N. Stamatopoulos

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.

Is there a correlation between birth weights and first-trimester crown-rump length growth velocity?

Objective: To test the hypothesis that small- or large-for-gestational-age (SGA or LGA) newborns have anomalous crown-rump length (CRL) growth rates in the first trimester. Methods: Prospective observational study. Women in the first trimester presenting to the Early Pregnancy Unit, between November 2006 and December 2010, underwent transvaginal scan. Women with viable singleton pregnancies in the first trimester who had at least two CRL measurements > 5 mm, recorded at least 2 weeks apart, and also had birth weight data available were included in the final analysis. Birth weight percentiles were calculated and adjusted for gestational age and gender. SGA was equivalent to < 10th centile and LGA was equivalent to > 90th centile. Correlation analysis was performed between birthweight percentiles and first-trimester CRL growth-rate coefficients. In addition, we estimated early fetal growth rates (EFGR) by calculating the Δ CRL/Δ time (mm/day) to see if these differed according to the birth-weight percentiles. Results: A total of 107 women had complete data. The mean maternal characteristics were age 27.5 ± 6 years, weight 87 ± 29 kg and height 163 ± 8 cm. The mean birth weight and gestational age at delivery were 3405 g (SD = 597) and 269 days (SD = 13), respectively. The proportions of SGA and LGA were 7.5% and 18.7%, respectively. There were no significant correlations between birth-weight percentiles and any of the CRL growth rates. There were also no significant differences in the mean CRL velocities when comparing the SGA and LGA newborns birth weights. EFGR for SGA and LGA newborns were 1.34 mm/day (SD = 0.17) and 1.32 mm/day (SD = 0.24), respectively (p > 0.05). Conclusions: Newborns who are found to be SGA or LGA at delivery do not appear to have anomalous CRL growth patterns in the first trimester. The EFGR also did not correlate with birth-weight percentiles.

Chlamydia trachomatis in fallopian tubes of women undergoing laparoscopy for ectopic pregnancy

To study whether Chlamydia trachomatis is absent or persists in a latent state in the fallopian tube at the time of laparoscopic salpingectomy for tubal ectopic pregnancy (EP).

OP16.05: Scoring system to predict the subsequent risk of miscarriage in women with a viable intrauterine pregnancy at the primary transvaginal ultrasound: Short oral presentation abstracts

compared between the non-surgical group (n=78) and the surgical group (n=61). Thereafter, the non-surgical group was subdivided into the local injection group (n=16) and the systemic injection group (n=62) in order to compare with respect to the procedure-related and subsequent pregnancy outcomes. Results: Compared to the non-surgical group, the surgical group had a significantly higher mean extent of hemoglobin decrease after the procedure (1.29±0.09dL vs. 2.10±0.14dL; p=<0.01). The observed subsequent pregnancy was 20.5% (16/78) in the non-surgical group and 14.8% (9/61) in the surgical group. In the latter group, there were also 2 cases (3.2%) of uterine rupture during subsequent pregnancy. In comparison of non-surgical group, success rate was higher in local injection group (93.7% vs. 69.4%, p=0.046) and with less side effect compare to systemic injection group (0% vs. 25%, p=0.036), respectively. The observed subsequent pregnancy was 25.0% (4/16) in the local injection group and 19.4% (12/62) in the systemic injection group. Conclusions: The non-surgical management of interstitial pregnancy with local and systemic injection appears to be as effective as and even safer than the surgical management. Furthermore, our results suggest that local injection is superior to systemic injection in terms of success rate and side effects. Therefore, ultrasound-guided local injection may have advantages over systemic injection and surgical management as the first-line treatment in the population of young and nulliparous women who desire future fertility.

OP16.08: The proportion of women with a histological diagnosis of molar pregnancy who are diagnosed with ultrasound prior to uterine evacuation: Short oral presentation abstracts

Objectives: The aim of the study was to identify the preoperative ultrasound measurements of tubal ectopic pregnancies which correlate best with surgical findings. Methods: This was a prospective study of women diagnosed with a tubal ectopic pregnancy and managed in the Early Pregnancy Unit (EPU) at University College London Hospital (UCLH) between November 2015 and August 2016. Each tubal ectopic pregnancy was measured in three perpendicular planes using the following protocol:

P18.02: Prevalence of negative 'sliding sign' in low-risk population: a feasibility study

Objectives: To investigate whether or not an ovarian endometrioma detected by ultrasound was associated with other appearances of pelvic endometriosis such as adhesions and/or deep infiltrating endometriosis (DIE) in order to improve the management of patients with pelvic pain or infertility. Methods: This is an observational retrospective study including a group of women (n=255) with at least an ovarian endometrioma (at least diameter of ≥ 20 mm) detected by transvaginal ultrasound (TVS). Patients with previous pelvic surgery and without symptoms were excluded. Other associated sonographic signs of pelvic endometriosis such as adhesions, tubal pathology, adenomyosis and DIE were recorded according to a detailed TVS mapping of pelvic endometriosis. Subsequently a group of women (n=50) underwent laparoscopic treatment and during surgery a complete endometriosis mapping was assessed. Results: Mean age was 34.2 ± 6.6 years, mean endometriomas diameter was 40.0 ± 18.1mm, bilateral endometriomas were observed in 65patients (25.5%). Of the 255 patients 50 underwent laparoscopic surgery due to severe symptoms whereas 205 had indications to medical therapy or ART. At TVS 55 (21.5%) showed posterior rectal DIE and 93 (36.4%) a thickening of at least one uterosacral ligament. 186 patients (73%) showed adhesions and 134 (53%) showed ultrasonographic features of adenomyosis. Only 57 (22%) had a single isolated ovarian lesion with a mobile ovary and without any other ultrasound signs of pelvic endometrioma. No statistically significant differences were observed in the TVS mapping and histological confirmation. Conclusions: Ovarian endometrioma is a marker for pelvic endometriosis and is rarely isolated 44% patients with an endometrioma showed DIE. Adhesions and adenomyosis are associated to endometrioma in more than 50%. In a clinical context when there is an ovarian endometrioma an accurate TVS should investigate the extension of the disease to check for other endometriotic lesions in order to choose the most appropriate treatment to manage pain and infertility.

OP31.10: Performance of the transvaginal sonographic ‘sliding sign’ in prediction of pouch of Douglas obliteration: does this improve over time?

Methods: Two experienced observers performed a review of stored 2D and 3D sonographic examinations of 50 consecutive women with typical sonographic signs of adenomyosis according of the MUSA. 20 patients without any sonographic signs of myometrial pathology were used as control group. Each observer, independently and blinded to each other, evaluated the presence or absence and the severity of adenomyosis using a new score system. The score system evaluated ultrasonographic criteria for focal and diffuse adenomyosis, adenomyoma and for junctional zone (JZ). A score number from 1 to 4 were assigned to the extension and myometrial involvement of each type of adenomyotic lesions and for JZ alterations. Numerical score obtained was classified in three group: mild (ranged between 1 to 7), moderate (8-13) and severe (14-20). Results: With respect to interpretation of the presence or not of adenomyosis ultrasonographic findings, the agreement was perfect (Cohen kappa, K=1). Multiple rater agreements to classify the different features of adenomyosis (diffuse, focal adenomyoma and focal or diffuse alteration of JZ) ranged from good to almost perfect (Cohen k 0.678 – 0.953). According to numerical score the agreement for minimal, moderate and severe adenomyosis ranged from substantial to almost perfect (respectively Cohen k=1, K=0.94, K= 0.79). Conclusions: Our new score system to diagnose adenomyosis severity were reproducible and could be useful in clinical practice. The high percentage of agreement obtained in the JZ evaluation could improve the sensitivity of adenomyosis diagnosis. The ultrasonographic quantification of severity and the extension of adenomyosis in the myometrium could be helpful in correlation to the severity of symptoms but also for an emerging request of surgical treatment.

P18.04: Transvaginal ultrasound ( TVS) combined evaluation of pelvic sites of implants and the “sliding sign” to predict likelihood of rectal/rectosigmoid deep infiltrating endometriosis (DIE) at laparoscopy

M. Espada6, C. Lu1, S. Reid3, B. Shakeri5, N. Stamatopoulos4, G. Condous2 1Computer Science, Aberystwyth University, Aberystwyth, United Kingdom; 2Obstetrics and Gynecology, Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia; 3Nepean Hospital, Chiswick, NSW, Australia; 4Early Pregnancy & Advanced Endosurgery Unit, Nepean Hospital, Penrith, NSW, Australia; 5Obstetrics and Gynecology, Nepean Hospital, Penrith, NSW, Australia; 6Acute Gynecology Service, Sydney, Medical School Nepean, Eastwood, NSW, Australia

Ultrasound follow‐up in the first trimester when pregnancy viability is uncertain

Miscarriage is a common complication of pregnancy affecting up to one in four clinical pregnancies. Ultrasound is the diagnostic tool of choice when evaluating not only pregnancy gestation and location but also pregnancy viability. Mean gestational sac diameter (MSD) and crown-rump length (CRL) are used to diagnose miscarriage. Experienced operators using high resolution transvaginal ultrasound (TVS) can make a diagnosis of a missed miscarriage when there is the presence of a CRL measuring >7 mm with no embryonic heart rate (EHR) present. The diagnosis of an empty sac miscarriage can be made when there is an empty intra-uterine gestational sac (GS) present with a MSD of >25 mm. In both instances, the absolute level of serum human chorionic gonadotrophin (hCG) does not influence the diagnosis. It is important to note that in the presence of an ultrasound diagnosis of miscarriage (per the previously mentioned definitions), serum hCG levels can continue to increase. A couple’s desire to confirm pregnancy viability can often mean that an early TVS, even in the most experienced hands, can be inconclusive. When pregnancy location is confirmed to be intra-uterine using TVS, if the CRL measures less than 7 mm or there is the presence of an empty GS with a MSD <25 mm, these women are classified with an intra-uterine pregnancy of uncertain viability (IPUV). Importantly, when the primary scan demonstrates a ‘live’ intra-uterine pregnancy, previously formulated algorithms have predicted an 8% chance of subsequent miscarriage. The later the gestation at first presentation, the lower the rate of subsequent pregnancy loss. It is recommended that women with an IPUV are rescanned in 10–14 days’ time to assess for interval change in the ultrasound parameters and confirm pregnancy viability or non-viability (NICE guidelines). However, this recommendation is not evidence based, but rather based on expert opinion and consensus. In 2013, a review in the New England Journal of Medicine based on a consensus meeting of the United States Society of Radiologists in Ultrasound highlighted the risks of incorrectly diagnosing early pregnancy failure and recommended criteria to diagnose miscarriage. In the absence of an embryo with a heartbeat ≥14 day after a scan showing an empty GS or absence of an embryo heartbeat ≥11 days after a scan showing a GS and yolk sac were both categorically a miscarriage. These couples are left waiting for up to 2 weeks in a state of uncertainty, and this can be extremely psychologically distressing. Is there any way that can give these couples an answer with respect to the viability of their pregnancy without the agonising wait? The initial article that instigated the changes in miscarriage criteria was as follows: ‘Limitations of current definitions of miscarriage using mean gestational sac diameter and crown–rump length measurements (CRL): a multicenter observational study’ by Abdallah et al. After that study in 2011, cut-off values to define miscarriage using ultrasound changed; however, the data supporting this change had wide confidence intervals. Several reviews of this initial article raised concerns regarding the study design as well as the potential for false-positive diagnoses of missed miscarriage despite the revised criteria. Ross et al. raised concerns about the conflicting information regarding the study type and the lack of histological diagnosis of miscarriage as well as the varying quality of ultrasounds at the different sites. There was concern that some of the scanning quality may have been below average. Another criticism of the initial study was that regardless of the new criteria, there would continue to be misdiagnoses of miscarriage due to false-positive findings. While Jurkovic acknowledges that occasional diagnostic errors are accepted and unavoidable, when it comes to miscarriage, even one misdiagnosis is unacceptable. The best approach to avoiding such a situation would be ‘never in one visit and never by one person’. Comments such as these may limit using ultrasound findings in isolation at one visit to diagnose a miscarriage in women who have IPUV. When these cut-offs to define, non-viability are not met, it is not unreasonable to utilise a multicategorical algorithm. While such an approach may not give a definitive diagnosis at the initial visit, it may assist in counselling women and couples can be given an individualised likelihood of the pregnancy continuing. Several scoring systems have been developed to individualise early pregnancy counselling and incorporate it into early normal pregnancy care. Bottomley et al. developed a scoring system to assess whether an IPUV will continue to be an ongoing Correspondence to email gcondous@omnigynaecare.com.au doi: 10.1002/ajum.12063

Is there a correlation between aberrant embryonic crown-rump length growth velocities and subsequent birth weights?

In this study, we tested the hypothesis that anomalous first trimester growth affects birth weight. Four hundred and fifteen women with viable singleton pregnancies at the primary transvaginal scan who had at least two crown rump length (CRL) and birth weight data were included. A linear mixed model was fitted to the Box-Cox transformed CRL values to evaluate the association between the GA and the embryonic growth. For multivariate analysis we included maternal age, height, weight, parity, number of miscarriages, vaginal bleeding, smoking, foetal gender, birth weight, small-for-gestation (SGA) and large-for gestation (LGA) categories at delivery. Smoking appeared to be significant for predicting the initial CRL from the beginning of the pregnancy (p value = 0.013). The SGA foetuses appeared to have slightly slower embryonic growth rates compared to non-SGA (p value = 0.045), after taking into account the effect of smoking on the initial CRL. None of the other variables including subsequent birth weight or LGA category have statistically significant effect on the first trimester embryonic growth curve when tested separately.