F. Mukri

Evidence of early first‐trimester growth restriction in pregnancies that subsequently end in miscarriage

Objectives  To examine whether viable early pregnancies that subsequently end in miscarriage exhibit evidence of first‐trimester growth restriction.

Assessing first trimester growth: the influence of ethnic background and maternal age

BACKGROUND First trimester growth restriction may predict miscarriage or adverse outcome later in the pregnancy, but determinants of early growth are not well described. Our objective was to examine factors influencing fetal and gestational sac size in the first trimester. METHODS Prospective observational study of 1828 singleton pregnancies before 12 weeks gestation. Maternal characteristics (ethnicity, maternal age, obstetric history, abdominal pain and vaginal bleeding), crown rump length (CRL) and mean gestational sac diameter (MSD) were recorded. A stepwise linear mixed effects analysis was performed to determine factors influencing rate of change in CRL and MSD. RESULTS 1063 scans, in 464 women, were included. Rate of increase in CRL was higher in women of black ethnic origin (P = 0.0261) compared with white, and increased with advancing maternal age (P = 0.0046). Maternal age also influenced MSD: older women had gestational sacs which were 0.118 mm larger for each one year increase in maternal age (P = 0.0073). Bleeding, pain and prior obstetric history did not influence CRL or MSD. CONCLUSIONS Rate of increase in CRL was greater in fetuses of black versus white women and increased with advancing maternal age. As CRL is used to date pregnancies, and this influences further growth assessment, consideration should be given to the use of individualized growth charts which take account of maternal factors found to influence first trimester growth.

The optimal timing of an ultrasound scan to assess the location and viability of an early pregnancy

BACKGROUND The objective of this study was to determine the optimal gestational age at which to establish the location and viability of an early pregnancy using transvaginal ultrasonography (TVS). METHODS This was a prospective study of 1442 women undergoing initial TVS at no more than 84 days gestation. Logistic regression analysis was performed to determine the relationship between gestational age and the ability to confirm viability or non-viability, in women with and without symptoms of pain and bleeding. RESULTS The commonest TVS finding prior to 35 days was a pregnancy of unknown location, from 35 to 41 days an early intrauterine pregnancy of uncertain viability and from 42 days a viable intrauterine pregnancy. Miscarriage could only be diagnosed on initial TVS after 35 days. There was no difference between the ability to make a diagnosis for women with certain or uncertain dates (P = 0.719). The chance of confirming viability increased rapidly per day of gestation until 49 days and thereafter plateaued. Of the 29 ectopic pregnancies diagnosed, 72% presented prior to 49 days gestation and all of these women presented with pain, bleeding or a previous ectopic pregnancy history. CONCLUSIONS The ability to confirm viability or non-viability is significantly related to gestational age. In asymptomatic women with no previous ectopic pregnancy TVS should be delayed until 49 days. Our data suggest that this would reduce the number of inconclusive scans, without an associated increase in morbidity from missed ectopic pregnancies.

Impact of the availability of sonography in the acute gynecology unit.

The initial assessment of acute gynecology patients is usually based on history and clinical examination and does not involve ultrasound. The aim of this study was to investigate the impact of the availability of transvaginal sonography at the time of initial assessment of the emergency gynecology patient.

Functional linear discriminant analysis: a new longitudinal approach to the assessment of embryonic growth

BACKGROUND Functional linear discriminant analysis (FLDA) is a new growth assessment technique using serial measurements to discriminate between normal and abnormal fetal growth. We used FLDA to assess and compare growth in live pregnancies destined to miscarry with those remaining viable. METHODS This was a prospective cohort study of women with ultrasound scans on at least two separate occasions showing live pregnancies. Serial crown-rump length (CRL), mean gestational sac diameter and mean yolk sac diameter measurements were recorded. The ability of FLDA to predict subsequent miscarriage was compared with that of a single CRL measurement. RESULTS Of 521 included pregnancies, 493 (94.6%) remained viable at 14 weeks and 28 (5.4%) miscarried. The CRL growth rate was significantly lower in those that miscarried (one-sample t-test, P = 2.638E-22). The sensitivity of FLDA in predicting miscarriage from serial CRL measurements was 60.7% and specificity was 93.1% [positive predictive value (PPV) 33.3%, negative predictive value (NPV) 97.7%]. This was significantly better for predicting miscarriage than a single CRL observation of more than 2SD below that expected (sensitivity 53.6%, specificity 72.2%, PPV 9.9%, NPV 96.5%). CONCLUSIONS FLDA discriminates between normal and abnormal growth to predict miscarriage with high specificity. FLDA predicts miscarriage better than a single observation of a small CRL.

A model and scoring system to predict outcome of intrauterine pregnancies of uncertain viability

To define the incidence and outcome of intrauterine pregnancy of uncertain viability (PUV) and to develop and assess the performance of a model and a scoring system to predict ongoing viability.

The simple outpatient management of Bartholin's abscess using the Word catheter: A preliminary study

Introduction:  Bartholins cysts/abscess affects 2% of women. Conventional treatment is marsupialisation under general anaesthetic. We evaluated a conservative approach in a non‐randomised prospective interventional study over 12 months.

OC69: Ability to make a diagnosis at first early pregnancy ultrasound assessment according to gestational age

Objectives: Persisting pregnancy of unknown location (PPUL) remains a controversial clinical problem with no consensus on diagnosis or management. Biochemically, these behave like ectopic pregnancies (EP) or sick intrauterine pregnancies (IUPs). Many clinicians perform laparoscopy with dilatation and curettage (D&C) to exclude these and subsequently treat with systemic methotrexate (MTX). The aim of this study was to define this challenging group of PULs and to achieve guidelines for the management of PPUL. Methods: This retrospective analysis included pregnancies in the interval 2001–2006. All women who had PUL on transvaginal scan (TVS) were followed up with serial human chorionic gonadotrophin (hCG) levels and TVS until the eventual outcome of the pregnancy was established. Conventional PUL outcomes included failing PUL, IUP and EP. Where the location of pregnancy was never visualized on TVS, and when hCG levels reached a plateau on three or more consecutive measurements, the diagnosis of PPUL was made. All PPUL cases were collected retrospectively from the Early Pregnancy Unit database and management was analyzed. Results: Some 3050 PUL were studied; 42 (1.3%) of these were diagnosed as PPUL. At initial presentation, the median gestational age was 42 (range, 17–73) days and median initial hCG was 180 (range, 39–1491) IU/mL. Management included laparoscopy in 5/42(12%) women to exclude EP, and two had D&C. No EPs were found at the time of laparoscopy and no chorionic villi discovered at D&C. All 42 women received systemic MTX, with two women requiring two doses. There were no adverse outcomes. Conclusions: PPUL is a diagnosis of exclusion. We define this entity as gestations where the site of pregnancy is never localized on TVS and serum hCG levels plateau on three or more occasions. In the worst-case scenario PPUL can represent ultrasonically missed EPs, but there is little place for laparoscopy or D&C. According to our data, MTX without surgical intervention is the preferred method of treatment.

OP04.01: Has ultrasound eliminated the need for a vaginal speculum examination in the assessment of women with bleeding in early pregnancy?

Objectives: The differential diagnosis of fetal renal or suprarenal pathology includes severe or life-threatening conditions such as infantile renal polycystosis or bilateral renal agenesis as well as potentially malignant forms such as a Wilms’ tumor, suprarenal neuroblastomas or lymphangiomas. The nature and exact location of these lesions are important for diagnosis and optimal perinatal management and cannot always be made conclusively on ultrasound. This report evaluated the added value of fetal Magnetic Resonance Imaging (fMRI) in the differential diagnosis of fetuses with renal or suprarenal pathology. Methods: All fetuses with suspected but inconclusive ultrasound diagnosis of (supra)renal lesions underwent fMRI during the study period (2001–2006). The fMRI scanning protocol consisted of T1, T2 and diffusion weighed images (DWI) in the three orthogonal axes. Results: During the study period 547 fMRI examinations were performed. There were 28 cases (5.1%) with (supra)renal pathology suspected on ultrasound examination. Antenatal MRI was performed at a median gestational age of 24 (range 17–39) weeks. The tentative sonographic diagnosis was confirmed by fMRI and postnatal imaging studies in 22 cases (78.5%). In 5 cases (17.8%) MRI added relevant information. In one case (3.8%) the MRI was of no value due to the poor image quality. Conclusions: MRI can have an additive value in the perinatal workup of renal and suprarenal pathology of unclear origin on prenatal ultrasound. It is especially helpful to differentiate renal from adrenal origin of the lesions and offers good image quality in the presence of oligoor anhydramnios.

OC58: Ectopic pregnancy diagnosis and management: a 4-year experience

odds ratio (OR) for each previous delivery 1.48 (95% CI, 1.22–1.80), P < 0.0001; OR for each previous miscarriage 1.34 (95% CI, 1.07–1.68), P = 0.01. Excluding women with any previous miscarriage and adjusting for parity we found a U-shaped relationship between maternal age and miscarriage (P = 0.04). Conclusions: In singleton pregnancies with an estimated risk of Down syndrome < 1 : 250 according to NT screening at 12–14 weeks, the spontaneous fetal loss rate before 25 weeks is likely to be around 0.5%. NT thickness up to 3 mm does not seem to affect the risk of miscarriage in such pregnancies. Instead, the risk seems to increase with number of previous miscarriages and deliveries, and possibly the risk is highest in the youngest and oldest women.