant women and fetus at the limits of viability, those with
severe congenital anomalies and other life threatening disorders. Fellow should also understand the role of ethics
committee and importance of multidisciplinary work and approach. Learn the basic steps in patient counselling.
Learning and teaching
methods
Blended learning approach is utilised, linking academic theory to clinical practice via work based learning, formal key
note lectures, seminars, tutorials, hands-on training, demonstrations, e-learning, shared learning and self-directed
study.
Modules are composed of the theoretical part and practical training (scanning demonstration and hands-on training
which is almost 70% of the curriculum).
Each module delivers 50 hours of training including the theoretical and practical part.
Assessment A comprehensive end of module exam will be given at the end of each module. After successful completion of
each module, the fellow should present or send via e-mail the certificate proving attendance and log book, which
qualifies him/her to take the summative (final) exam. Final exam includes ultrasound skills exam, written essay and
theoreticaloralexamwithcommitteeof3examiners.AftersuccessfulcompletionofFellowshipprograminUltrasound
in Obstetrics and Gynecology, the fellow receives diploma and becomes Master in Ultrasound in Obstetrics and
Gynecology.
Afterreceivingthediploma,thefellowmaycontinuedirectlysecondyearofthedoctoralcoursetoobtainaPhDdegree.
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xix
Student commitments If some of the applicants do not complete the program within the defined period of time, they can continue in the
next academic year. In these circumstances, they have to attend all the missing lectures and pass the separate exam
and final exam.
Place of the realization of the
program
Zagreb, Dubrovnik (Croatia)
Sarajevo (BIH)
Ahmedabad (India)
Literature Compulsory
• Kurjak A, Chervenak FA. Donald School Textbook of Ultrasound in Obstetrics and Gynecology, 4th edition. Jaypee
Brothers, New Delhi, 2017.
• Pooh RK, Kurjak A. Donald School Atlas of Advanced Ultrasound in Obstetrics and Gynecology, Jaypee Brothers,
New Delhi, 2015.
• Kurjak A, Spalldi Barišić L, Kupešić Plavšić S. Ultrazvuk u Ginekologiji i Perinatologiji, 2nd edition, Medicinska
Naklada, Zagreb, 2019.
• Panchal S, Nagori C. Color Doppler in Obstetrics & Gynecology. Text and Atlas. Jaypee Brothers Medical Publishers,
New Delhi, 2019.
• Kupesic S. Color Doppler, 3D and 4D Ultrasound in Gynecology, Infertility and Obstetrics, Jaypee Brothers, New
Delhi, 2011.
• Kupesic S. Donald School video on Ultrasound in Obstetrics and Gynecology, Jaypee Brothers, New Delhi, 2013.
• Kurjak A, Chervenak F. Textbook of Perinatal Medicine, 3rd edition, Jaypee Brothers, New Delhi, 2015.
• Badreldeen A, Kurjak A. Donald school Textbook of Diabetic Pregnancy & Ultrasound, Jaypee Brothers, New
Delhi, 2018.
• Wataganara T, Pooh RK, Kurjak A. Donald School Textbook of Power-Point Presentation on Advanced Ultrasound
in Obstetrics and Gynecology, Jaypee Brothers, New Delhi, 2015.
• Pooh RK, Kurjak A. Fetal Neurology, Jaypee Brothers, New Delhi, 2009.
• D'Addario V. Donald School Basic Textbook of Ultrasound in Obstetrics and Gynecology, Jaypee Brothers, New
Delhi, 2008.
• Kurjak A, Chervenak FA: Donald School EMBRYO AS A PERSON AND ASA PATIENT, Jaypee Brothers, New Delhi, 2019
• Merz E, Kurjak A: Donald School Textbook CURRENT STATUS OF CLINICAL USE OF 3D/4D ULTRASOUND IN
OBSTETRICS AND GYNECOLOGY, Jaypee Brothers, New Delhi, 2019
• Subscription to the Donald School Journal of Ultrasound in Obsetrics and Gynecology- DSJUOG (web page www.
jaypeebrothers.com)
Optional
• Kurjak A, Bajo Arenas J. Donald School Textbook of Transvaginal Sonography, 3rd ed, Jaypee Brothers, New Delhi,
2017 (early in 2018)
• Carrera JM, Kurjak A. Donald School Atlas of Clinical Application of Ultrasound in Obstetrics and Gynecology.
Jaypee Brothers, New Delhi, 2006
• Kurjak A. Donald School Atlas of Fetal Anomalies. Jaypee Brothers, New Delhi, 2006
• Antsaklis A, Troyano JM. Donald School Textbook of Interventional Ultrasound. Jaypee Brothers, New Delhi, 2008
Total 300 hours of lectures, seminars and hands-on
ECTS 60
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xx
Course title Perinatal medicine
Course leaders Asim Kurjak, professor Emeritus, University Sarajevo School of Science and Technology, Sarajevo, BIH
Ivica Zalud, professor, Honolulu, Hawaii, USA
Milan Stanojevic, professor, Zagreb, Croatia
Faculty Frank Chervenak, USA
Asim Kurjak, Croatia
Giovanni Monni, Italy
Eberhard Merz, Germany
Ivica Zalud, USA
Aris Antsaklis, Greece
Panagiotis Antsaklis, Greece
Lara Spalldi Barišić, Croatia
Radu Vladareanu, Romania
Simona Vladareanu, Romania
Zlatan Fatušić, BIH
Emina Hadžimuratović, BIH
Prerequisites Those with a diploma of completed education, residents or specialists of OB/GYN, pediatrics, license
Obligatory module 1: Organization, statistics, evidence based medicine and research in perinatal care
Obligatory module 2: Ethical and legal dimensions of perinatal care
Obligatory module 3: Prevention, diagnosis and therapy in perinatal period
Obligatory module 4: Ultrasound and Doppler diagnosis in perinatal medicine
Obligatory module 5: Maternal disease affecting perinatal period
Obligatory module 6: Basics of neonatology
Elective module 1: Perinatal genetics
Elective module 2: Preterm labor
Objectives Postgraduate Fellowship program on Perinatal medicine is designed to broaden the knowledge and skills for obstetricians
and pediatricians involved in delivery of perinatal health care. Besides the objectives to foster acquisition, integration and
implementation of new knowledge and the newest technologies into all levels of perinatal health care, this program offers
to participants the insight into many interdisciplinary problems in perinatal medicine like ethics, organization, statistics,
molecular genetics and genomics, research, and applied technology.
Learning outcomes • Understand the concept of perinatal medicine and regionalization of perinatal care with levels of care. They should
understand the meaning of follow - up of the outcome based on perinatal statistics, with basic and advanced knowledge
of definitions and indicators of the audit in perinatal medicine from obstetrical and neonatal point of view
• Broaden the knowledge and consciousness of important ethical and legal issues in perinatal medicine in the decision
making process while caring for pregnant women and neonates at the limits of viability, those with severe congenital
malformations and other life threatening disorders. They should also understand the role of ethics committee and
patient counseling
• Become aware of the stepwise analysis during prenatal and postnatal decision making process when making the
diagnosis and differential. They will be given means to understand the most important diseases pre- and postnatally,
to diagnose, to prevent and to treat them
• Be able to understand the concept and to recognize five great obstetrical syndromes (pre-eclampsia, premature labor,
placental abruption, premature rupture of membranes and fetal growth retardation) and will be given state of the art
and the most recent information on all of them
• Be aware that most diseases must be identified early enough to allow intervention and prevention not only of the clinical
manifestation of disease but also of the long-term handicaps it may cause.
• Be informed about diagnostic value of transabdominal and transvaginal ultrasound in perinatal medicine. Be able to
perform independently complete ultrasound examination in all trimesters of pregnancy. Be skilled in 1st trimester
ultrasound scan and complete fetal anatomy scan in the 2nd and the 3rd trimester of pregnancy
• Recognize fetal dysmorphology by ultrasound and know the significance of presence of congenital malformations
• Assess fetal well being and know how and when to use color Doppler in obstetrics
• Witness and become acquainted with invasive procedures in fetal medicine
• Witness and become acquainted with 3D/4D ultrasound application in obstetrics
• Be informed and understand the meaning of intrauterine growth restriction from obstetrical and neonatological point
of view, with special emphasis on prenatal origin of adult disease (Barker hypothesis)
• Understand the causes of preterm delivery with consequences for the mother, baby and the society
• Understand why multiple pregnancies are high risk pregnancies and how to manage them prenatally, intrapartum and
postnatally
• Be informed about the management of labor and delivery with the concept of natural versus programmed labor, with
special emphasis on normal and abnormal process of labor and delivery, intrapartum-follow up of fetal well being, and
the criteria of fetal distress and hypoxia during delivery
• Be acquainted with the most common maternal diseases during preconception, pregnancy, delivery and puerperium
such as: diabetes mellitus, thyroid disease in pregnancy, preexisting- and pregnancy induced hypertension with special
forms like HELLP syndrome, uterine structural anomalies and their impact on pregnancy outcome, thrombophilia,
collagen disorders and many more.
• Be- as obstetricians- educated in neonatology about basic neonatal problems.
• Be-as pediatricians- competent in neonatology at subspeciality level.
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xxi
• Be- as neonatologists- capable of providing best care for newborn infants in primary, secondary, and tertiary care,
including intensive care of highest standard for critically sick neonates and very low birth weight infants using advanced
therapeutic and supportive modalities and skills. Effectively plan therapeutic, rehabilitative, preventive and promotive
measures or strategies
• Make rationale decision in the face of ethical dilemmas in perinatal and neonatal diseases
• Demonstrate empathy and humane approach towards patients and their families and exhibit interpersonal behavior
in accordance with social norms and expectations
• Exhibit excellent communication skills in dealing with parents and practice compassionate attitude in the field of
neonatology
• Implement a comprehensive follow up- and early intervention program for the “at risk” newborn infants, and plan,
counsel and advice rehabilitation of the neurodevelopmentally and physically challenged infants.
Learning and teaching
methods
Each module is composed of the theoretical part and practical training (scanning demonstration and hands-on training
which is almost 40% of the curriculum).
Assessment A comprehensive end of module exam will be given at the end of each module. After completion of each module, the
fellow should present or send via e-mail the certificate proving attendance and log book, which qualifies him/her to take
the summative (final) exam. Final exam includes test and theoretical oral exam in front of the committee of 3 examiners.
Student commitments If some of the applicants do not complete the program within the defined period of time, they can continue in the next
academicyear.Inthesecircumstances,theyhavetoattendallthemissinglecturesandpasstheseparateexamandfinalexam.
Place of the realization of
the program
Zagreb and Dubrovnik (Croatia)
Ahmedabad (India)
• Kurjak A, Chervenak FA. Textbook of Perinatal Medicine, 3rd edition. Jaypee Brothers, New Delhi, 2015.
• Kurjak A, Chervenak FA. Donald School Textbook of Ultrasound in Obstetrics and Gynecology, 4th edition. Jaypee
• Kurjak A, Spalldi Barišić L, Kupešić Plavšić S. Ultrazvuk u Ginekologiji i Perinatologiji, 2nd edition, Medicinska Naklada,
Zagreb, 2018.
• Cunningham F, Leveno KJ, Bloom S, Dashe J, Hoffman BL, Casey BM, Spong CY. Williams Obstetrics, 25th Edition.
MacGraw Hill Companies, New York, 2018.
• AAP, ACOG. Guidelinef for perinatal care, 8th edition. ACOG, Washington, 2017.
• Badreldeen A, Kurjak A. Donald school Textbook of Diabetic Pregnancy & Ultrasound, Jaypee Brothers, New Delhi, 2018.
• Macones GA, Odibo AO. Fetal Assessment, An Issue of Clinics in Perinatology. Saunders, Philadelphia, 2011.
• Gleason CG, Sherin Devaskar S, Ed. Avery’s Diseases of the Newborn, 9th edition. Saunders, Philadelphia, 2012.
• Rennie JM. Rennie & Roberton's Textbook of Neonatology, 5th Edition. Churchill Livingstone, 2012.
• Pooh RK, Kurjak A. Fetal neurology. Jaypee Brothers, New Delhi, 2009.
• White RL. Foundations of Developmental Care, An Issue of Clinics in Perinatology Saunders, Philadelphia, 2011.
• Alan Fleischman A, Iams JD. Prematurity: Art and Science, An Issue of Clinics in Perinatology. Saunders, Philadelphia, 2011.
• Spitzer AR, Ellsbury D. Quality Improvement in Neonatal and Perinatal Medicine, An Issue of Clinics in Perinatology.
Saunders, Philadelphia, 2010.
• Fairchild KD, Polin RA. Healthcare Associated Infections in the Neonatal Intensive Care Unit, An Issue of Clinics in
Perinatology. Saunders, Philadelphia, 2010.
• du Plessis AJ. Neurology of the Newborn Infant, An Issue of Clinics in Perinatology. Saunders, Philadelphia, 2010.
• Remington JS, Klein JO, Wilson CB, Nizet V, Maldonado Y. Infectious Diseases of the Fetus and Newborn, 7th Edition,
• Goldsmith JP, Karotkin EH. Assisted Ventilation of the Neonate, 5th Edition. Saunders, Philadelphia, 2011.
• Levene MI, Chervenak FA. Fetal and Neonatal Neurology and Neurosurgery, 4th Edition, Churchill Livingstone, New
York, 2009.
• Volpe JJ. Neurology of the Newborn, 5th Edition. Saunders, Philadelphia, 2008.
• Blickstein I, Chervanak J, Chervanak F. Medical Legal Issues in Perinatal Medicine: Part I, An Issue of Clinics in Perinatology.
• BlicksteinI,ChervanakJ,ChervanakF.MedicalLegalIssuesinPerinatalMedicine:PartII,AnIssueofClinicsinPerinatology.
• Schenker GJ. Ethical dilemmas in perinatal medicine. Jaypee Brothers Medical Publishers, St. Louis, Panama City, Delhi,
2010.
• KliegmanRM,StantonBMD,JosephSt.Geme,SchorN,BehrmanRE.NelsonTextbookofPediatrics,19thEdition.Saunders,
Philadelphia, 2011.
• Polin RA, Fairchild KD. Early Onset Neonatal Sepsis, An Issue of Clinics in Perinatology. Saunders, Philadelphia, 2010.
• Spitzer AR, White R. Neuroprotection in the Newborn, An Issue of Clinics in Perinatology. Saunders, Philadelphia, 2008.
• Bancalari E. The Newborn Lung: Neonatology Questions and Controversies. Saunders, Philadelphia, 2008.
• UhingMR,KliegmanRM.CurrentControversiesinPerinatology,AnIssueofClinicsinPerinatology.Saunders,Philapdelphia,
2009.
• SubscriptiontotheDonaldSchoolJournalofUltrasoundinObsetricsandGynecology(webpagewww.jaypeebrothers.com)
ECTS 60
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xxii
Course Title Human Reproduction, Reproductive Endocrinology and Infertility
Type of the course University Specialized Fellowship Program
Course leaders Sanja Kupesic Plavsic, professor, El Paso, USA
Veljko Vlaisavljevic, professor, Maribor, Slovenia
Faculty Sanja Kupesic Plavsic, USA
V. Vlaisavljević, Slovenia
Sonal Panchal, India
Aleksandar Ljubić, Serbia
Renato Bauman, Croatia
Biserka Funduk Kurjak, Croatia
Davor Ježek, Croatia
Asim Kurjak, Croatia
Mustafa Bahceci, BiH
Eda Vrtačnik Bokal, Slovenia
Uršula Reš Muravec, Slovenia
Jure Knez, Slovenia
Suada Tinjić, BiH
M. Reljic, Slovenia
Prerequisites University diploma of completed medical school education valid license for clinical work, specialists of OB/
GYN or residents at the second or higher year of specialist training.
Syllabus outline The fellowship consists of 9 obligatory sessions condensed in 6 modules (each lasting one week) and 1
elective module.
Obligatory session 1: Basic science concepts of reproductive endocrinology
Obligatory session 2: Clinical endocrinology
Obligatory session 3: Infertility
Obligatory session 4: Psychology, ethics and law regulation in human reproduction
Obligatory session 5: Menopause
Obligatory session 6: Contraception
Obligatory session 7: Epidemiology and statistics in reproductive medicine
Obligatory session 8: Imaging in human reproduction
Obligatory session 9: Assisted reproductive techniques, laboratory experience and surgical skills
Elective module 1: How to write scientific text
Objectives Graduate educational program in human reproduction, reproductive endocrinology and infertility is
developed along the following guidelines to ensure a clinical and research experience consistent with the
following educational goals:
• Experience in the management of a wide variety of clinical problems affecting the development, the
function and the aging of the human reproductive system. This experience should include disorders
related to both men and women;
• Adequate clinical knowledge and basic clinical skills in treatment of infertility and reproductive disorders
(including management of ovulation defects and techniques of assisted reproduction, which must
include an adequate number and success rate), contraception, aging, diagnostic imaging and the surgical
management of acquired and developmental abnormalities of the reproductive tract;
• Knowledge of the techniques and limitations of various diagnostic, surgical, and laboratory procedures
utilized in clinical reproductive endocrinology and infertility; and
• A research experience centered into a specific area of investigation that will provide a thesis for the fellow
and also stimulate future independent study.
Learning outcomes Atthecompletionofafellowshipprograminhumanreproduction,reproductiveendocrinologyandinfertility,
the physician will be able to manage complex endocrine problems related to function of the reproductive
system and to select and conduct appropriate therapies for the infertile couple. The fellow must understand
endocrine assay methodology and principles of molecular biology and be skilled in laboratory techniques,
clinical research design and statistical analysis. The fellow is expected to be proficient in the clinical diagnosis,
utilization of most recent imaging techniques and in the surgical management of structural problems related
to fertility and developmental abnormalities of the reproductive tract, as well as contemporary techniques
involved in assisted reproductive technology.
Learning and teaching methods Each module is composed of the theoretical part and practical training (scanning demonstration and hands-
on training which is almost 40% of the curriculum).
Assessment After successful completion of the modules and satisfactory performance on final exam, the fellow receives a
certificatethathe/shehassuccessfullycompletedaFellowshipprograminHumanReproduction,Reproductive
Endocrinology and Infertility, and become a Master in Human Reproduction, Reproductive Endocrinology
and Infertility. After receiving the diploma, the fellow may continue directly second year of the doctoral
course to obtain a PhD degree.
Student commitments If some of the applicants do not complete the program within the defined period of time, they can continue
in the next academic year. In these circumstances, they have to attend all the missing lectures and pass the
separate exam and final exam.
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xxiii
Place of the realization of the program Sarajevo and Tuzla, Bosnia and Herzegovina (BiH)
Maribor and Ljubljana, Slovenia
Nagori Institute, Ahmedabad, India
Belgrade, Serbia
• B. Alberts, A. Johnson, P. Walter Julian Lewis (Eds). Molecular biology of the cell, 6th edition, 2014.
• L. Speroff and M.A. Fritz (Eds). Clinical Gynecologic Endocrinology and Infertility. 8th edition, Lippincott
Williams Wilkin, 2011.
• J. Larry Jameson (Ed). Harrison’s Endocrinology. 4th edition, Mc Graw Hill, 2016.
• W. Klug, MR Cummings, CA Spencer, NA Palladino (Eds). Essentials of Genetics, 9th Edition, 2015. ISBN-
13:978-0134047799
• S. Panchal. Donald School textbook of Human Reproduction & Gynecological Endocrinology. Jaypee
• S. Kupesic. Color Doppler, 3D and 4D Ultrasound in Gynecology, Infertility and Obstetrics. Jaypee 2011.
ISBN 978-93-5025-090-7.
• S. Kupesic (Ed). Video Atlas of Ultrasound in Obstetrics and Gyencology. Jaypee 2011.
• S. Kupesic (Ed.) Step by Sep Through Ob Gyn Cases. Distance learning website, Jaypee 2012.
• D. K. Gardner , A. Weissman, C.M. Howels,Z. Shoham (Eds) Textbook of Assisted Reproductive Techniques:
Laboratory and Clinical Perspectives, Informa Healthcare UK Ltd, 2009.
• Peter R. Brinsden (Ed). A Textbook of In Vitro Fertilization and Assisted Reproduction: The Bourn Hall
Guide to Clinical and Laboratory Practice: Includes Bourn Hall Protocols on CD-ROM, Third Edition ,
Taylor and Francis, 1999.
• J. Van Blerkom and L. Gregory (Eds) . Esential IVF. Besic research and clinical aplication. Kluwer Academic
Publishers, Boston /Dordrecht/ London, 2004.
• E. Nieschlag, H. M. Behre, S. Nieschlag (Eds). Andrology. Springer 2010. ISBN 3 900051 07 0.
• The Division of Reproductive Endocrinology and Infertility The American Board of Obstetrics and
Gynecology, Inc – Guide to learning 2008.
• Kurjak A, Chervenak FA. Donald School Textbook of Ultrasound in Obstetrics and Gynecology, 4th edition.
Jaypee Brothers, New Delhi, 2017.
• Subscription to the Donald School Journal of Ultrasound in Obsetrics and Gynecology (web page www.
jaypeebrothers.com)
ECTS 50
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xxiv
Course Title Minimally Invasive Gynecologic Surgery
Course leaders Miroslav Kopjar, Zlatan Fatušić, Asim Kurjak
Faculty Silvio Altarac, Croatia
Renato Bauman, Croatia
Stanko Belina, Croatia
Tomislav Čanić, Croatia
Dževad Džanic, Bosnia &Herzegovina
Rajko Fureš, Croatia
Zulfo Godinjak, Bosnia & Herzegovina
Jasna Gutić, Bosnia & Herzegovina
Dubravko Habek, Croatia
Herman Haller, Croatia
Krunoslav Kuna, Croatia
Zoran Rajković, Croatia
Stanislav Rupčić, Croatia
Vladimir Šparac, Croatia
Martina Ribič-Pucelj, Slovenia
Iztok Takač, Slovenia
Prerequisites University diploma of completed medical school education, valid license for clinical work, specialists of
OB/GYN or residents at the second or higher year of specialist training. The choice of candidates for the
studyandtherankinglistofappliedcandidatesismadebasedonthecriteriaannouncedinthedailypress.
Syllabus outline The fellowship consists of 12 obligatory and 1 elective modules
Obligatory module 1: Anatomy, Embryology and Physiology
Obligatory module 2: Instruments used in endoscopic surgery
Obligatory module 3: Operative Laparoscopy
Obligatory module 4: Operative Hysteroscopy
Obligatory module 5: Complications of Laparoscopy and Hysteroscopy
Obligatory module 6: Vaginal Surgery
Obligatory module 7: Benign Gynecologic conditions
Obligatory module 8: Reproductive Surgery
Obligatory module 9: Urogynecology
Obligatory module 10: Urology
Obligatory module 11: General Surgery
Obligatory module 12: Medico-legal issues
Elective module 1: Telemedicine and Robotic surgery: current issues
Objectives Postgraduate Fellowship program in Minimally invasive gynecologic surgery (MIGS) is designed to train
ObGyn and Urology specialists and residents for sub-specialization in the constantly developing field of
endoscopic surgery. A physician who is a subspecialist in the field of MIGS has an advanced knowledge
of laparoscopic and hysteroscopic surgery and is capable of performing various minimally invasive
procedures in gynecologic and urologic surgery and basic procedures in general surgery.
Learning outcomes Atthecompletionofafellowshipprogramthefellowwillhaveasubstantialknowledgeinabdominaland
pelvic anatomy and physiology, endoscopic technology and operative technique, and advanced clinical
research design and statistical analysis. The fellow will become proficient in various surgical procedures,
and indications, methodology, risks and complications of such procedures. The fellow will also be
trained to successfully recognize and manage any complication that may occur during and after MIGS
procedure. Having conducted investigative work leading to the production of a thesis, it is anticipated
that the fellow will be capable of continued research endeavors and of preparation of research grants.
Thus, by completion of a fellowship program, a fellow will have demonstrated progressive professional
and intellectual growth.
Learning and teaching methods Each module is composed of the theoretical part and practical training (scanning demonstration and
hands-on training which is almost 40% of the curriculum).
Assessment The candidate must pass all the exams in the first year. In case a fellow would like to enroll in the second
year of our fellowship program and complete the thesis, Postgraduate Course Committee and the
program director will identify a mentor and will guide a candidate through the process of submission
of the thesis. Submission of an approved thesis will be a requirement for entrance to the oral exam.
Student commitments If some of the applicants do not complete the program within the defined period of time, they can
continue in the next academic year. In these circumstances, they have to attend all the missing lectures
and pass the separate exam and final exam.
Place of the realization of the program
• Kopjar M. Ginekološka endoskopija. Laparoskoija, histeroskopija. Vlastita naklada, 1999.
• Kopjar M, Pašić RP, Takač I Proceedings: Ginekološka kirurgija i endoskopija-Kurt Semm2017.
• Kopjar M, Šijanović S. Minimally invasive gynecologic surgery. Osijek University Medical School, in
press.
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xxv
• Pasic RP, Brill AI. Practical Manual of Minimally Invasive Gynecologic and Robotic Surgery: A Clinical
Cook Book 3E. 3rd Ed. CRC Press, 2018.
• Einarsson JI, Wattiez A. Minimally Invasive Gynecologic Surgery: Evidence-Based Laparoscopic,
Hysteroscopic & Robotic Surgeries. JP Medical Ltd:London, 2016.
• Schollmeyer T, Mettler L, Ruther D, Alkatout I: Laparoscopic&Hysteroscopic Gynecological Surgery
(Kiel School -second edition) Jaype, 2013
• Kurjak A, Chervenak FA. Donald School Textbook of Ultrasound in Obstetrics and Gynecology, 4th
edition. Jaypee Brothers, New Delhi, 2017.
Optional
• Kurjak A, Bajo Arenas J. Donald School Textbook of Transvaginal Sonography. 3rd Ed. Jaypee Brothers
Medical Pub, London, 2018.
• Kupesic S. Video Atlas of Ultrasound in Obstetrics and Gyencology. Jaypee, 2011.
• Nezhat CR, Nezhat FR, Nezhat CH. Nezhat’s Operative gynecologic laparoscopy and hysteroscopy.
Cambridge University Press, 2008.
• Pašić RP, Levine RL. A practical manual of laparoscopy: A clinical cookbook. The Parthenon Publishing
group, 2007.
ECTS 60
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xxvi
Course title Fetal, Neonatal and Pediatric Echocardiography
Type of the course Specialized Fellowship Program
Course leaders Asim Kurjak, Zagreb, Croatia
Senka Mesihovic-Dinarevic, BIH
Faculty Senka Mesihovic-Dinarevic, BIH
Ida Jovanovic, Serbia
Cihat Sen, Turkey
Prerequisites Thosewithadiplomaofcompletededucation,residentsorspecialistsofPediatricsorOB/GYNlicense
Obligatory module 1: Ultrasound physics, instrumentation and techniques
Obligatory module 2: Cardiac anatomy, normal and congenital heart diseases
Obligatory module 3: Fetal echocardiography imaging and diagnostic procedures
Obligatory module 4: Neonatal echocardiography imaging and diagnostic and therapeutic
procedures
Obligatory module 5: Pediatric echocardiography imaging
Elective module: How to write scientific texts – Prof. Amir Muzur (Rijeka, Croatia)
Objectives To gain advanced knowledge of ultrasound assessment in the field of cardiology, from fetal to
adolescent period
Learning outcomes • Knowing US physics, instrumentation and techniques
• Knowing how and when to use US modalities: M mode, B mode, Color Doppler.
• Witnessing and being acquainted for the 3D/4D US application in Obstetrics and Gynecology.
• Basics of 3D sonography.
• Embryology and function of fetal heart.
• Knowing cardiac anatomy, normal and congenital heart diseases
• Knowing nomenclature and segmental approach to congeniotal heart disease
• Knowing how to use and adjust and being oriented with images produced by transabdominal
and transthoracic US.
• Identifying and differentiating between normal and abnormal fetal, neonatal and paediatric
US examination.
• Performing complete US examination in fetus, neonate and paediatric patient.
• Performing a 1st trimester and 2nd trimester of pregnancy US.
• Recognizing fetal dysmorphology and knowing the significance of their presence.
• Witnessing and getting acquainted by the invasive procedures in fetal medicine.
• Performing normal pediatric echocardiogram and US assessment of congenital and acquired
heart diseases
• Learning how to write a comprehensive US report depending on patient’s age.
Learning and teaching methods Modules are composed of the theoretical part and practical training (scanning demonstration and
hands-on training which is almost 70% of the curriculum).
Assessment A comprehensive end of module exam will be given at the end of each module. After completion
of each module, the fellow should present or send via e-mail the certificate proving attendance,
which qualifies him/her to take the summative (final) exam. Final exam includes ultrasound skills
exam, written essay and theoretical oral exam with committee of 3 examiners.
Student commitments If some of the applicants do not complete the program within the defined period of time, they can
continue in the next academic year. In these circumstances, they have to attend all the missing
lectures and pass the separate exam and final exam.
Place of the realization of the program Polyclinic “Sunce”, Sarajevo, BIH
• Kurjak A, Chervenak FA. Donald School Textbook of Ultrasound in Obstetrics and Gynecology,
4th edition. Jaypee Brothers, New Delhi, 2017
• Kupesic S. Color Doppler, 3D and 4D Ultrasound in Gynecology, Infertility and Obstetrics, Jaypee
Brothers, New Delhi, 2011
• D’Addario V. Donald School Basic Textbook of Ultrasound in Obstetrics and Gynecology, Jaypee
Brothers, New Delhi, 2014
• Pooh RK, Kurjak A. Donald School Atlas of Advanced Ultrasound in Obstetrics & Gynecology,
Jaypee Brothers, New Delhi, 2015
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xxvii
• Wataganara T, Pooh RK, Kurjak A. Donald School Textbook of PowerPoint Presentation on
Advanced Ultrasound in Obstetrics & Gynecology, Jaypee Brothers, New Delhi, 2015
• Sen C, Stanojevic M. Fetal Echocardiography, Jaypee Brothers, New Delhi, 2019
• Subscription to the Donald School Journal of Ultrasound in Obsetrics and Gynecology (web
page www.jaypeebrothers.com)
Optional
• Kurjak A, Bajo Arenas J. Donald School Textbook of Transvaginal Sonography, Jaypee Brothers,
New Delhi, 2016
• Carrera JM, Kurjak A. Donald School Atlas of Clinical Application of Ultrasound in Obstetrics and
Gynecology. Jaypee Brothers, New Delhi, 2006
• Kurjak A. Donald School Atlas of Fetal Anomalies. Jaypee Brothers, New Delhi, 2006
• Antsaklis A, Troyano JM. Donald School Textbook of Interventional Ultrasound. Jaypee Brothers,
New Delhi, 2008
ECTS 60
Contd…

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)xxviii
Contents
DSJUOG
Donald School Journal of Ultrasound
in Obstetrics and Gynecology
Volume 14 Issue 1 January–March 2020
Picture of the Month
HDlive Flow with Spatiotemporal Image Correlation for Assessment of Fetal Goiter..................................................................1
Toshiyuki Hata, Riko Takayoshi, Takahito Miyake, Nobuhiro Mori, Kenta Yamamoto, Kosuke Koyano, Takashi Kusaka,
Kenji Kanenishi
Research Article
A Noninvasive Screening Tool for Abnormal Uterine Bleeding: An Attempt to Reduce Numbers of
Endometrial Biopsies.................................................................................................................................................................................4
Deeksha Pandey, Sri V Kummarapurugu, Gazal Jain, Keerthi Kyalakond, Priya Pai, MG Sayyad, Muralidhar V Pai
Case Reports
Fetal Massive Pericardial Effusion as a Sign of Bilateral Diaphragmatic Agenesis: A Case Report...........................................11
S Adelita Híjar, P Susy Ruiz, Saul Levy-Blitchtein
Klippel–Feil Syndrome: A Rare Case Report........................................................................................................................................14
Sally DE Mohammed, Mona AM Ali, Hassan Osman
Papers Dedicated to Shocking Data on Maternal Mortality in Developing Countries
Review Articles
Maternal Mortality: Tragedy for Developing Countries and Shame for Developed World........................................................17
Asim Kurjak, Milan Stanojević, Cihat Sen, Frank Chervenak
How to Increase Resilience of Healthy Newborns in Underdeveloped Countries?......................................................................28
Asim Kurjak, Milan Stanojevic
Health-dedicated Millennium Development Goals: What has been Done Wrong?.....................................................................32
Milan Stanojevic, Asim Kurjak
Maternal Mortality in the USA................................................................................................................................................................36
Amos Grunebaum, Frank Chervenak
Role of Obstetric Ultrasound in Reducing Maternal and Neonatal Mortality in Developing Countries:
From Facts to Acts.....................................................................................................................................................................................43
Vedran Stefanovic
Maternal Mortality: The Indian Story....................................................................................................................................................50
Narendra Malhotra, Jaideep Malhotra, Neharika M Bora

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) xxix
Improving the Quality of Training and Service in Obstetrics and Gynecology Practice.............................................................54
Abdel-Lateef Ashmaig, Mohammed Abdelmoneim
Some Solutions to Reduce Maternal Mortality...................................................................................................................................56
Gliozheni Orion, Gliozheni Elko
Maternal Mortality among Refugees and in Zones of Conflict........................................................................................................61
Abdallah Adra, Mariam Saad
Maternal Mortality: What are Women Dying from?...........................................................................................................................64
Aris Antsaklis, Maria Papamichail, Panos Antsaklis
Health System and Markers of Health in Uruguay.............................................................................................................................70
Ana Bianchi
Commentary
From Safe Motherhood to Sustainable Development Goals: Unmet Targets; What are We Missing?......................................76
Aliyu L Dayyabu, Mahmood K Magashi
Contents

SUBSCRIPTION INFORMATION
Annual Subscription:
Individual: ` 8000.00 (National)
$ 400.00 (International)

Institutional: ` 12000.00 (National)
$ 450.00 (International)
This journal is published quarterly in a year, i.e. January, April, July and October. Dollar rates apply to subscribers
in all the countries except India where INR price is applicable. All subscriptions are payable in advance and all the
rates include postage. Journals are sent by air to all the countries except Indian subcontinent. Subscriptions are
on an annual basis, i.e. from January to December. Payment will be made by dollar, cheque, credit card or directly
through our bank account at the following address:
1. Our Banker’s Name: ICICI Bank Ltd.
2. Our Current A/c No: JAYBRZ
3. Amount to be Transferred JAYPEE BROTHERS MEDICAL
in the Name of: PUBLISHERS (P) LTD., NEW DELHI
4. IFSC Code: ICIC0000106
For further queries, please do not hesitate to contact at subscriptions@jaypeebrothers.com
Subscription can be sent to
M/s Jaypee Brothers Medical Publishers (P) Ltd.
Journals Department
4838/24 Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
ADVERTISEMENT RATES
(For the Print Issues)
Page Single issue
Back cover—color ` 50,000 $ 1000.00
Inside front cover–color ` 40,000 $ 800.00
Inside back cover–color ` 35,000 $ 700.00
Inside full page–color ` 30,000 $ 600.00
Special position: Price on request
Technical Details
Paper size 8.5” x 11”
Text size 7.5” x 10”
Digital file format EPS on CD (at 300 dpi resolution)
Printed on art paper using by offset printing.
Schedule
Issues are published in the months of January, May and September.
Advertisement material along with purchase order and payment should reach us at least four weeks prior to the
scheduled print date.
Payment Details
• Payment should favour “Jaypee Brothers Medical Publishers (P) Ltd.” and should be payable at New Delhi, India.
• Payment to be done at the time of submitting the advertisement material/booking the advertisement. Please
send your advertisement request, payment and advertisement material to the address given above. Editorial
board reserves the right to accept or decline the advertisement.
For further queries, please contact: ashwani.shukla@jaypeebrothers.com

PICTURE OF THE MONTH
HDlive Flow with Spatiotemporal Image Correlation for
Assessment of Fetal Goiter
Toshiyuki Hata1
, Riko Takayoshi2
, Takahito Miyake3
, Nobuhiro Mori4
, Kenta Yamamoto5
, Kosuke Koyano6
, Takashi Kusaka7
,
Kenji Kanenishi8
Abstract
Casedescription:WepresentourexperienceofdiagnosingfetalgoiterusingradiantflowandHDliveflowwithspatiotemporalimagecorrelation
(STIC). A 39-year-old pregnant Japanese woman, gravida 3, para 1, with Graves’disease was referred to our ultrasound clinic at 37 weeks and
1 day of gestation because of suspected fetal goiter. Two-dimensional (2D) sonography revealed enlarged thyroid glands (left lobe, 29.5 ×
22 mm; right lobe, 32.9 × 21.2 mm). Radiant flow showed abundant blood flow on both lobes. HDlive flow with STIC clearly demonstrated
spatial relationships of pulsatile dilated blood vessels in the fetal goiter. Our results suggest that HDlive flow with STIC shows precise spatial
vascularity with pulsation of fetal goiter in utero.
Keywords: 3D ultrasound, Fetal goiter, HDlive flow, Radiant flow, Spatiotemporal image correlation.
Donald School Journal of Ultrasound in Obstetrics and Gynecology (2020): 10.5005/jp-journals-10009-1616
Introduction
Radiant flow is a novel form of color Doppler that generates three-
dimensional(3D)datatoproduceatwo-dimensional(2D)gray-scale
image utilizing shading determined by the color Doppler signal’s
amplitude.1
HDlive flow is made of 3D color Doppler with an
adjustable light source to realize lighting and shadowing effects,
which means that depth perception is possible on fetal 3D blood
flow examination.2
Several reports are available on the antenatal diagnosis of fetal
goiter using 2D color/power and 3D power Doppler ultrasound;3–6
however, to the best of our knowledge, this is the first report on
HDlive flow with spatiotemporal image correlation (STIC) for the
prenatal diagnosis of fetal goiter.
Case Description
A 39-year-old pregnant Japanese woman, gravida 3, para 1, with
Graves’ disease was referred to our ultrasound clinic at 37 weeks
and 1 day of gestation because of suspected fetal goiter (Fig. 1).
She has been treated with levothyroxine sodium hydrate,
potassium iodide, and propylthiouracil, and her thyroid status was
euthyroid. The 2D sonography revealed enlarged thyroid glands
(left lobe, 29.5 × 22 mm; and right lobe, 32.9 × 21.2 mm) (Fig. 2).
The fetal trachea was not compressed by either lobe. Radiant flow
showed abundant blood flow on both lobes, especially on the left
lobe (Fig. 3). HDlive flow with STIC clearly demonstrated precise
spatial relationships of pulsatile dilated blood vessels in the fetal
goiter (Fig. 4).
Elective cesarean section was performed on the next day
(37 weeks and 2 days), and a female infant weighing 2811 g was
delivered with an umbilical artery pH of 7.348 and Apgar score of
8/9 at 1 minute and 5 minutes, respectively. Thyroid-stimulating
hormone (TSH), FT3, and FT4 levels in the cord blood were
203.7 μIU/mL (0.35 to 3.73), 2.71 pg/mL (2.2 to 4.1), and 0.54 ng/mL
(0.88–1.81), respectively. Neonatal goiter was confirmed (Fig. 5),
1,3
Department of Perinatology and Gynecology, Kagawa University
Graduate School of Medicine, Kagawa, Japan; Department of
Obstetrics and Gynecology, Miyake Clinic, Okayama, Japan
2
Department of Obstetrics and Gynecology, Miyake Clinic, Okayama,
Japan
4,5,8
Department of Perinatology and Gynecology, Kagawa University
Graduate School of Medicine, Kagawa, Japan
6,7
Department of Pediatrics, Kagawa University Graduate School of
Medicine, Kagawa, Japan
Corresponding Author: Toshiyuki Hata, Department of Perinatology
and Gynecology, Kagawa University Graduate School of Medicine,
Kagawa, Japan; Department of Obstetrics and Gynecology, Miyake
Clinic, Okayama, Japan, Phone: +81 (0)87-891-2174, e-mail: toshi28@
med.kagawa-u.ac.jp
How to cite this article: HataT,Takayoshi R, MiyakeT, et al. HDlive Flow
with Spatiotemporal Image Correlation for Assessment of Fetal Goiter.
Donald School J Ultrasound Obstet Gynecol 2020;14(1):1–3.
Source of support: Nil
Conflict of interest: None
©TheAuthor(s).2020OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0InternationalLicense(https://creativecommons.
org/licenses/by-nc/4.0/),whichpermitsunrestricteduse,distribution,andnon-commercialreproductioninanymedium,providedyougiveappropriatecreditto
theoriginalauthor(s)andthesource,providealinktotheCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Fig. 1: HDlive image of fetal neck at 33 weeks and 5 days of gestation.
Fetal neck swelling (arrow) is noted

HDlive Flow with STIC for Fetal Goiter
Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)2
and levothyroxine sodium hydrate was administered for 3 days.
On the first neonatal day, atrial flutter (200–230 bpm) was noted.
Electrical defibrillation with 2 joules was performed and the atrial
flutter disappeared. Thereafter, the neonate showed a favorable
course. The mother also followed a favorable course after delivery.
Discussion
A unique characteristic of fetal goiter is the rich vascularity of
the thyroid gland.3,4
In our case, radiant flow clearly showed
abundant blood flow in the fetal goiter using the 3D color Doppler
informationona2Dgrayscaleimage.Onlytworeportsareavailable
regarding the 3D power Doppler ultrasound diagnosis of fetal
goiter.5,6
However, spatial relationships of the vascularity of fetal
goiter were still poor. In this study, HDlive flow with STIC clearly
demonstrated precise spatial relationships of dilated thyroid blood
vessels in real-time. HDlive flow with STIC was a useful diagnostic
modalityfortheassessmentofcongenitalheartanomaly,especially
great vessel abnormalities.7–11
Tenkumo et al.12
reported that
HDlive flow showed the characteristic vascular pattern of fetal
hepatic hemangioma. Therefore, the current study also suggests
that this technique provides additional diagnostic information on
the assessment of fetal peripheral vascular abnormality. Further
studies involving a larger sample size are needed to assess the
true usefulness of HDlive flow with STIC for the diagnosis of fetal
peripheral vascular abnormalities.
References
1. Hata T, Kanenishi K, Nitta E, et al. HDlive Flow with HDlive silhouette
mode in diagnosis of molar pregnancy. Ultrasound Obstet Gynecol
2018;52(4):552–554. DOI: 10.1002/uog.19106.
2. HataT,AboEllailMAM,SajapalaS,etal.HDliveFlowintheassessment
of fetal circulation. Donald School J Ultrasound Obstet Gynecol
2015;9(4):462–470. DOI: 10.5005/jp-journals-10009-1433.
3. Morine M, Takeda T, Minekawa R, et al. Antenatal diagnosis and
treatment of a case of fetal goitrous hypothyroidism associated
with high-output cardiac failure. Ultrasound Obstet Gynecol
2002;19(5):506–509. DOI: 10.1046/j.1469-0705.2002.00680.x.
Fig. 2: Transverse two-dimensional sonographic image of fetal neck
at 37 weeks and 1 day of gestation. Enlarged thyroid glands (left lobe,
29.5 × 22 mm; and right lobe, 32.9 × 21.2 mm) are noted. Fetal trachea
is not compressed by either lobe
Fig. 3: Radiant flow image of fetal goiter at 37 weeks and 1 day of
gestation. Abundant blood flow on both lobes, especially the left lobe
Fig. 4: Precise spatial relationships of pulsatile dilated blood vessels in
thefetalgoiterareclearlydepictedwithHDliveflowwithspatiotemporal
image correlation at 37 weeks and 1 day of gestation
Fig. 5: Neonatal neck just after delivery. Mild swelling of the fetal neck
is noted

HDlive Flow with STIC for Fetal Goiter
Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020) 3
4. Huel C, Guibourdenche J, Vuillard E, et al. Use of ultrasound to
distinguish between fetal hyperthyroidism and hypothyroidism on
discoveryofagoiter.UltrasoundObstetGynecol2009;33(4):412–420.
DOI: 10.1002/uog.6315.
5. Nath CA, Oyelese Y, Yeo L, et al. Three-dimensional sonography in
the evaluation and management of fetal goiter. Ultrasound Obstet
Gynecol 2005;25(3):312–314. DOI: 10.1002/uog.1863.
6. Marin RC, Bello-Munoz JC, Martinez GV, et al. Use of 3-dimensional
sonography for prenatal evaluation and follow-up of fetal goitrous
hypothyroidism. J Ultrasound Med 2010;29(9):1339–1343. DOI:
10.7863/jum.2010.29.9.1339.
7. AboEllail MAM, Kanenishi K, Tenkumo C, et al. Diagnosis of trncus
arteriosus in first trimester of pregnancy using transvaginal four-
dimensional color Doppler ultrasound. Ultrasound Obstet Gynecol
2015;45(6):759–760. DOI: 10.1002/uog.14868.
8. AboEllail MAM, Kanenishi K, Tenkumo C, et al. Four-dimensional
power Doppler sonography with the HDlive silhouette mode in
antenatal diagnosis of a right aortic arch with an aberrant left
subclavianartery.JUltrasoundMed2016;35(3):661–663.DOI:10.7863/
ultra.15.05047.
9. Yang PY, Sajapala S, Yamamoto K, et al. Antenatal diagnosis of
idiopathicdilatationoffetalpulmonaryarterywith3DpowerDoppler
imaging.JClinUltrasound2017;45(2):121–123.DOI:10.1002/jcu.22367.
10. ItoM,AboEllailMAM,YamamotoK,etal.HDliveFlowsilhouettemode
and spatiotemporal image correlation for diagnosing congenital
heart disease. Ultrasound Obstet Gynecol 2017;50(3):411–415. DOI:
10.1002/uog.17519.
11. Hata T, Ito M, Nitta E, et al. HDlive Flow silhouette mode for diagnosis
of ectopia cordis with a left ventricular diverticulum at 15 weeks’
gestation. J Ultrasound Med 2018;37(10):2465–2467. DOI: 10.1002/
jum.14583.
12. TenkumoC,HanaokaU,AboEllailMAM,etal.HDliveFlowwithHDlive
silhouettemodeindiagnosisoffetalhepatichemangioma.Ultrasound
Obstet Gynecol 2017;49(4):540–545. DOI: 10.1002/uog.16215.

RESEARCH ARTICLE
A Noninvasive Screening Tool for Abnormal Uterine
Bleeding: An Attempt to Reduce Numbers of Endometrial
Biopsies
Deeksha Pandey1
, Sri V Kummarapurugu2
, Gazal Jain3
, Keerthi Kyalakond4
, Priya Pai5
, MG Sayyad6
, Muralidhar V Pai7
Abstract
Introduction: Endometrial pathologies contribute to a large proportion of abnormal uterine bleeding (AUB). The aim of this study was to
prospectively validate a novel scoring tool [diseases of endometrium–evaluation and risk scoring (DEERS)] as compared with the gold standard
histology. Diseases of endometrium–evaluation and risk scoring is a scoring system based on patient characters and endometrial features that
are visualized in gray scale transvaginal sonography (TVS). We hypothesized that this tool will help screen women who present with AUB for
premalignant and malignant diseases of endometrium, in a noninvasive way.When performed routinely in women prior to subjecting them to
endometrial sampling, it would reduce anxiety for the patient till the final histology report is awaited. It may also be used to help reduce the
burden of unnecessary samplings to the clinicians as well as decrease the burden of histological slide review for the pathologist.
Materials and methods: A total of 454 women were included. Patients with AUB in whom cervical, myometrial, ovarian, and endocrinal causes
were ruled out and were planned for endometrial sampling were recruited for the study, as cases (n = 284). Women who were planned for
hysterectomy for reason other than endometrial pathologies were taken as controls (n = 170). Preoperatively patient characteristics were noted,
and TVS was performed to calculate DEERS for all.
Results: In the study cohort, DEERS showed specificity of 100% for cancers, 88.12% for complex hyperplasia, 67.12% for benign lesions, and
76.35% for normal endometrium. However, the sensitivity of prediction was not encouraging. The 95% accuracy of the test for various lesions
ranged from 60 to 97%. We noted a high efficacy (sensitivity of 72.2%, specificity of 92.1%) of DEERS in predicting malignant/premalignant
diseases of endometrium, when coupled in one group.
Conclusion: This scoring system looks promising for screening endometrial malignancy in women who present with AUB.
Keywords: Endometrium, Screening, Sonography, Uterine bleeding.
Donald School Journal of Ultrasound in Obstetrics and Gynecology (2020): 10.5005/jp-journals-10009-1623
Introduction
Abnormal uterine bleeding (AUB) is one of the common
presenting symptoms in gynecological practice. Around 30% of
women experience AUB during their lifetime.1
More than 30% of
gynecological visits among premenopausal women and more
than 70% of visits among peri and postmenopausal women
are because of AUB.2
The cause of AUB may vary and include
polyps, adenomyosis, leiomyoma, malignancy (and hyperplasia),
coagulopathy, ovulatory disorders, endometrial, iatrogenic, and
not otherwise classified (PALM-COEIN).3
Endometrial pathologies
contribute to a large proportion of AUB during the reproductive
years as well as after menopause. AUB that occurs when the uterus
is structurally normal, menstrual cycles are regular, and there
is no evidence of coagulopathy is likely to have an underlying
endometrial cause and is denoted as AUB-E in the PALM-COEIN
system. In this system, disorders/lesions of endometrium in
actuality are grouped in three different groups (AUB-P, -M, and -E);
it is also clinically convenient to arrange endometrial pathologies
in a spectrum ranging from disordered proliferation, polyps,
hyperplasia, to endometrial malignancy.
Histological diagnosis following curettage or sampling (with or
without hysteroscopy) is the gold standard investigation modality
to differentiate these endometrial causes of AUB. Presently, there
is a lack of clinically available noninvasive tests or biomarkers
to differentiate these.4
Invasive sampling and subjecting it to
histological diagnosis is the only confirmatory way to direct
treatment and prognosticate the pathologies of endometrium.
Transvaginal sonography (TVS) is a popular primary imaging
modality for women with AUB. Although TVS delineates
myometrial, ovarian, cervical lesions with efficacy, techniques to
differentiate various endometrial causes are not well established.
Endometrial thickness (ET) is the only parameter popularly used to
1–4,7
Department of Obstetrics and Gynecology, Kasturba Medical
College, Manipal Academy of Higher Education, Manipal, Karnataka,
India
5
Kasturba Medical College, Manipal Academy of Higher Education,
Manipal, Karnataka, India
6
Department of Statistics, Abeda Inamdar Senior College, Pune,
Maharashtra, India
Corresponding Author: Deeksha Pandey, Department of Obstetrics
and Gynecology, Kasturba Medical College, Manipal Academy of
Higher Education, Manipal, Karnataka, India, Phone: +91 9241216016,
e-mail: deekshiiiobg@gmail.com
How to cite this article: Pandey D, Kummarapurugu SV, Jain G,
et al. A Noninvasive Screening Tool for Abnormal Uterine Bleeding: An
Attempt to Reduce Numbers of Endometrial Biopsies. Donald School J
Ultrasound Obstet Gynecol 2020;14(1):4–10.
Source of support: Nil
Conflict of interest: None
©TheAuthor(s).2020OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0InternationalLicense(https://creativecommons.
org/licenses/by-nc/4.0/),whichpermitsunrestricteduse,distribution,andnon-commercialreproductioninanymedium,providedyougiveappropriatecreditto
theoriginalauthor(s)andthesource,providealinktotheCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

A Noninvasive Screening Tool for Abnormal Uterine Bleeding
define endometrial pathologies, which miserably fails to diagnose
specific lesions of the endometrium.5–7
The aim of this study was to validate a novel scoring tool
[diseases of endometrium–evaluation and risk scoring (DEERS)]
to determine its efficacy as compared with the gold standard
histology. Diseases of endometrium–evaluation and risk scoring
is a combination of patient characteristics and TVS indicators to
differentiate various endometrial causes of AUB.8
We hypothesize
that this model will help in advance to prognosticate the
disease, thus reducing the anxiety for the patient till the final
histology report confirms it. It may also help reduce the burden
of unnecessary samplings to the clinicians as well as decrease the
burden of histological slide review for the pathologist.
Materials andMethods
This prospective case–control study was conducted in a university
teaching hospital, in a span of 2 years. Institutional review board
approved the study protocol (IEC402/2015).
This study was undertaken to validate encouraging results
from a pilot study, in which we developed a scoring system
(DEERS) to categorize endometrial pathologies into normal,
benign, premalignant, and malignant groups. This scoring system
was developed based on our experience and literature review.
It includes patient characters and endometrial features that
could be visualized in gray scale TVS. The scores were based on
multivariate regression analysis from the pilot study conducted
on 96 patients who presented with AUB and were found to have
spectrum of endometrial pathologies from normal (proliferative/
secretory endometrium) to endometrial malignancy. Five experts
in the field individually assessed the score for content validity
and modifications incorporated as per the suggestions, following
detailed discussion (Table 1).
Patients
Patients with AUB in whom cervical, myometrial, ovarian,
and endocrinal causes were ruled out and were planned for
endometrial curettage were recruited as cases for the study.
Patient characteristics were documented. All of these women were
subjected to a TVS examination by experts to look for five specific
features: ET, endometrial–myometrial (E–M) junction, endometrial
echotexture, presence or absence of endometrial polyps, and
endometrial collection. The details of TVS evaluation are described
below. We also required a group with no endometrial pathology
(negative control), for comparison where histological findings of
endometriumcouldberetrieved.Therefore,wechosetotakethose
women who were planned for hysterectomy for reason other than
endometrial pathologies. Preoperatively for these controls also,
we documented the patient characteristics and performed TVS
to calculate DEERS in a similar way (as for the women undergoing
curettage).
Sample Size
Anticipating sensitivity of at least 90%, based on our pilot study,
with 5% precision and prevalence of endometrial pathology as 5%,
at 95% confidence level (CI), a minimum of 81 cases (curettage for
AUB) and 162 controls (hysterectomy for indications other than
endometrial pathology) were required to be studied.
Scoring System
The scoring system encompasses of two groups—patient
characteristics (five) and TVS features (five). Patient characteristics
are based on the proven risk factors for endometrial cancer.
Individual numeric scores are given to specific characteristics based
on the strength of its association with endometrial cancer. FiveTVS
features were also given a numeric score based on the regression
analysis, experts’experience, and available literature (Table 1A). On
adding up the numeric values, the minimum possible score is 6 and
the maximum is 35 (keeping in mind that a woman can practically
be either on hormone replacement therapy (HRT) or tamoxifen,
and cannot be on both). Then, we categorized the numeric
value obtained into four broad categories: normal endometrium
(secretary/proliferative), benign pathologies (polyp, submucus
myoma, and simple hyperplasia), premalignant lesions (complex
hyperplasia), and endometrial malignancy (Table 1B).
Methodology
After recruitment of women who were planned for curettage
or hysterectomy, an informed consent was obtained. Required
patient data were elicited and documented. Transvaginal
Tables 1A and B: Diseases of endometrium–evaluation and risk
scoring system to screen endometrial pathologies by demographic
characteristics and transvaginal sonography findings
A: Score allocation system based on demographic and transvaginal
sonography findings characteristics—devised after literature review
and clinical experience (minimum score: 2 + 4 = 6, maximum score:
13 + 22 = 35)
Demographic characteristic Score
Age 20–40 (score 1), 41–55 (score 2),
56 and above (score 5)
Menopausal status Premenopause (score 1), post-
menopause (score 4)
Diabetes, obesity, hypertension Score 1 each
HRT Score 1
Tamoxifen Score 1
TVS characteristic Score
Endometrial thickness Up to 5 mm (score 1), 6–10 mm
(score 2), 11–20 mm (score 3),
>21 mm (score 4)
E–M junction Distinct (score 1), indistinct
(score 5)
Echotexture Homogeneous (score 1), cystic
spaces (score 3), heterogeneous
(score 5)
Polyp Score 4
Endometrial collection Up to 5 mm (score 1), 6–10 mm
(score 2), 11–20 mm (score 3),
>21 mm (score 4)
B: Score interpretation for prediction of endometrial pathology
(minimum score: 2 + 4 = 6, maximum score: 13 + 22 = 35)
Score Interpretation
6–9 Normal endometrium (secretary/
proliferative)
10–15 Benign pathologies: polyp,
submucus myoma, disordered
proliferation, simple endometrial
hyperplasia
16–25 Complex hyperplasia
26–35 Endometrial malignancy

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 14 Issue 1 (January–March 2020)6
sonography was performed by an expert using Phillips HD IIXE
UltrasoundSystem(PhillipsUltrasound;Bothell,WE,USA),machine
equipped with a multifrequency (6–12 MHz) endovaginal probe.
We followed certain prerequisites while obtaining the values for
TVS features, in order to ensure reliability and reproducibility.
The sagittal section image of uterus (fundus to external os) was
focused in a way that it occupied around 75% of the screen and
the endometrial lining could be traced from the fundus up to its
mergence into endocervical canal down (Fig. 1). In this view, the
maximum thickness of endometrium anterio-posteriorly (A-P) was
taken(ET).Endometrial–myometrialjunctionwastracedintotality;
overall haziness or any breach was scored as indistinct junction.
Echotexture was noted as homogeneous, heterogeneous, or
with multiple cystic spaces. Polyps, if evident, were recorded
as presence or absence. Endometrial collection, if present,
was measured A-P at its maximum breadth. A preprocedure/
preoperative score was given to every patient, and based on that
categorization was done. The pathologist reporting the results of
curettage or hysterectomy, however, was blinded to this score. On
receiving the final histology report, the diagnosis was allotted a
broader category, as the final score (normal, benign, premalignant,
and malignant).
Statistical Analysis
The data on categorical variables are shown as percentage. The
intergroup comparison of categorical variables is done using Chi-
square test or Fisher’s exact probability test for a 2 × 2 contingency
table. The diagnostic efficacy measures such as sensitivity,
specificity,positivepredictivevalue(PPV),negativepredictivevalue
(NPV), and accuracy along with 95% CI are calculated for DEERS
against the outcome of histopathology examination as a gold
standard. Multivariate logistic regression analysis is used to obtain
the independent determinants of the positivity of disease. The p
values less than 0.05 are considered to be statistically significant.
All the hypotheses were formulated using two-tailed alternatives
against each null hypothesis (hypothesis of no difference). The
entire data are statistically analyzed using Statistical Package for
Social Sciences (SPSS version 20.0, IBM Corporation, USA) for MS
Windows.
Results
A total of 470 women fulfilled the inclusion criteria and were
enrolled for the study. Seven cases were excluded as the samples
were reported inadequate for opinion, whereas in nine cases,
endometrium was reported as “pill endometrium” or “lytic
endometrium.” Therefore, for the final analysis, 454 (curettage/
cases: 284, hysterectomy/controls: 170) women were included.
Patient Characteristics
Demographic features of cases and control were statistically
similar (p > 0.05). Most of the women (n = 317, 69.8%) in our
cohort belonged to perimenopausal age group (41–55 years). Most
women were parous (n = 403, 88.8%), and less than a third (n =
141, 31.3%) had attained menopause. Around a half (46.5%) were
obese [body mass index (BMI) ≥ 25], 16.7% had diabetes, 18.5%
had hypertension, and there was considerable overlap as expected
among these three comorbidities. The cutoff BMI for overweight
and obese were used keeping in mind the different criteria for
Figs 1A to D: Representative transvaginal sonography pictures from patients depicting prerequisites/principles while obtaining the values for
transvaginal sonography features, to ensure reliability and reproducibility: (A) Thick endometrium with indistinct/irregular E–M junction; (B)
Thick endometrium with distinct/regular E–M junction with cystic spaces; (C) Thick endometrium with fluid in the endometrial cavity; (D) Thick
endometrium with polyp

Indian Asian population.8
In our cohort, only one woman was on
HRT, whereas four were on tamoxifen therapy.
Out of 284 patients who underwent curettage, the most
common indication was postmenopausal bleeding (PMB; n = 122,
43%), followed by menorrhagia (n = 46, 16.2%), continuous vaginal
bleeding (n = 42, 14.8%), metrorrhagia (n = 40, 14%), amenorrhea
followed by excessive bleeding (n = 30, 10.6), and tamoxifen with
thick ET (n = 4, 1.4%). As has been mentioned above, we included
170 women who underwent hysterectomy during the same time
spanforindicationsotherthanendometrialpathology;theseacted
as controls. Indications of hysterectomy (with or without bilateral
salpingo-oophorectomy)werefibroiduterus(n=123,72%),adnexal
masses (n = 28, 16.5%), and adenomyosis (n = 19, 11.2%).
Comparison of DEERS
ComparisonofDEERScalculatedpriortocurettageorhysterectomy
with the final histological report of the endometrium showed
100% correlation for endometrial cancer and 77.3% correlation for
normal endometrium. While for benign lesions of endometrium,
the score could pick up only around half of the cases (49.5%). For
complex endometrial hyperplasia, the score could pick up on 7%
of the cases (Fig. 2).
Efficacy of DEERS for Individual Categories
On calculating the sensitivity, specificity, PPV, and NPV, we found
a wide variation in the efficacy of the test. DEERS showed a good
specificity for all the lesions (100% for cancers, 88.12% for complex
hyperplasia, 76.35% for normal endometrium, and 67.12% for
benign lesions). The 95% accuracy of the test for various lesions
ranged from 60% to 97% (Table 2).
Efficacy of DEERS in Predicting Malignancy/
Premalignant Disease
As the major utility of this scoring system is to differentiate lesions
that require histology confirmation and surgical intervention, we
unified normal and benign categories into one (disease negative),
while complex hyperplasia and cancer into one (disease positive).
This way, DEERS showed a significant agreement with the overall
outcome of histopathology examination (p value < 0.001;
Table 3A). We found a sensitivity of 72.2%, specificity of 92.1%, PPV
of 44.1%, and NPV of 97.5% for DEERS in prediction of malignancy/
premalignant disease of endometrium (Table 3B).
Fig. 2: Comparison of diseases of endometrium–evaluation and risk
scoring (calculated prior to curettage/hysterectomy) with the final
histopathology report of endometrial tissue
Tables 3A and B: Efficacy of diseases of endometrium–evaluation and risk scoring in predicting malignancy/premalignant disease: on unifying
normal and benign category into one (disease negative) while complex hyperplasia and cancer into one (disease positive)
A: Agreement between DEERS and histopathology
DEERS
Histopathology status (gold standard)
Agreement statisticsPositive Negative
n % n % Kappa value p value
Score Disease positive (n = 59) 26 72.2 33 7.9 0.498 0.001*
Disease negative (n = 395) 10 27.8 385 92.1
Total (N = 454) 36 100.0 418 100.0
Values are n (% of cases). p value by Chi-square test. p value <0.05 is considered to be statistically significant. *p value < 0.001
B: Efficacy of DEERS for prediction of disease positive cases that require histological confirmation and surgical intervention
Diagnostic efficacy measures of DEERS with histopathology as a gold standard
Sensitivity Specificity PPV NPV Accuracy (95% CI)
Efficacy measures (%) 72.2 92.1 44.1 97.5 90.5 (87.8–93.2)
Table 2: Efficacy (specificity, sensitivity, positive predictive value and negative predictive value) of diseases of endometrium–evaluation and risk
scoring for detection of endometrial pathologies as per individual categories
Finding Sensitivity Specificity PPV NPV Accuracy 95% of accuracy
Normal 58.57 76.35 75.38 59.85 66.52 62.18—70.86
Benign 59.12 67.12 49.21 75.29 64.32 59.91—68.72
Complex 50.0 88.12 7.02 98.99 87.44 84.40—90.49
Carcinoma 10.71 100.0 100.0 94.75 94.78 92.79—96.77

DONALD SCHOOL JOURNAL OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY

DONALD SCHOOL JOURNAL OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to DONALD SCHOOL JOURNAL OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY

Similar to DONALD SCHOOL JOURNAL OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY (20)

More from NARENDRA MALHOTRA

More from NARENDRA MALHOTRA (20)

Recently uploaded

Recently uploaded (20)

DONALD SCHOOL JOURNAL OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY