E. Domali

Recurrent benign leiomyomas after total abdominal hysterectomy. Rich or poor estrogenic environment may lead to their recurrence

Highlights • BML is a rare entity that usually affects women after hysterectomy for leiomyomas.• This is one of few reports in literature of tumors’ appearance in the same patient both in estrogen rich and poor environment.• Τransvaginal ultrasonography seems to be a pivotal tool for the diagnosis and follow up of these challenging lesions.

EP28.09: Ultrasonic images might be able to inform regarding the benignity or malignancy of endometrial lesions

diameter, volume and vascularisation, considering supplying vessel PI and RI). Surgery was performed by a second physician and the outcome parameters considered were: surgical time, intraoperative blood loss, pre-and post-operative hemoglobin, use of abdominal drains, duration of hospital stay, post-operative fever and need of blood transfusion. Results: 23 women were enrolled in the study. The mean uterine volume was 381.9±189.4 mm3 and it had a correlation with the length of surgery (p=0.045). The mean diameter of fibroids evaluated was 62.2±24.2 mm with a mean volume of 131.7±117 mm3. A significant association was found between fibroid position and surgical time, in particular lateral myomectomies had the longest duration (p=0.049). No other correlations were found among the ultrasound preoperative parameters and the different complications during and after surgery. Dividing myomas in two groups considering their larger diameter, fibroids of 50 mm or more showed higher length of surgery, more blood loss and higher difference between pre and post-operative hemoglobin, but these results did not reach significance (p>0.05). Conclusions: Ultrasound calculation of uterine and fibroid volume can be useful in the estimation of surgical time but determination of uterine and fibroid vascularisation seems not to be a predictor for the risks of complications during and after myomectomy.

OC11.03: Prospective validation of IOTA methods in the differentiation between benign and malignant adnexal masses

W. Froyman16,17, C. Landolfo16, B. De Cock16, L. Wynants16, A.C. Testa15, E. Domali14, P. Sladkevicius13, L. Savelli12, D. Franchi11, E. Epstein10,18, C. Van Holsbeke9, R. Fruscio19, M. Blanco20, J. Alcázar8, S. Guerriero7, A. Rossi6, A. Czekierdowski5, V. Chiappa4, F. Buonomo21, M.J. Kudla3, T. Bourne2,16, L. Valentin1, J.Y. Verbakel16,22, B. Van Calster16, D. Timmerman16,17 1Department of Obstetrics and Gynecology, Skåne University Hospital Malmö, Lund University, Malmö, Sweden; 2Queen Charlotte’s and Chelsea Hospital, Imperial College, London, United Kingdom; 3Clinical Department of Oncological Gynecology, Medical University of Silesia, Katowice, Poland; 4Department of Gynecological Oncology, National Cancer Institute of Milan, Milan, Italy; 5First Department of Gynecological Oncology and Gynecology, Medical University of Lublin, Lublin, Poland; 6Department of Obstetrics and Gynecology, University of Udine, Udine, Italy; 7Department of Obstetrics and Gynecology, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy; 8Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, School of Medicine, Pamplona, Spain; 9Department of Obstetrics and Gynecology, Ziekenhuis Oost-Limburg, Genk, Belgium; 10Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; 11Preventive Gynecology Unit, Division of Gynecology, European Institute of Oncology, Milan, Italy; 12Department of Obstetrics and Gynecology, S Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; 13Department of Obstetrics and Gynecology, Skåne University Hospital Malmö, Lund University, Malmö, Sweden; 14First Department of Obstetrics and Gynecology, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece; 15Department of Oncology, Catholic University of the Sacred Heart, Rome, Italy; 16Department of Development and Regeneration, KU Leuven, Leuven, Belgium; 17Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; 18Department of Women and Children’s Health, Karolinska Institutet, Stockholm, Sweden; 19Clinic of Obstetrics and Gynecology, University of Milan-Bicocca, San Gerardo Hospital, Monza, Italy; 20Department of Obstetrics and Gynecology, Ospedale Garibaldi, Catania, Italy; 21Institute for Maternal and Child Health – IRCCS ‘‘Burlo Garofolo’’, Trieste, Italy; 22Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom

P23.05: Medical termination of pregnancy in a tertiary centre in Greece: a case series of a diverse population including refugees and travellers

Results: There was no significant difference between groups in age (t=-1,7; p>0,05), in previous gravida numbers (U=3577,5; p>0,1), pelvic inflammatory diseases rate (χ2 =1,31; p>0,05), adnexa surgery numbers (U=3220,5; p>0,1), spotting days (t=-1,7; p=0,088). Significant difference was revealed in the uterus surgery numbers (U=1214,5; p<0,001), parity (U=2746,5; p<0,05), Caesarean scar numbers (U=2170; p<0,001). In 2nd group the gestation age, HCG-level, the presence of embryo cardiac activity, ultrasound mistakes rate and time from first admission for right diagnosis were significantly higher (U=1245; p<0,001, U=646,5; p<0,001, χ2 =16,6 p<0,0001, χ2 =20,2, p<0,05, U=1886; p<0,001 respectively). Intraoperative blood loss, operation time, follow-up duration, chorion persistence rate, readmission rate in LIP were significantly higher than in tubal pregnancy (U=2692,5; p<0,05, χ2 =28,0; p<0,0001, U=1284; p<0,0001, U=257,5; p<0,0001, χ2 =22,0; p<0,0001, χ2 =29,9; p<0,0001 respectively). Conclusions: Early ultrasound criteria are necessary for correct diagnosis of LIP among patients with previous surgery on uterus.

EP25.18: Risk of borderline malignancy and ultrasonic assessment

Objectives: To investigate if the calculation of the digital signal of the images that are produced via 3D software application could help in the identification of ovarian borderline lesions via ultrasonography. Methods: Ultrasonographic volumes of 22 borderline ovarian tumours and 18 serous cysts (as controls) were analysed via 3D Render Mode application. Main image was isolated from the surrounded noise and inverted. The signals produced by these images may be transformed into numerical data via ImageJ system; the last is a free web application. Results: Signals produced by images originated from inverted borderline volumes were calculated at the level of 68.566, ranging from 1.677-128.776. On the other hand, images produced by images that belong to the inverted serous cysts volumes gave significantly increased signals when compared to borderline tumours (135.264; range: 96.308-165.978; p<0.01). Conclusions: Despite the limited number of cases, it is indicated that calculation of the signals produced by specific images of borderline tumours could imply the malignant nature of the mass. Pattern recognition of the cyst could support the diagnosis.

EP25.17: Images produced by 3D ultrasound scan could warn investigator regarding the nature of the ovarian lesion

Objectives: To investigate if the calculation of the digital signal of the images that are produced via 3D software application could help in the identification of ovarian borderline lesions via ultrasonography. Methods: Ultrasonographic volumes of 22 borderline ovarian tumours and 18 serous cysts (as controls) were analysed via 3D Render Mode application. Main image was isolated from the surrounded noise and inverted. The signals produced by these images may be transformed into numerical data via ImageJ system; the last is a free web application. Results: Signals produced by images originated from inverted borderline volumes were calculated at the level of 68.566, ranging from 1.677-128.776. On the other hand, images produced by images that belong to the inverted serous cysts volumes gave significantly increased signals when compared to borderline tumours (135.264; range: 96.308-165.978; p<0.01). Conclusions: Despite the limited number of cases, it is indicated that calculation of the signals produced by specific images of borderline tumours could imply the malignant nature of the mass. Pattern recognition of the cyst could support the diagnosis.

P14.12: 3D parameters via Render Mode during transvaginal ultrasonography and endometrial malignancy

Objectives: To identify factors that impact the visibility of the endometrial echo (EE) on transvaginal sonography (TVS) of postmenopausal women. Methods: A prospective study of women, 50 years and older, who underwent TVS. EE was measured according to IETA guidelines. An EE visibility scoring system was developed (0-not seen, 1-poorly seen, 2-borderline, 3-satisfactory and 4-optimal visibility). Images were scored by three solonogists trained in the EE scoring system. Patient and sonographic characteristics were compared between those with low visibility scores (0-2) and those with adequate visibility scores (3-4). P<0.05 was considered significant. Results: 440 scans were evaluated. Mean patients age was 60.1y (50-91) and mean BMI was 33.3kg/m2. The main indication for imaging was vaginal bleeding (87.2). African Americans (AA) and Hispanics encompassed 85.0% of the study population. The EE was adequately seen in 278/440 (63.2%). Younger women (50-59) had poorer visibility than older women (70-79, 60.7% vs 75.9%, p=0.04). African Americans (AA) had significantly poorer visibility than Hispanics and Asians (p=0.01 and 0.04 respectively). However, AA women had significantly more fibroids than other ethnicities (40.9% vs 18.2%, p<0.01). The presence of endometrial polyps improved visibility (74.2% vs 52.9% p<0.001), while presence of fibroids decreased visibility (50.6 vs 63.7, p=0.01). There were no statistically significant differences in EE visibility between women with BMI >30 or <30kg/m2 (p=0.65), uterine position (p=0.07) and presence of endometrial neoplasia (p=0.19). Conclusions: In our patient population of postmenopausal women EE was adequately seen in 63.2% of TVS. Younger age, African American ethnicity and presence of fibroids are associated with poor visibility while presence of endometrial polyps improves visibility. Patients BMI, uterine position and presence of cancer did not affect EE visibility.

P14.02: Ultrasonographic evaluation of possible endometrial pathology in symptomatic women via IETA and MUSA rules

Objectives: The popularity of minimally invasive techniques for the treatment of symptomatic uterine fibroids as an alternative to surgical procedures is increasing. The most widely used procedure of this type is uterine artery embolisation (UAE). During UAE embolic material is administered into bilateral uterine arteries to reduce the tumour’s blood supply. This results in necrosis, fibroid volume reduction and relief of symptoms. In some cases tumour regrowth and recurrence of clinical symptoms after UAE are observed, due to fibroid revascularisation. In this study uterine fibroid vascularisation changes after UAE were analysed during a 3 months follow-up period. Methods: 64 premenopausal patients with symptomatic intramural fibroids qualified for UAE in the 3rd Chair and Department of Gynecology, Medical University of Lublin, were included in the study. Dominant fibroid vascularisation was evaluated before UAE, 24 hours and 3 months after UAE using the VOCAL technique by calculating the vascular-flow index (VFI). Data were analysed using the repeated measures ANOVA with the post hoc Fisher’s test. P values below 0,05 were considered significant. Results: Mean fibroid VFI before UAE was estimated at 0,85 (±0,11 SE), 24 hours after UAE at 0,03 (±0,01 SE), and after 3 months at 0,08 (±0,02 SE). Analysis of variance showed a significant (p <0.0001) effect of time after UAE on the vascularisation of uterine fibroids. A post hoc analysis showed that the fibroid VFI’s assessed after 24 hours and 3 months after UAE were significantly lower than before UAE (p <0,0001). Fibroid VFI assessed 24 hours after UAE was not significantly different from VFI 3 months after UAE (p = 0.62). Conclusions: Statistically significant fibroid vascular-flow index reduction was observed at 24 hours after UAE. Three months after UAE this effect was maintained, with an insignificant increase of VFI between 24 hours and 3 months post UAE.

P23.02: Ectopic pregnancies and treatment: surgery is not the only choice

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

OHSS Complicated With PID and Pelvic Abscess after IVF in a 35 Year Old Woman: A Case Report and Review of the Literature

Background: Ovarian hyper stimulation syndrome is an iatrogenic serious complication that presents after human chorionic gonadotropin stimulation or after the spontaneous peak of luteizing hormone. Pelvic inflammatory disease following the in vitro fertilization and oocyte retrieval is a rare and infrequent complication. Tubo-ovarian abscess has been described as rare and significant complication .We present an uncommon case according the literature in which rare complications of IVF are described. Methods: We present a case of a 35 year old female patient, gravida 1, para 0 with history of in vitro fertilization short protocol and oocytes retrieval before a month ,attended our hospital complaining for deep abdominal pain since 8 days with significant gynecological past history. Clinical evaluation proved abdominal pain on palpation without fever. Serum levels of C-reactive protein were significantly elevated reaching the plateau of 320,943. Results: Transvaginal ultrasonography noticed the presence of a big left adnexal formation max diameter 18 cm that could be attributed to marked inflammation. Behind this, free fluid detected by the presence of adhesions that could be attributed to hydrosalpinx. The diagnosis of ovarian hyper stimulation syndrome followed by pelvic inflammatory disease was made and she hospitalized for 10 days. The patient came to our hospital 3 months later for her follow up and the transvaginal examination revealed left tubo-ovarian abscess. A new transvaginal ultrasonography after 3 months was clearly improved compared to the previous images. Conclusion: Ovarian hyper stimulation syndrome which is complicated with pelvic inflammatory disease and especially pelvic abscess after in vitro fertilization and oocyte retrieval guided by ultrasound is a rare and simultaneously significant complication. Transvaginal ultrasonographical examination seems to be a pivotal tool primarily for the diagnosis and secondarily for the follow up of these infertile women.