E. Okaro

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.

The conservative management of early pregnancy complications: a review of the literature

Early pregnancy complications include miscarriage, ectopic pregnancies, adnexal masses and pregnancies of unknown location. In this review, we evaluate the role of conservative management in these complications. We also evaluate the role of transvaginal sonography for diagnosis, treatment and follow up.

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.

Pregnancies of unknown location: diagnostic dilemmas and management.

Purpose of review This review discusses various aspects of the management of women with pregnancies of unknown location. Recent findings The prevalence of pregnancies of unknown location is dependent on the quality of scanning for a given early-pregnancy unit. The higher the quality of scanning, the better the detection of ectopic pregnancy using ultrasound as a single diagnostic test, which in turn results in fewer women being classified with a pregnancy of unknown location. Varying the discriminatory zone does not significantly improve the detection of ectopic pregnancies in a pregnancy of unknown location population. A single serum human chorionic gonadotrophin, when used in a specialized transvaginal scanning unit, is not only potentially falsely reassuring but also unhelpful in excluding the presence of an ectopic pregnancy. A single-visit approach has also been shown to be ineffective. The vast majority of women with a pregnancy of unknown location are at low-risk for ectopic pregnancy. Traditional strategies are capable of detecting the failing pregnancies of unknown location and intra-uterine pregnancies within a pregnancy of unknown location population, but they lack sensitivity for detecting ectopic pregnancies. This justifies the recent development and use of mathematical modelling techniques to predict ectopic pregnancies in the pregnancies of unknown location population. Summary New mathematical models have been developed to predict the outcome of pregnancies of unknown location; however, prospective studies are needed to assess the reproducibility of these models in different centres on different populations. Hopefully such models will enable the clinician to correctly classify pregnancies of unknown location earlier, in turn reducing the number of follow-up visits.

Placental site trophoblastic tumor masquerading as an ovarian ectopic pregnancy

The vast majority of pregnancies of unknown location (PUL) will be failing pregnancies and early intrauterine or ectopic pregnancies (EPs) that are too early to visualize on transvaginal scan. Very rarely, a positive pregnancy test in the presence of a negative scan will reflect an underlying human chorionic gonadotropin (hCG)‐secreting tumor. We report a case in which elevated serum hCG led to the initial diagnosis of an EP which was subsequently found to be a placental site tumor of the ovary. This case shows that a misinterpretation of signs of EP can result in a delay in accurate diagnosis. Copyright

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.

Diagnostic and therapeutic capabilities of ultrasound in the management of pelvic pain.

Purpose of review This review discusses the current diagnostic and therapeutic role of ultrasound in the management of pelvic pain. Recent findings Recent advances in ultrasound technology and expertise have facilitated the accurate diagnosis of common gynaecological and nongynaecological pathologies. Peritoneal and deep infiltrating endometriosis can now be diagnosed using hard and soft ultrasound-based markers. The combination of ultrasound-guided aspiration and instillation of a sclerosant is an alternative to surgery in the management of adnexal masses. Summary Experience is a key factor in the ability of transvaginal ultrasound to characterize common gynaecological disorders with accuracy. Therapeutic ultrasound provides an alternative to surgery.

The management of ectopic pregnancies and pregnancies of unknown location

Since the introduction of dedicated Early Pregnancy Units and the use of high-resolution transvaginal probes ectopic pregnancies are diagnosed at earlier gestations. As a result, the treatment options in the management of ectopic pregnancies have diversified. In this review, the role of transvaginal sonography in the management of women with ectopic pregnancies is described and the different treatment modalities available in their management are critically evaluated. We assert that ectopic pregnancy should be diagnosed on the basis of positively visualising an adnexal mass using transvaginal sonography, rather than the absence of an intrauterine pregnancy. If a pregnancy cannot be seen, either inside or outside the uterus, this should be described as a pregnancy of unknown location and managed expectantly until the outcome is confirmed.

The role of transvaginal ultrasound in the management of abnormal uterine bleeding

Abnormal uterine bleeding is a common symptom. Modern management should be based on a “one-stop” approach to which transvaginal ultrasound is ideally suited as a primary diagnostic tool. In premenopausal women focal pathology, such as fibroids and polyps, as well as extra uterine pathology, can be accurately diagnosed. In postmenopausal women endometrial cancer can be excluded. In the majority of women diagnostic hysteroscopy can thus be avoided, and patients with focal pathology detected with transvaginal ultrasound can be triaged for operative intervention. Outpatient endometrial biopsy should still be used to exclude endometrial pathology. This one-stop ultrasound-based clinical approach provides a rapid, accurate diagnosis, with the minimum of investigations and invasive procedures. In this way multiple outpatient visits and unnecessary inpatient admissions can be avoided.