Arnaud Fauconnier

Uterine artery embolization for severe symptomatic fibroids: effects on fertility and symptoms

STUDY QUESTION Does uterine artery embolization (UAE) permit fertility in childbearing women who have extensive symptomatic fibroids and are not eligible for surgery? SUMMARY ANSWER Although UAE was effective in improving bleeding, bulking and pain symptoms, and in sparing the ovarian reserve, no woman in this study delivered successfully after UAE. WHAT IS KNOWN ALREADY Although pregnancies have been reported after UAE, the actual fertility rate after this treatment remains uncertain. STUDY DESIGN, SIZE, DURATION This prospective cohort study included 66 women who desired a future pregnancy and were treated with UAE for symptomatic fibroids. PARTICIPANTS/MATERIALS, SETTING, METHODS This cohort of consecutive patients had extensive symptomatic fibroids but were not eligible for abdominal myomectomy because of fibroid recurrence despite previous surgery, because of current risks of surgery, or because of patient refusal. The patients were enrolled in a tertiary referral center for fibroid treatment. All patients had a pre-operative ovarian function assessment and underwent bilateral superselective embolization of both uterine arteries using 500-1200 µm Tris acryl microspheres. MAIN RESULTS AND THE ROLE OF CHANCE Fibroid symptoms including menorrhagia (OR 0.08, 95% CI 0.02-0.27), metrorrhagia (OR 0.05, 95% CI 0.01-0.39), pain (OR 0.08, 95% CI 0.03-0.22) and bulk syndrome (OR 0.02, 95% CI 0.01-0.07) were significantly improved after UAE. According to magnetic resonance imaging, the dominant fibroid volume decreased by 31.8% (95% CI 12.2-51.3%). Ovarian reserve demonstrated no change after embolization. Thereafter the women were prospectively followed, and 31 of them (aged 37.3 ± 3.5 years) were actively trying to conceive. In spite of 33.4 ± 14.5 months of attempts, only 1 in 31 women became pregnant and she finally miscarried (monthly fecundability rate 0.1% 95% CI 0-0.3%). LIMITATIONS, REASONS FOR CAUTION The high rate of associated infertility factors in our population, and the high frequency of previous surgery, could in part explain these poor reproductive outcomes; however, they should not account for the total absence of ongoing pregnancy. Embolization might have had a negative impact on fertility in our population, which may not be related to ovarian function. WIDER IMPLICATIONS OF THE FINDINGS The low reproductive outcomes reported in the present study suggest that UAE should not be performed routinely in young women of childbearing age with extensive fibroids. Although this finding was established in a population for whom abdominal myomectomy was declined, a possible adverse effect of UAE on fertility potential should be considered for woman of childbearing age scheduled for embolization. STUDY FUNDING/COMPETING INTEREST(S) No particular funding was obtained for this study and the authors have no conflict of interest.

Ultrasound assessment of haemoperitoneum in ectopic pregnancy: derivation of a prediction model

BackgroundTo derive an ultrasound-based prediction model for the quantification of haemoperitoneum in ectopic pregnancy (EP).MethodsRetrospective study of 89 patients operated upon EP between January 1999 and March 2003 in a French Gynaecology and Obstetrics department in a university hospital. Transvaginal sonograms, clinical and biological variables from patients with haemoperitoneum ≥ 300 ml at surgery were compared with those from patients with haemoperitoneum < 300 ml or no haemoperitoneum. Sensitivity, specificity, positive and negative likelihood ratios were calculated for each parameter after appropriate dichotomization. Multiple logistic regression analysis was used to select the best combination at predicting haemoperitoneum ≥ 300 ml.ResultsThree parameters predicted haemoperitoneum ≥ 300 ml independently: moderate to severe spontaneous pelvic pain, fluid above the uterine fundus or around the ovary at transvaginal ultrasound, and serum haemoglobin concentration < 10 g/dL. A woman with none of these three criteria would have a probability of 5.3% for haemoperitoneum ≥ 300 ml. When two or more criterias were present, the probability for haemoperitoneum ≥ 300 ml reached 92.6%.ConclusionThe proposed model accurately predicted significant haemoperitoneum in patients diagnosed to have EP.

Routine ultrasound examination by OB/GYN residents increase the accuracy of diagnosis for emergency surgery in gynecology

IntroductionDiagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain.MethodsA cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both.ResultsEmergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%.ConclusionsFirst-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain.

Non-Invasive Tools for the Diagnosis of Potentially Life-Threatening Gynaecological Emergencies: A Systematic Review

Objective To identify non-invasive tools for diagnosis of the major potentially life-threatening gynaecological emergencies (G-PLEs) reported in previous studies, and to assess their diagnostic accuracy. Methods MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched to identify all eligible studies published in English or French between January 1990 and December 2012. Studies were considered eligible if they were primary diagnostic studies of any designs, with a gold standard and with sufficient information for construction of a 2 × 2 contingency table, concerning at least one of the following G-PLEs: complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Extraction of data and assessment of study quality were conducted by two independent reviewers. We set the thresholds for the diagnostic value of signs retrieved at Sensibility ≥ 95% and LR—≤ 0.25, or Specificity ≥ 90% and LR+ ≥ 4. Results We identified 8288 reports of diagnostic studies for the selected G-PLEs, 45 of which met the inclusion criteria. The methodological quality of the included studies was generally low. The most common diagnostic tools evaluated were transvaginal ultrasound (20/45), followed by medical history (18/45), clinical examination (15/45) and laboratory tests (14/45). Standardised questioning about symptoms, systolic blood pressure<110 mmHg, shock index>0.85, identification of a mass by abdominal palpation or vaginal examination, haemoglobin concentration <10 g/dl and six ultrasound and Doppler signs presented high performances for the diagnosis of G-PLEs. Transvaginal ultrasound was the diagnostic tool with the best individual performance for the diagnosis of all G-PLEs. Conclusion This systematic review suggests that blood pressure measurement, haemoglobin tests and transvaginal ultrasound are cornerstone examinations for the diagnosis of G-PLEs that should be available in all gynaecological emergency care services. Standardised questioning about symptoms could be used for triage of patients.

Optimal Combination of Non-Invasive Tools for the Early Detection of Potentially Life-Threatening Emergencies in Gynecology

Objectives Potentially life-threatening gynecological emergencies (G-PLEs) are acute pelvic conditions that may spontaneously evolve into a life-threatening situation, or those for which there is a risk of sequelae or death in the absence of prompt diagnosis and treatment. The objective of this study was to identify the best combination of non-invasive diagnostic tools to ensure an accurate diagnosis and timely response when faced with G-PLEs for patients arriving with acute pelvic pain at the Gynecological Emergency Department (ED). Methods The data on non-invasive diagnostic tools were sourced from the records of patients presenting at the ED of two hospitals in the Parisian suburbs (France) with acute pelvic pain between September 2006 and April 2008. The medical history of the patients was obtained through a standardized questionnaire completed for a prospective observational study, and missing information was completed with data sourced from the medical forms. Diagnostic tool categories were predefined as a collection of signs or symptoms. We analyzed the association of each sign/symptom with G-PLEs using Pearson’s Chi-Square or Fischer’s exact tests. Symptoms and signs associated with G-PLEs (p-value < 0.20) were subjected to logistic regression to evaluate the diagnostic value of each of the predefined diagnostic tools and in various combinations. Results The data of 365 patients with acute pelvic pain were analyzed, of whom 103 were confirmed to have a PLE. We analyzed five diagnostic tools by logistic regression: Triage Process, History-Taking, Physical Examination, Ultrasonography, and Biological Exams. The combination of History-Taking and Ultrasonography had a C-index of 0.83, the highest for a model combining two tools. Conclusions The use of a standardized self-assessment questionnaire for history-taking and focal ultrasound examination were found to be the most successful tool combination for the diagnosis of gynecological emergencies in a Gynecological ED. Additional tools, such as physical examination, do not add substantial diagnostic value.