M. Alkatib

Vesicouterine fistula following Cesarean delivery—ultrasound diagnosis and surgical management

Vesicouterine fistulae are uncommon, with most units reporting 1–5 cases over 5–15‐year periods. To date there has been a paucity of case reports regarding this problem and only a few case series. In this report we outline the presentation and management of a vesicouterine fistula complicating a repeat Cesarean delivery, specifically describing the role of transvaginal ultrasound. 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.

OC016: Can we safely adopt a single visit approach to the management of pregnancies of unknown location?

the pattern of serum hCG levels in early normal pregnancy, and also the correlation between low serum progesterone levels and spontaneous resolution of pregnancy. The diagnostic dilemma is how to predict which PUL are early ectopic pregnancies. There is no role for single serum hCG measurement in the management of PUL. Based on serum hCG > 1000 U/L, only 30% of ectopic pregnancies would be detected. In clinical terms, if one relied on the discriminatory zone alone, 6 laparoscopies would be performed in order to detect one ectopic pregnancies. Current hormonal criteria including initial serum progesterone < 20 nmol/L and an increasing serum hCG > 66% over 48 hours (hr) are very reliable in predicting pregnancy viability, but not its location. This question of establishing the location of a PUL was further investigated using subjective assessment of serum hCG and progesterone levels at defined times by gynaecologists of varying experience. It was found that experience per se did not play any role in the classification of PUL based on serum hormone evaluation and in this series only 25%–60% of ectopic pregnancies were detected. Interobserver agreement is almost perfect (Kappa 0.87) in the classification of non-EP, i.e. failing PUL and viable IUP. Conversely, the interobserver agreement in the classification of EP is only fair (Kappa 0.49). The development of new methods to establish pregnancy location has been investigated extensively in our unit. Using the hCG ratio (hCG 48 hr/hCG 0 hr), the detection of EP is improved to 75%. This figure has been improved significantly with the use of logistic regression analysis. This utilises the hCG ratio alone and is found not only to predict viability, but most importantly locate the pregnancy. The sensitivity and specificity of the model for the detection of ectopic pregnancies were 91.7% and 84.2% respectively.

OC070: Can transvaginal ultrasound detect and localize endometriosis in women with chronic pelvic pain?

and symptoms. All patients had a transvaginal ultrasound scan (TVS) 1–2 weeks before laparoscopy. All patients had a negative pelvic infection screen. During the transvaginal scan (TVS), the vaginal probe was used to assess ovarian location and mobility, and site-specific tenderness. Results: The average age of the patients was 31 years (range 18–50 years) and the average duration of pain was 46 months (range 6–180 months). At laparoscopy 70 (58%) patients had pelvic pathology and 50 (42%) patients had a normal pelvis. The historical factors – severity of symptoms (1–10), and previous gynaecological surgery were predictive of pelvic pathology (p < 0.05). The factors dysmenorrhoea, dyschesia, dyspareunia, age, parity, previous endometriosis and previous pelvic infection were not predictive of pelvic pathology (p > 0.05). On TVS the presence of an endometrioma or hydrosalpinx were predictive of pelvic pathology (accuracy 100% and 86% respectively). Reduced ovarian mobility and site-specific tenderness were predictive of pelvic pathology (p < 0.01). Stepwise logistic regression revealed ultrasound based site-specific tenderness as the most predictive factor. Conclusion: Historical factors and TVS findings are considered important in the assessment of patients with CPP. In this study logistic regression analysis has shown site-specific tenderness on its own to be as accurate as all the other factors.

P12.01: Reducing the number of follow up visits for pregnancies of unknown location

3137 + 462 grams. Eleven patients delivered vaginally and 2 had Cesareans. The average length of labor was 374 + 198 minutes and 5 patients received oxytocin augmentation. The median onset of bleeding after delivery was 1.5 hours. All patients received uterotonics, 8 had curettage, 2 had radiographic embolization, 2 had uterine packing, and 1 patient required hysterectomy. Conclusions: Focal atony of the lower uterine segment, as identified by ultrasound, appears to be a distinct clinical entity that is associated with postpartum hemorrhage. Traditional risk factors for generalized uterine atony were not identified. Further study is needed to confirm our findings, determine etiology, and develop targeted therapies.

P390: Suspected gynaecological malignancies—role of ultrasound in a ‘fast track’ referral clinic

history. When abnormalities were detected CDTVU was repeated after 4–6 weeks, if the abnormality persisted, tumor markers, CT and laparoscopy were done. The mean age of the patients was 47 ± 12 year ranging from 16 to 88 years. Results: From 22.013 CDTVU performed 35 were diagnosed as suspicious of malignancy. Twenty nine of these patients have been surgically treated, in two the repeated CDTVU was normal and 4 were lost from follow-up. Nineteen of the surgically treated women had malignant lesions hystologically confirmed, 15 of them were tumors in stage I, 3 in stage III and one was a metastatic melanoma. In 10 patients benign lesions were diagnosed (3 serous cysts, 2 mucinous cysts, 2 endometriotic cysts, 1 cystadenofibroma, 1 cystic teratoma and 1 hydrosalpinx with paraovarian cyst). Conclusion: Although consensus about the benefits of using CDTVU as a screening procedure are not conclusive, our results suggest that it can help in diagnose of ovarian cancer in early stages.

P112: Is the use of prophylactic antibiotics required in women being managed expectantly with incomplete miscarriage?

c) Suboptimal: Only mentioned an empty uterus, and nothing else. Results: Of the 52 cases of confirmed ectopic pregnancies, 17 (32.7%) had diagnostic scan reports, 23 (43.3%) were adequately detailed, and 12 (23.1%) were considered suboptimal. Conclusions: An unacceptably high proportion of reports (23.1%) were considered suboptimal. We are now working on a standard reporting format for all early pregnancy ultrasound scans performed in this trust. This will improve communication between practitioners involved in the care of these patients, and improve patient care.

P113: Can serum hormonal levels predict ectopic pregnancies

c) Suboptimal: Only mentioned an empty uterus, and nothing else. Results: Of the 52 cases of confirmed ectopic pregnancies, 17 (32.7%) had diagnostic scan reports, 23 (43.3%) were adequately detailed, and 12 (23.1%) were considered suboptimal. Conclusions: An unacceptably high proportion of reports (23.1%) were considered suboptimal. We are now working on a standard reporting format for all early pregnancy ultrasound scans performed in this trust. This will improve communication between practitioners involved in the care of these patients, and improve patient care.

OC195: The transvaginal ultrasound based acute gynaecology unit: Short term follow up of women seen with acute pelvic pain

and end systolic volumes were measured, and ejection fraction was calculated for each ventricle. Results: In approximately 90% of cases in which the fourchamber view was visualized, it was possible to calculate ventricular volumes. Volume of both ventricles increased in the course of pregnancy correlating with gestational age and estimated fetal weight. Unexpectedly, there was no significant difference between right and left ventricular volumes in the gestational ages studied. Ejection fraction of the ventricles was calculated at about 70%. Conclusion: 3D echocardiography can provide estimates of ventricular volume and function and may be used for evaluation of fetuses with congenital heart disease.

P386: Screening for endometrial cancer in a high‐risk population (Hereditary Non Polyposis Colorectal Cancer)—a pilot study

Clinical evaluation of the tumors of lower and higher stage is reliable. Accuracy of transvaginal ultrasonography in evaluation and staging of cervical cancer in comparison to MRI volumetry has been revised in our study. 21 patients with cervical cancer finally staged as IA2-IB2 and treated accordingly by laparoscopically assisted lymphadenectomy and trachelectomy, primary radical hysterectomy or neoadjuvant chemotherapy followed by radical hysterectomy. All patients were evaluated by transvaginal ultrasonography as well as MRI volumetry. Patients were blinded for the examinations. Staging was accurate in 96% of ultrasound exams in comparison with the MRI volumetry. Tumors staged IB1 were distributed into two categories: small tumors less than 2 cm in diameter and bulky tumors more than 2 cm in the largest diameter. Ultrasound results agreed with MRI findings in small tumors less than 2 cm in 100% of cases. The agreement in bulky tumors staged IB1 2–4 cm was 87%. Transvaginal ultrasound appears to be a useful method for the pretreatment assessment of small cervical tumors with accuracy close to that of MRI volumetry.