A. Khalid

The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with chronic pelvic pain--can we reduce the need for laparoscopy?

Objective  To assess the accuracy of new transvaginal ultrasound‐scan‐based markers and to compare them to conventional ultrasound methods used in the detection of common pelvic pathology in women with chronic pelvic pain (CPP).

Should we be examining the ovaries in pregnancy? Prevalence and natural history of adnexal pathology detected at first‐trimester sonography

To assess the prevalence and natural history of ovarian pathology in pregnancy.

Impact of the availability of sonography in the acute gynecology unit.

The initial assessment of acute gynecology patients is usually based on history and clinical examination and does not involve ultrasound. The aim of this study was to investigate the impact of the availability of transvaginal sonography at the time of initial assessment of the emergency gynecology patient.

Do we need to follow up complete miscarriages with serum human chorionic gonadotrophin levels

Despite a history of heavy vaginal bleeding with clots, a proportion of women diagnosed with complete miscarriage, using transvaginal sonography (TVS), have an underlying ectopic pregnancy (EP). We evaluated the need for hormonal follow up in women with history and scan findings suggestive of complete miscarriage. One hundred and fifty‐two consecutive women with findings suggesting complete miscarriage at presentation based on their history and TVS were presented to the Early Pregnancy Unit. Serum human chorionic gonadotrophin (hCG) levels were taken at presentation and 48 hours. All women were followed up until hCG was <5 u/L or a pregnancy was visualised on TVS either inside or outside the uterus. Overall, 9 (5.9%) of 152 women with an apparent complete miscarriage had an underlying EP. A diagnosis of complete miscarriage based on history and scan findings alone is unreliable. These women should be managed as ‘pregnancies of unknown location’ with serum hCG follow up.

OC198: Should an ectopic pregnancy always be diagnosed using transvaginal ultrasonography in the first trimester prior to surgery?

16/37 (43%) had a normal scan with mobile ovaries and no pelvic tenderness. 8/37 (22%) patients had a normal scan with no abnormality but tenderness. 5/37 (14%) had an ovarian cyst rupture. 8/37 had a normal scan with a non-gynaecological diagnosis. 27/37 (73%) of patients returned the follow up questionnaire. 22/35 (63%) of the patients had satisfactory resolution of their symptoms. Conclusion: The majority of patients attending an acute gynaecology unit with acute pelvic pain will have no gross pathology. In the majority of patients the symptoms will resolve satisfactorily within 7 days.

OC190: Should all emergency gynecology patients have an ultrasound scan?

and end systolic volumes were measured, and ejection fraction was calculated for each ventricle. Results: In approximately 90% of cases in which the fourchamber view was visualized, it was possible to calculate ventricular volumes. Volume of both ventricles increased in the course of pregnancy correlating with gestational age and estimated fetal weight. Unexpectedly, there was no significant difference between right and left ventricular volumes in the gestational ages studied. Ejection fraction of the ventricles was calculated at about 70%. Conclusion: 3D echocardiography can provide estimates of ventricular volume and function and may be used for evaluation of fetuses with congenital heart disease.

OC016: Can we safely adopt a single visit approach to the management of pregnancies of unknown location?

the pattern of serum hCG levels in early normal pregnancy, and also the correlation between low serum progesterone levels and spontaneous resolution of pregnancy. The diagnostic dilemma is how to predict which PUL are early ectopic pregnancies. There is no role for single serum hCG measurement in the management of PUL. Based on serum hCG > 1000 U/L, only 30% of ectopic pregnancies would be detected. In clinical terms, if one relied on the discriminatory zone alone, 6 laparoscopies would be performed in order to detect one ectopic pregnancies. Current hormonal criteria including initial serum progesterone < 20 nmol/L and an increasing serum hCG > 66% over 48 hours (hr) are very reliable in predicting pregnancy viability, but not its location. This question of establishing the location of a PUL was further investigated using subjective assessment of serum hCG and progesterone levels at defined times by gynaecologists of varying experience. It was found that experience per se did not play any role in the classification of PUL based on serum hormone evaluation and in this series only 25%–60% of ectopic pregnancies were detected. Interobserver agreement is almost perfect (Kappa 0.87) in the classification of non-EP, i.e. failing PUL and viable IUP. Conversely, the interobserver agreement in the classification of EP is only fair (Kappa 0.49). The development of new methods to establish pregnancy location has been investigated extensively in our unit. Using the hCG ratio (hCG 48 hr/hCG 0 hr), the detection of EP is improved to 75%. This figure has been improved significantly with the use of logistic regression analysis. This utilises the hCG ratio alone and is found not only to predict viability, but most importantly locate the pregnancy. The sensitivity and specificity of the model for the detection of ectopic pregnancies were 91.7% and 84.2% respectively.

OC070: Can transvaginal ultrasound detect and localize endometriosis in women with chronic pelvic pain?

and symptoms. All patients had a transvaginal ultrasound scan (TVS) 1–2 weeks before laparoscopy. All patients had a negative pelvic infection screen. During the transvaginal scan (TVS), the vaginal probe was used to assess ovarian location and mobility, and site-specific tenderness. Results: The average age of the patients was 31 years (range 18–50 years) and the average duration of pain was 46 months (range 6–180 months). At laparoscopy 70 (58%) patients had pelvic pathology and 50 (42%) patients had a normal pelvis. The historical factors – severity of symptoms (1–10), and previous gynaecological surgery were predictive of pelvic pathology (p < 0.05). The factors dysmenorrhoea, dyschesia, dyspareunia, age, parity, previous endometriosis and previous pelvic infection were not predictive of pelvic pathology (p > 0.05). On TVS the presence of an endometrioma or hydrosalpinx were predictive of pelvic pathology (accuracy 100% and 86% respectively). Reduced ovarian mobility and site-specific tenderness were predictive of pelvic pathology (p < 0.01). Stepwise logistic regression revealed ultrasound based site-specific tenderness as the most predictive factor. Conclusion: Historical factors and TVS findings are considered important in the assessment of patients with CPP. In this study logistic regression analysis has shown site-specific tenderness on its own to be as accurate as all the other factors.

OC068: Patient history and ultrasound findings: A logistic regression model for the prediction of pelvic pathology in women with chronic pelvic pain

Objectives: To develop transvaginal ultrasound scan (TVS) based ‘‘soft markers’’ to improve the definition of a normal scan in women undergoing diagnostic laparoscopy for chronic pelvic pain (CPP). Materials and methods: 120 consecutive patients had TVS 1–2 weeks before diagnostic laparoscopy for CPP. Anatomical abnormalities (hard markers) were documented; the presence of ‘‘soft markers’’ (reduced ovarian mobility, site-specific pelvic tenderness and free fluid) was also assessed. Results: Average age of the patients was 31 years (18–50), the average duration of pain was 45 months (6–180). 24 (20%) had hard markers for pelvic pathology (18 endometriomas, 6 hydrosalpinges). 96 (80%) had a normal conventional scan, of which 53 (55%) had soft markers for pelvic pathology while 43 (45%) did not. At laparoscopy, 51 had endometriosis, 7 endometriosis/pelvic adhesions, 6 pelvic adhesions, 1 hydrosalpinx/endometriosis and 5 hydrosalpinx/pelvic adhesions. The sensitivity and specificity of TVS to detect pathology based on hard markers was 68.5% and 100% respectively. The positive and negative predictive value of was 100%, and 49.3% respectively. The sensitivity and specificity of TVS to detect pathology based on soft markers was 87.5% and 78% respectively. The positive and negative predictive value of was 75.7% and 80% respectively. Conclusion: 80% of women who have a normal scan will have a normal laparoscopy. A pelvic scan should report on the presence of site-specific pelvic tenderness and ovarian mobility. This novel approach improves the predictive value of transvaginal ultrasound and reduces the need for unnecessary laparoscopy in women with chronic pelvic pain.

OC31.03: The role of ultrasound in acute gynaecology and its impact on management

period. The results of fetoscopic laser surgery at the novice site were compared to that reported in the literature. Results: The novice team has performed 58 fetoscopic laser surgeries to date. Results from the first 50 cases are reported here. The overall survival of babies is 84%. At least one baby survived in 92% of pregnancies, with both babies surviving in 76% of pregnancies. In a large report of 200 consecutive fetoscopic laser surgeries, the reported overall survival improved from 61% to 68% after 70 procedures, suggesting a long learning curve. Overall perinatal survival rate reported by some other recent series include: 65% from another novice site in Netherlands on 49 patients, and 56% in 72 patients treated with laser surgery from the randomised controlled trial in Europe. Our overall survival rate of 84% is significantly better than all of these reported series (p values range from < 0.003 to < 0.0001), suggesting that our learning curve has been significantly shortened. Conclusions: There may be many factors involved in shortening the learning curve for a new operative procedure. Telemedicine appeared to have assisted in this.