B. Gerges

Sonographic evaluation of immobility of normal and endometriotic ovary in detection of deep endometriosis

To examine the association between ovarian immobility and presence of endometriomas and assess the diagnostic accuracy of transvaginal sonographic (TVS) ovarian immobility in the detection of deep infiltrating endometriosis (DIE).

Minimising harm in the early pregnancy population

Since the establishment of early pregnancy units (EPUs) in the 1990s throughout the United Kingdom and more recently in Australia, women are being seen earlier in their pregnancies. This has been further compounded by the advancement in transvaginal ultrasound (TVS) technology and women’s access to highly sensitive urinary pregnancy kits. These factors have resulted in a reduction in adverse outcomes, particularly with regard to delayed diagnosis of an ectopic pregnancy and the subsequent risk of rupture requiring emergency laparoscopy or laparotomy. However, it has also resulted in women undergoing TVS at earlier gestations where the viability of the pregnancy cannot be ascertained or the location of the pregnancy is not determined. These clinical entities are referred to as an ‘intrauterine pregnancy of uncertain viability’ (IPUV) and ‘pregnancy of unknown location’ (PUL), respectively. Miscarriage is one of the most common early pregnancy outcomes managed in the EPU setting. Prior to 2011, the American College of Radiologists’ guidelines stated ‘the embryo will initially appear as a thickened, linear echogenic structure between the yolk sac and the gestational sac, possibly seen at 8 mm sac size, but definitely by 16 mm,’ and ‘embryonic demise may be diagnosed with an embryo >5 mm without cardiac activity’. However, this guideline referred to two small papers, one from 1988 based on 35 women assessing the mean gestational sac diameter (MSD) of 16 mm, and the other from 1990 based on 12 women assessing crown rump lengths (CRL) between 4.0 and 4.9 mm. In 2011, Jeve, et al. found that the use of a MSD of 16 mm was associated with a false-positive rate of 4.4% which fell to 0.5% with an MSD cut-off of 20 mm. Abdallah, et al. reported the change in MSD and CRL over time and observed that a CRL growth rate of less than 0.2 mm per day had a 100% specificity, whereas changes of 1.4 mm in a week can be associated with a viable pregnancy. Further, if there was no development of embryonic structures within a gestational sac between seven and 14 days, this was almost always associated with a miscarriage. Following these publications, the recommended criteria to define miscarriage were revised to be more conservative. These changes included ‘a MSD ≥25 mm (with no obvious yolk sac), or with a fetal pole with CRL ≥7 mm (the latter without evidence of embryonic heart activity)’ and ‘where there is any doubt about the diagnosis and/or a woman requests a repeat scan, this should be performed at an interval of at least one week from the initial scan before medical or surgical measures are undertaken for uterine evacuation. No growth in gestation sac size or CRL is strongly suggestive of a nonviable pregnancy in the absence of embryonic structures on a repeat scan’. This implies that prior to 2011, 4.4% of the early pregnancies which would now be identified as an ‘IPUV’ would have been termed a ‘miscarriage’ and may have resulted in an inadvertent termination if they had have proceeded to medical or surgical evacuation of the pregnancy. The implementation of these more conservative cut-offs to define miscarriage has been advocated and accepted across North America, United Kingdom and Australasia. We believe that all ultrasound-based units in Australia who review women in early pregnancy must adhere to these updated cut-offs in order to minimise potential harm to women and their developing fetus. The death of an embryo in early pregnancy should be regarded as equal significance to that occurring at a later stage. Pregnancy of unknown location is a term used to classify a pregnancy when there is no evidence of an intraor extrauterine pregnancy on TVS. The main concern in the management of women with PUL is the potential for delay in the diagnosis of an underlying or developing ectopic pregnancy. In 2005, 5544 consecutive women underwent TVS and the rate of PUL was 10.1% (560/5544). In those women with complete data, the rate of ectopic pregnancy was 7.1% and importantly no woman suffered tubal rupture whilst awaiting outpatient follow-up to diagnose her ectopic pregnancy (the median number of days required to diagnose an ectopic pregnancy was five days (range 2–25 days)). Therefore, we believe that this diagnostic delay in those women in the PUL population with a developing ectopic pregnancy will not result in harm due to tubal rupture. The other PUL outcomes include an intrauterine pregnancy (viable or nonviable), a failed PUL or a persisting PUL. The rates of PUL in women attending a TVS in early pregnancy have been reported to be 5–42%, although the accepted consensus is that units should aim to have a PUL rate <15%. This large range in PUL rate is likely due to the lack of clear criteria for the diagnosis of PUL as well as the great variation in ultrasound operator experience. We know that the rate of PULs is indirectly proportional to the experience of operator. Studies show that 6–20% of PUL have an underlying or developing ectopic pregnancy and 30–47% have an underlying or developing IUP with the majority of PULs resulting in a failed PUL (50–70%), some of which represent complete miscarriages or self-limiting forms of ectopic pregnancy (where the location is never identified). Intervention in women with a PUL should not be routine unless the location of the pregnancy has been determined and more importantly the viability of the underlying pregnancy confirmed to be nonviable. The use of the human chorionic gonadotrophin (hCG) ratio (hCG 48 h/ hCG 0 h) in women with a PUL is key to determining nonviability before implementation of curettage or methotrexate protocols. A minimum rise of 15% in serum hCG levels which equates to an hCG ratio of 1.15 has been

Transvaginal Ultrasound Soft Markers for the Prediction of Endometriosis Type and Location in Women Undergoing Laparoscopy

STAGING SYSTEM 1 (SS1) Stage I Sot markerPositive site specific tenderness in PC with mobile Level 1 ovaries Endometrioma absent POD Positive sliding sign DIE nodules Absent Stage II Sot marker Positive site specific tenderness in PC with/without Level 2 mobile ovaries Endometrioma Present POD Positive sliding sign DIE nodules Absent Stage III Sot marker Positive site specific tenderness in PC with/without Level 2 mobile ovaries Endometrioma Present or absent POD Positive sliding sign DIE nodules Present Stage IV Sot marker Positive site specific tenderness in PC with/without Level 3 mobile ovaries Endometrioma Present or absent POD Negative sliding sign DIE nodules Present STAGING SYSTEM 2 (SS2) Stage 1 Sot marker Positive site specific tenderness in PC with mobile Level 1 ovaries Endometrioma absent POD Positive sliding sign DIE nodules Absent Stage II Sot marker Positive site specific tenderness in PC with/without Level 2 mobile ovaries Endometrioma Present POD Positive sliding sign DIE nodules Absent Stage IIIA Sot marker Positive site specific tenderness in PC with/without Level 2 mobile ovaries Endometrioma Present POD Positive sliding sign Non bowel DIE nodules – Present Stage IIIB Sot marker Positive site specific tenderness in PC with/without Level 3 mobile ovaries Endometrioma Present POD Positive sliding sign Bowel DIE nodules – Present Stage IV Sot marker Positive site specific tenderness in PC with/without mobile ovaries Endometrioma Present or absent Level 3 POD Negative sliding sign DIE nodules – Present S27 Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253

Diagnostic Accuracy and Reproducibility of Predicting Cul-de-Sac Obliteration by General Gynaecologists and Minimally Invasive Gynaecologic Surgeons

OBJECTIVEnKnowledge of rectouterine cul-de-sac state and consistent classification among surgeons are important in the surgical management of women with endometriosis. The objective of this study was to determine the diagnostic accuracy and interobserver and intraobserver agreement among general gynaecologists (GGs) and minimally invasive gynaecologic surgeons (MIGSs) in the prediction of cul-de-sac obliteration at off-line analysis of laparoscopic videos.nnnMETHODSnFive GGs and five MIGSs viewed 33 prerecorded laparoscopic video sets off-line to determine cul-de-sac obliteration state (non-obliterated, partially obliterated, or completely obliterated) on two occasions (at least 7days apart). Diagnostic accuracy and interobserver and intraobserver agreement were evaluated.nnnRESULTSnThe interobserver agreements for all 10 observers for the description of cul-de-sac state ranged from fair to substantial agreement, with moderate overall agreement. MIGSs had slightly higher within-group interobserver agreement compared with GGs. MIGSs achieved overall almost perfect intraobserver agreement compared with substantial agreement for GGs. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for MIGSs classifying the cul-de-sac state were 83.9%, 88.5%, 88.5%, 89.2%, 92.0%, and 84.7%, respectively, whereas for GGs, they were 79.1%, 79.4%, 88.1%, 89.9%, and 76.1%, respectively.nnnCONCLUSIONnDiagnostic accuracy and interobserver and intraobserver agreement for cul-de-sac obliteration state classification is acceptable in both groups. MIGSs had greater diagnostic accuracy and exhibited high interobserver and intraobserver agreement, a finding suggesting that their advanced training makes them more reliable in cul-de-sac obliteration assessment. Partial cul-de-sac obliteration was the most commonly incorrectly diagnosed state, thus implying that partial obliteration is not well understood.

Three-dimensional transvaginal sonographic assessment of uterine volume as preoperative predictor of need to morcellate in women undergoing laparoscopic hysterectomy

In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two‐ (2D) and three‐ (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH).

Three-dimensional transvaginal sonographic assessment of uterine volume as preoperative predictor of need to morcellate in women undergoing laparoscopic hysterectomy: Predicted probability of morcellation

In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two‐ (2D) and three‐ (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH).

3D transvaginal sonography as pre‐operative predictor of the need to morcellate in women undergoing laparoscopic hysterectomy

In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two‐ (2D) and three‐ (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH).

The Performance of “The Endometriosis Scan” Preoperatively for the Detection of Deep Infiltrating Endometriosis

The Performance of ‘‘The Endometriosis Scan’’ Preoperatively for the Detection of Deep Infiltrating Endometriosis Gerges B, Lu C, Reid S, Menakaya U, Nadim B, Chou D, Condous G. Obstetrics and Gynaecology, Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Kingswood, NSW, Australia; Department of Computer Sciences, University of Wales, Aberystwyth, United Kingdom; The Sydney Women’s Endosurgery Centre (SWEC), Hurstville, NSW, Australia

OC10.06: The association between vaginal childbirth and hiatal dimensions

delivered of a second child between the first and second postnatal assessments. Results: Out of 715 participants seen at an average gestation of 36+5, 529 returned for their first postnatal assessment at a median follow-up time of 4.2 (2.3–22.1) months postpartum. Of those, 227 were again seen for a second postnatal appointment, and 94 of them seen at an average of 2.7 (1.43–4.21) years after their first delivery reported a second birth. 65 (69%) had a vaginal delivery (NVD 58 [62%], vacuum 4, [4%]; forceps 3 [3%]), and 29 (31%) a Caesarean section. There were 9 VBAC attempts, of which 6 were successful (2 NVD, 3 Vacuum, 1 FD). On imaging there was a trend towards increased bladder neck descent, with no significant change observed for cystocele descent and hiatal area on valsalva. Delivery mode of the second birth seemed to have little effect on changes observed between follow ups. On reviewing patients who were diagnosed with avulsion at their 2–3 year visit and comparing them with findings at the first follow up, we found identical normal findings in 87. In 5 there was an unchanged avulsion. In one case findings had improved from complete to partial avulsion – after a second NVD. There was one new avulsion in a patient who had delivered her first baby by emergency C/S, and her second by vacuum. Conclusions: A second pregnancy and delivery do not seem to have a major effect on pelvic organ support and/ or levator functionunless the pregnancy results in that patient’s first vaginal birth.