B. Nadim

Morphological ultrasound types known as ‘blob’ and ‘bagel’ signs should be reclassified from suggesting probable to indicating definite tubal ectopic pregnancy

In a recent consensus statement on early pregnancy nomenclature by Barnhart, a definite ectopic pregnancy (EP) was defined morphologically on transvaginal sonography (TVS) as an extrauterine gestational sac with yolk sac and/or embryo, with or without cardiac activity, whilst a probable EP was defined as an inhomogeneous adnexal mass (‘blob’ sign) or extrauterine sac‐like structure (‘bagel’ sign). This study aims to determine whether these ultrasound markers used to define probable EP can be used to predict a definite tubal EP.

Association between three‐dimensional transvaginal sonographic markers and outcome of pregnancy of unknown location: a pilot study

To assess the accuracy of three‐dimensional (3D) transvaginal sonographic (TVS) parameters in predicting the evolution of a pregnancy of unknown location (PUL).

The association between 3-D transvaginal ultrasound markers and pregnancy of unknown location outcome: a pilot study.

To assess the accuracy of three‐dimensional (3D) transvaginal sonographic (TVS) parameters in predicting the evolution of a pregnancy of unknown location (PUL).

Relationship Between Ultrasonographic and Biochemical Markers of Tubal Ectopic Pregnancy and Success of Subsequent Management: Ultrasonographic and Biochemical Markers of Tubal Ectopic Pregnancy

To determine whether there is an association between morphologic types of tubal ectopic pregnancy (EP), 0‐hour human chorionic gonadotropin (hCG) levels, and subsequent management success.

EP26.03: Prediction of pouch of Douglas obliteration by analysing offline ultrasound and laparoscopic videosets: a diagnostic accuracy and interobserver study

follow-up. Patient was discharged stable. Ultrasound performed six months later noted a left ovarian cyst with low-level echoes. On follow-up, she was noted to have recovered completely and a scan performed a year later did not demonstrate any abnormalities in the pelvis. Conclusion: Patient was virgo intacta. Transrectal scan was attempted but unsuccessful. Transabdominal ultrasound was restricted by body habitus, hence resulting in suboptimum demonstration of the dermoid.

P18.02: Prevalence of negative 'sliding sign' in low-risk population: a feasibility study

Objectives: To investigate whether or not an ovarian endometrioma detected by ultrasound was associated with other appearances of pelvic endometriosis such as adhesions and/or deep infiltrating endometriosis (DIE) in order to improve the management of patients with pelvic pain or infertility. Methods: This is an observational retrospective study including a group of women (n=255) with at least an ovarian endometrioma (at least diameter of ≥ 20 mm) detected by transvaginal ultrasound (TVS). Patients with previous pelvic surgery and without symptoms were excluded. Other associated sonographic signs of pelvic endometriosis such as adhesions, tubal pathology, adenomyosis and DIE were recorded according to a detailed TVS mapping of pelvic endometriosis. Subsequently a group of women (n=50) underwent laparoscopic treatment and during surgery a complete endometriosis mapping was assessed. Results: Mean age was 34.2 ± 6.6 years, mean endometriomas diameter was 40.0 ± 18.1mm, bilateral endometriomas were observed in 65patients (25.5%). Of the 255 patients 50 underwent laparoscopic surgery due to severe symptoms whereas 205 had indications to medical therapy or ART. At TVS 55 (21.5%) showed posterior rectal DIE and 93 (36.4%) a thickening of at least one uterosacral ligament. 186 patients (73%) showed adhesions and 134 (53%) showed ultrasonographic features of adenomyosis. Only 57 (22%) had a single isolated ovarian lesion with a mobile ovary and without any other ultrasound signs of pelvic endometrioma. No statistically significant differences were observed in the TVS mapping and histological confirmation. Conclusions: Ovarian endometrioma is a marker for pelvic endometriosis and is rarely isolated 44% patients with an endometrioma showed DIE. Adhesions and adenomyosis are associated to endometrioma in more than 50%. In a clinical context when there is an ovarian endometrioma an accurate TVS should investigate the extension of the disease to check for other endometriotic lesions in order to choose the most appropriate treatment to manage pain and infertility.

OP31.10: Performance of the transvaginal sonographic ‘sliding sign’ in prediction of pouch of Douglas obliteration: does this improve over time?

Methods: Two experienced observers performed a review of stored 2D and 3D sonographic examinations of 50 consecutive women with typical sonographic signs of adenomyosis according of the MUSA. 20 patients without any sonographic signs of myometrial pathology were used as control group. Each observer, independently and blinded to each other, evaluated the presence or absence and the severity of adenomyosis using a new score system. The score system evaluated ultrasonographic criteria for focal and diffuse adenomyosis, adenomyoma and for junctional zone (JZ). A score number from 1 to 4 were assigned to the extension and myometrial involvement of each type of adenomyotic lesions and for JZ alterations. Numerical score obtained was classified in three group: mild (ranged between 1 to 7), moderate (8-13) and severe (14-20). Results: With respect to interpretation of the presence or not of adenomyosis ultrasonographic findings, the agreement was perfect (Cohen kappa, K=1). Multiple rater agreements to classify the different features of adenomyosis (diffuse, focal adenomyoma and focal or diffuse alteration of JZ) ranged from good to almost perfect (Cohen k 0.678 – 0.953). According to numerical score the agreement for minimal, moderate and severe adenomyosis ranged from substantial to almost perfect (respectively Cohen k=1, K=0.94, K= 0.79). Conclusions: Our new score system to diagnose adenomyosis severity were reproducible and could be useful in clinical practice. The high percentage of agreement obtained in the JZ evaluation could improve the sensitivity of adenomyosis diagnosis. The ultrasonographic quantification of severity and the extension of adenomyosis in the myometrium could be helpful in correlation to the severity of symptoms but also for an emerging request of surgical treatment.

P23.01: Doppler colour scoring system using offline video analysis in women with an incomplete miscarriage: inter- and intraobserver reproducibility study

G.T. Leong7, C. Lu5, B.J. Mein6, M. Espada4, B. Shakeri4, B. Nadim4, S. Reid2, I. Casikar3, G. Condous1 1Obstetrics and Gynecology, Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia; 2Nepean Hospital, Chiswick, NSW, Australia; 3Early Pregnancy, Acute Gynecology and Advanced Endosurgery Unit, Nepean Hospital, Enu Plains, NSW, Australia; 4Obstetrics and Gynecology, Nepean Hospital, Penrith, NSW, Australia; 5Computer Science, Aberystwyth University, Aberystwyth, United Kingdom; 6Perinatal Ultrasound, Nepean Hospital, Kingswood, NSW, Australia; 7University of Sydney, Sydney, NSW, Australia

Ultrasound features of tubal ectopic pregnancy

During the last two decades, there have been tremendous advances in the recognition and management of ectopic pregnancies (EPs); nevertheless, EP remains a major cause of maternal morbidity and mortality. In westernised countries like the United Kingdom, the rate of EP is 11/ 1000 pregnancies with maternal mortality of 0.2/1000 (NICE guidelines 2012). While in the United States of America 9% of maternal mortality is attributed to EP. In Australia, there were three maternal deaths between 2006 and 2010 (in comparison with two between 2000 and 2005) all of which were preventable. The rates of EP are even higher in developing countries. Importantly, we must also not underestimate the psychological trauma associated with EP and the impact on future fertility. Early recognition and prompt referral are key factors to prevent catastrophic events such as tubal rupture and collapse. Early diagnosis allows the clinician to decide for more conservative approaches in EP management avoiding surgery and its associated risks of anaesthesia, blood loss and inadvertent injury to vascular and other pelvic structures at the time of laparoscopy. Ultrasound is the imaging method of choice to diagnose EP. In the 1970s, the diagnosis of EP was based upon non-visualisation of a gestational sac inside the uterus, utilising transabdominal scan at different cut-off values of serum human chorionic gonadotrophin (hCG). ln the 1980s and 1990s, transvaginal ultrasound scan (TVS) was introduced and became widely used, resulting in earlier recognition of the EP mass at lower levels of quantitative hCG. The diagnosis of EP in modern practice is based upon the positive visualisation of an extrauterine mass on TVS rather than the absence of an intrauterine gestational sac. At the first presentation, TVS has a sensitivity of 73.9–74.7% in detecting EP, and the overall sensitivity of TVS in detecting EP in subsequent visits is 87–99% with specificity of 94–99%. There are four distinct TVS morphologic criteria used to classify women with a tubal EP: (i) an inhomogeneous mass or ‘blob’ sign adjacent to the ovary and moving separately from the ovary; or (ii) a mass with a hyper-echoic ring around the gestational sac or ‘bagel’ sign; or (iii) a gestational sac with an embryonic pole with cardiac activity; or (iv) a gestational sac with an embryonic pole without cardiac activity. According to a consensus statement in 2011, only the presence of a gestational sac with embryo (with or without cardiac activity) is considered to be a definite diagnosis of EP. According to the same consensus, the other two morphological ultrasound types ‘blob’ and ‘bagel’ signs are classified as probable EPs. The prevalence of these different morphological types in TVS has changed over the years. The most common morphological types are the ‘blob’ and ‘bagel’ signs accounting for almost 80% of all tubal EPs, whilst the presence of an embryo with or without cardiac activity accounts for 10–13%. The association between these different EP morphological types and management success has been examined in several studies. The presence of fetal cardiac activity on TVS is considered an indication for surgical management. A gestational sac with yolk sac on TVS appears to be highly associated with failure of non-surgical management. Various studies have also looked at predictors of tubal rupture from ultrasound findings, but none have been shown to be a true predictor. There are varying reports as to whether or not the size of the EP mass on TVS is a significant predictor of success for expectant management. Although ultrasound plays a major role in the diagnosis and management of EP, its role is subject to the competency level and experience of the operator. The more experienced the operator, the higher the rate of EP detection at the initial TVS and the lower the rate of women classified with a pregnancy of unknown location (PUL). PUL is defined as the absence of an intraor extrauterine gestational sac on TVS and these women should be followed up to determine the final outcome. Implementation of consultant-led early pregnancy assessment units, accessibility to high-resolution TVS under strict supervision provision and focused teaching programmes to recognise the risk factors for EP have led to recognisable improvements in the quality and reporting of early pregnancy TVSs. The future for EP management is to explore whether early detection of EP with the adaptation of conservative management strategies will reduce the future rate of EP morbidity and mortality.

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