G. Condous

Pregnancy of unknown location: a consensus statement of nomenclature, definitions, and outcome

OBJECTIVE To improve the interpretation of future studies in women who are initially diagnosed with a pregnancy of unknown location (PUL), we propose a consensus statement with definitions of population, target disease, and final outcome. DESIGN A review of literature and a series of collaborative international meetings were used to develop a consensus for definitions and final outcomes of women initially diagnosed with a PUL. RESULT(S) Global differences were noted in populations studied and in the definitions of outcomes. We propose to define initial ultrasound classification of findings into five categories: definite ectopic pregnancy (EP), probable EP, PUL, probable intrauterine pregnancy (IUP), and definite IUP. Patients with a PUL should be followed and final outcomes should be categorized as visualized EP, visualized IUP, spontaneously resolved PUL, and persisting PUL. Those with the transient condition of a persisting PUL should ultimately be classified as nonvisualized EP, treated persistent PUL, resolved persistent PUL, or histologic IUP. These specific categories can be used to characterize the natural history or location (intrauterine vs. extrauterine) of any early gestation where the initial location is unknown. CONCLUSION(S) Careful definition of populations and classification of outcomes should optimize objective interpretation of research, allow objective assessment of future reproductive prognosis, and hopefully lead to improved clinical care of women initially identified to have a PUL.

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).

Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location

Various serum human chorionic gonadotropin (hCG) discriminatory zones are currently used for evaluating the likelihood of an ectopic pregnancy in women classified as having a pregnancy of unknown location (PUL) following a transvaginal ultrasound examination. We evaluated the diagnostic accuracy of discriminatory zones for serum hCG levels of > 1000 IU/L, 1500 IU/L and 2000 IU/L for the detection of ectopic pregnancy in such women.

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.

Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements : A consensus opinion from the International Deep Endometriosis Analysis (IDEA) group

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright

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.

Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real‐time dynamic transvaginal ultrasound technique: the sliding sign

To evaluate preoperative real‐time dynamic transvaginal sonography (TVS) in the prediction of pouch of Douglas (POD) obliteration in women undergoing laparoscopy for suspected endometriosis.

Human chorionic gonadotrophin and progesterone levels in pregnancies of unknown location

Objective: To evaluate accuracy, user variability and impact of experience on the use of serum hCG and progesterone in women who have a pregnancy of unknown location (PULs). Materials and methods: This was a retrospective study. Presenting 1932 consecutive women to an Early Pregnancy Unit had a transvaginal scan. The location of the pregnancy could not be found in 189 women (Pregnancy of unknown location, PUL), and so blood was taken to measure serum hCG and progesterone at presentation and subsequently after 48 h, according to the protocol. All women were monitored at regular intervals until the final outcome was known, which was a failing PUL, a viable or failing intra‐uterine pregnancy, an ectopic pregnancy or a persisting PUL. The final study group comprised 185 PUL, as four cases of persisting PUL were treated and excluded from the analysis. Five investigators assessed the hormonal data independently. The investigators experience as defined by the number of years working in obstetrics and gynecology ranged from 2 to 15 years. Each investigator knew the women were clinically stable and that the scan result was consistent with a PUL, i.e. there were no signs of intra‐ or extra‐uterine pregnancy, and there was no hemoperitoneum on TVS. When assessing the PULs, each investigator was given the hormonal results at time 0 and 48 h for serum hCG and progesterone and asked to classify the PULs as failing PULs, immediately viable intra‐uterine PULs and ectopic PULs. No other clinical information about the women was made available. Results: Complete data 185 women (89%): 102 failing PULs, 63 immediately viable intra‐uterine PULs and 20 ectopic PULs (total 185). The most experienced investigator obtained the best accuracy 163/185 (88.1%); not significantly different from those obtained by less experienced investigators (range 85.9–87.6%). Mean correct classification of failing PUL and immediately viable intra‐uterine PULs was 93% (range 89–95%); corresponding value for ectopic PULs was 42% (range 25–60%). Agreement between observers for classification of failing PULs and immediately viable intra‐uterine PULs was almost perfect (Cohens kappa 0.86–0.90), whereas the value for ectopic PULs group was fair to moderate (Cohens kappa 0.39–0.67). All 5 investigators misdiagnosed same 35% of ectopic PULs. Conclusions: Serum hCG and progesterone levels at defined times can be used to predict the immediate viability of a PUL, but cannot be used reliably to predict its location. Clinical experience does not significantly improve the ability to assess PUL outcome.

The conservative management of cervical ectopic pregnancies.

To evaluate the role of conservative management in the treatment of cervical ectopic pregnancies.

Pregnancies of unknown location: consensus statement

*Early Pregnancy Unit, Nepean Centre for Perinatal Care and Research, Western Clinical School, Nepean Campus, University of Sydney, Nepean Hospital, Penrith, Sydney, Australia, †Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, K.U. Leuven, Leuven, Belgium, ‡Department of Obstetrics and Gynecology, New York University Medical Center, New York, USA, §Department of Obstetrics and Gynecology, Malmo University Hospital, Malmo, Lund University, Sweden, ¶Early Pregnancy and Gynaecology Assessment Unit, King’s College Hospital and **Early Pregnancy, Gynaecological Ultrasound and Minimal Access Surgery Unit, St George’s Hospital Medical School, London, UK (e-mail: gcondous@hotmail.com)