I. Casikar

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.

Office gel sonovaginography for the prediction of posterior deep infiltrating endometriosis: a multicenter prospective observational study

To use office gel sonovaginography (SVG) to predict posterior deep infiltrating endometriosis (DIE) in women undergoing laparoscopy.

Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'.

To assess uptake and success of expectant management of first‐trimester miscarriage for a finite 14‐day period, in order to evaluate our ‘2‐week rule’ of management.

The use of power Doppler colour scoring to predict successful expectant management in women with an incomplete miscarriage

OBJECTIVE To evaluate whether the use of power Doppler to confirm the presence or absence of blood flow within retained products of conception (RPC) in women with an incomplete miscarriage can predict subsequent successful expectant management. METHODS Prospective observational study in the Acute Gynaecology and Early Pregnancy Unit (AGEPU) at Nepean Hospital from November 2006 to February 2009. Incomplete miscarriage was defined by the presence of a measurable focus of hyperechoeic material, in three planes, within the endometrial cavity using two-dimensional greyscale transvaginal ultrasound (TVS). Subjective qualitative power Doppler colour scoring (PDCS) of the RPC was performed. The vascularization of the RPC was scored using the colour scoring system of the International Ovarian Tumour Analysis (IOTA) group. PDCS 1 meant absence of vascularity, PCDS 2 represented minimal vascularity, PDCS 3 rather strong vascularity and PDCS 4 very strong vascularity. The correlation between the PDCS and successful expectant management of miscarriage was analysed. The volume of RPC was calculated using the ellipsoid formula and then compared with both the PDCS and the outcome of expectant management. Successful expectant management was defined as the resolution of symptoms and the absence of RPC on follow-up TVS. RESULTS A total of 1395 consecutive pregnant women underwent TVS. Of them, 198 women were diagnosed with an incomplete miscarriage; 172 were managed expectantly. Complete data were available on 158 cases. In total 84.8% (134/158) were managed successfully whilst 15.2% (24/158) failed expectant management. Of the total, 89% (121/136) of women with a PDCS 1 had successful expectant management compared with 57.1 (8/14) with PDCS 2 and 62.5% (5/8) with PDCS 3. Comparing absence of flow (PDCS 1) to presence of flow (PDCS 2 or more), the rate of success was significantly higher in the first group (89 versus 60.9%, Fishers exact test P= 0.00136). In the prediction of success, the absence of flow showed a sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio of 90.3, 37.5, 89, 40.9% and 1.445 (95% confidence interval: 1.055-1.979), respectively. There was no correlation between the volume of RPC and the PDCS; and there was no relationship between the volume of RPC and the success of expectant management. CONCLUSIONS PDCS can predict the likelihood of successful expectant management of incomplete miscarriage. The absence of flow on power Doppler is associated with a significant improvement in the rate of successful expectant management. This new approach may be helpful in quantifying the chances of successful expectant management in those women with an incomplete miscarriage at the primary scan.

A prediction model for viability at the end of the first trimester after a single early pregnancy evaluation

The aim was to develop a new model to predict the outcome at the end of the 1st trimester after a single visit to the early pregnancy unit (EPU).

Methotrexate vs Placebo in Early Tubal Ectopic Pregnancy: A Multi- Centre Double-Blind Randomised Trial

BACKGROUND In the 21st century, tubal ectopic pregnancies (EPs) are diagnosed earlier in their natural history due to transvaginal ultrasound technology. More women are haemodynamically stable and therefore can be offered non-invasive outpatient management with systemic Methotrexate (MTX). However there is no evidence that MTX is necessary in all these early EPs, as many may resolve spontaneously in the absence of any treatment. To date there are no published randomized trials comparing systemic MTX with a placebo. The aim of this study is to verify if MTX is more effective than the placebo in women with tubal EP and rising/plateauing serum human chorionic gonadotrophin (hCG) levels. METHODS/DESIGN This is a multi-centre double-blind randomized controlled trial conducted in Australia. Haemodynamically stable women with a confirmed ultrasound diagnosis of tubal EP and a rising/plateauing serum hCG & < 1500 IU/L are eligible for the trial. Women with a declining serum hCG, hCG > 1500 IU/L at 48 hrs, viable tubal EP, severe abdominal pain, evidence of haemoperitoneum on ultrasound, diagnostic uncertainty, non-tubal ectopic pregnancy, or women with contraindications to MTX will be excluded. Systemic MTX in a single dose intramuscular regimen (50mg/m2) is compared to an identical placebo in an outpatient setting. All women will attend for a serum hCG measurement on day 4. Provided patients are haemodynamically stable, they will attend for another blood test on day 7. If a decline in serum hCG > 15% between days 4 - 7 is observed, weekly blood tests will be scheduled until undetectable hCG levels. If serum hCG levels increase or decrease < 15% between days 4 - 7, a second dose of MTX will be given and weekly blood tests will be scheduled until undetectable serum hCG. If any increase in serum hCG > 15% between days 4 - 7 or at any subsequent follow-up, women will be treated with MTX. Primary outcome measure is treatment success, defined as uneventful decline of serum hCG to an undetectable level ( < 5 IU/L) by the initial intervention. Secondary outcome measures are re-interventions (additional systemic MTX injections and/or surgery for haemodynamic instability/trophoblast persistence), treatment complications and length of follow-up. DISCUSSION This trial will clarify the actual effectiveness of MTX in haemodynamically stable women with an early tubal EPs and rising or plateauing hCG.

Prediction of subsequent miscarriage risk in women who present with a viable pregnancy at the first early pregnancy scan

To generate and evaluate a new prediction model for miscarriage in women who present with a viable intrauterine pregnancy (IUP) at the primary early pregnancy scan and to compare this new model to a previously published model.

How to effectively diagnose ectopic pregnancy using ultrasound

Over the past three decades, the diagno-sis and management of ectopic preg-nancy (EP) has witnessed significantchange. Key developments have been agreater awareness of EPs, tertiary hospi-tal early pregnancy units (EPUs), intro-duction of high resolution transvaginalultrasound (TVS) probes and availabilityof accurate and rapid serum human cho-rionic gonadotrophin (hCG) assays.However, EP is still a leading cause ofmaternal mortality and significant mor-bidity worldwide. On the basis of themost recent figures from the UK, EPaccounts for 54% of all first trimestermaternal deaths

Prediction of successful expectant management of first trimester miscarriage: Development and validation of a new mathematical model

To generate and evaluate a new logistic regression model for the prediction of successful expectant management of first trimester miscarriage.

OC13.03: Can we predict pouch of Douglas obliteration using a new real‐time ultrasound technique: the ‘sliding sign’

Objectives: The aim of this study was to evaluate pre-operative real-time dynamic transvaginal ultrasound (TVS) in the prediction of pouch of Douglas (POD) obliteration in women undergoing laparoscopy for suspected endometriosis. Methods: Multi-centre prospective observational study undertaken from January 2009 to November 2011. All women with symptoms suggestive of endometriosis scheduled for laparoscopy underwent a detailed pre-operative TVS, in particular, to ascertain whether the POD was obliterated. POD obliteration was assessed using a realtime TVS technique called the ‘sliding sign’. These pre-operative TVS ‘sliding sign’ findings were then compared to gold standard laparoscopic POD findings. Results: 100 consecutive women with pre-operative TVS and laparoscopic outcomes were included in the final analysis. Mean age was 32.8 years and mean age for diagnosis of endometriosis was 27.4 years. 84/100 (84%) were found to have some form of endometriosis at laparoscopy (73% peritoneal endometriosis, 35% ovarian endometrioma/s, 34% deep infiltrating endometriosis). At laparoscopy, 30/100 (30%) had an obliterated POD and 20/30 (66.7%) of these women also had evidence of bowel endometriosis. The accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio for using the real-time ‘sliding sign’ ultrasound technique to predict POD obliteration were 92.0%, 80.0%, 97.1%, 92.3%, 91.9%, 28.0 and 0.21, respectively. Conclusions: Pre-operative real-time dynamic TVS evaluation of the posterior compartment using the ‘sliding sign’ seems to establish whether the POD is obliterated with a high degree of certainty.