T. Bourne

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.

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.

Sonographic prediction of malignancy in adnexal masses using an artificial neural network

Objective To generate a neural network algorithm which computes a probability of malignancy score for pre‐operative discrimination between malignant and benign adnexal tumours.

Multicentre external validation of IOTA prediction models and RMI by operators with varied training

Background:Correct characterisation of ovarian tumours is critical to optimise patient care. The purpose of this study is to evaluate the diagnostic performance of the International Ovarian Tumour Analysis (IOTA) logistic regression model (LR2), ultrasound Simple Rules (SR), the Risk of Malignancy Index (RMI) and subjective assessment (SA) for preoperative characterisation of adnexal masses, when ultrasonography is performed by examiners with different background training and experience.Methods:A 2-year prospective multicentre cross-sectional study. Thirty-five level II ultrasound examiners contributed in three UK hospitals. Transvaginal ultrasonography was performed using a standardised approach. The final outcome was the surgical findings and histological diagnosis. To characterise the adnexal masses, the six-variable prediction model (LR2) with a cutoff of 0.1, the RMI with cutoff of 200, ten SR (five rules for malignancy and five rules for benignity) and SA were applied. The area under the curves (AUCs) for performance of LR2 and RMI were calculated. Diagnostic performance measures for all models assessed were sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR−), and the diagnostic odds ratio (DOR).Results:Nine-hundred and sixty-two women with adnexal masses underwent transvaginal ultrasonography, whereas 255 had surgery. Prevalence of malignancy was 29% (49 primary invasive epithelial ovarian cancers, 18 borderline ovarian tumours, and 7 metastatic tumours). The AUCs for LR2 and RMI for all masses were 0.94 (95% confidence interval (CI): 0.89–0.97) and 0.90 (95% CI: 0.83–0.94), respectively. In premenopausal women, LR2−RMI difference was 0.09 (95% CI: 0.03–0.15) compared with −0.02 (95% CI: −0.08 to 0.04) in postmenopausal women. For all masses, the DORs for LR2, RMI, SR+SA (using SA when SR inapplicable), SR+MA (assuming malignancy when SR inapplicable), and SA were 62 (95% CI: 27–142), 43 (95% CI: 19–97), 109 (95% CI: 44–274), 66 (95% CI: 27–158), and 70 (95% CI: 30–163), respectively.Conclusion:Overall, the test performance of IOTA prediction models and rules as well as the RMI was maintained in examiners with varying levels of training and experience.

Results from an ultrasound‐based familial ovarian cancer screening clinic: a 10‐year observational study

To assess the use of transvaginal sonography as a screening test for familial ovarian cancer and, secondarily, to determine the value of a family history of malignant disease and the potential role of serum CA 125 levels in the screening procedure.

Strategies to diagnose ovarian cancer: new evidence from phase 3 of the multicentre international IOTA study

Background:To compare different ultrasound-based international ovarian tumour analysis (IOTA) strategies and risk of malignancy index (RMI) for ovarian cancer diagnosis using a meta-analysis approach of centre-specific data from IOTA3.Methods:This prospective multicentre diagnostic accuracy study included 2403 patients with 1423 benign and 980 malignant adnexal masses from 2009 until 2012. All patients underwent standardised transvaginal ultrasonography. Test performance of RMI, subjective assessment (SA) of ultrasound findings, two IOTA risk models (LR1 and LR2), and strategies involving combinations of IOTA simple rules (SRs), simple descriptors (SDs) and LR2 with and without SA was estimated using a meta-analysis approach. Reference standard was histology after surgery.Results:The areas under the receiver operator characteristic curves of LR1, LR2, SA and RMI were 0.930 (0.917–0.942), 0.918 (0.905–0.930), 0.914 (0.886–0.936) and 0.875 (0.853–0.894). Diagnostic one-step and two-step strategies using LR1, LR2, SR and SD achieved summary estimates for sensitivity 90–96%, specificity 74–79% and diagnostic odds ratio (DOR) 32.8–50.5. Adding SA when IOTA methods yielded equivocal results improved performance (DOR 57.6–75.7). Risk of Malignancy Index had sensitivity 67%, specificity 91% and DOR 17.5.Conclusions:This study shows all IOTA strategies had excellent diagnostic performance in comparison with RMI. The IOTA strategy chosen may be determined by clinical preference.

Comparison of Transvaginal Color Doppler Imaging and Color Doppler Energy for Assessment of Intraovarian Blood Flow

Objective To investigate any systematic differences in the analysis of blood flow velocity waveforms derived by color Doppler imaging and color Doppler energy examination of corpora lutea and adnexal tumors, to test whether the accuracy for diagnosing ovarian malignancy differs between end points derived by color Doppler imaging and color Doppler energy, and to compare the reproducibility of flow velocity waveform analysis obtained by both methods. Methods Fifty-six asymptomatic women with presumed corpora lutea and 67 women with known adnexal masses were included in the study. They all were examined using transvaginal sonography with color Doppler imaging and color Doppler energy. Pulsed Doppler sonography was used to obtain flow velocity waveforms to determine the pulsatility index (PI), resistance index (RI), peak systolic velocity, and time-averaged maximum velocity, The tumors were classified retrospectively according to histologic criteria. Results There were 52 women with benign, three with borderline, and 12 with malignant ovarian tumors. Repeated-measures analysis of variance revealed no systematic differences in the values of all four measurements performed under color Doppler imaging and color Doppler energy for all cases of corpora lutea and adnexal tumors (PI: P = .153, RI: P = .197, peak systolic velocity: P = .355, time-averaged maximum velocity: P = .159). All cases of borderline and malignant tumors had detectable pulsatile blood flow with color Doppler imaging and color Doppler energy. Forty-two (80.8%) of the benign tumors had flow detectable with color Doppler imaging, compared with 40 (76.9%) with color Doppler energy (P = .480). Analysis of receiver operating characteristic curves showed a marginal but nonsignificant improvement in diagnostic performance with color Doppler energy compared with color Doppler imaging for all four measurements (PI: P = .182, RI: P = .178, peak systolic velocity: P = .254, time-averaged maximum velocity: P = .238). The intraclass correlation coefficients for all four measurements were superior with color Doppler imaging compared with color Doppler energy. Conclusion Flow velocity waveform analysis and diagnostic accuracy for ovarian malignancy are not significantly different between color Doppler imaging and color Doppler energy. Examinations with color Doppler imaging appear to be more reproducible than those with color Doppler energy.

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.

Predicting successful vaginal birth after Cesarean section using a model based on Cesarean scar features examined by transvaginal sonography: TVS of Cesarean scar to predict successful vaginal birth

To develop a model to predict the success of a trial of vaginal birth after Cesarean section (VBAC) based on sonographic measurements of Cesarean section (CS) scar features, demographic variables and previous obstetric history.

A Simplified Ultrasound Based Infertility Investigation Protocol and Its Implications for Patient Management

AbstractPurpose: To evaluate whether a simplified infertilityinvestigation protocol, focusing on the use of hysterocontrastsonography (HyCoSy), one blood test, and a semen analysis,would be sufficient as an initial screening test to selectcouples for specific treatment. Methods: The infertile couples underwent gynaecologicalexamination, cervical sampling for cytology and Chlamydiatrachomatis culture, B-mode transvaginal ultrasonographyand basic hormonal analyses followed by a HyCoSy, and asemen analysis. A preliminary diagnosis was made for allpatients. A management plan for treatment was suggestedwhen possible; otherwise further examinations wererecommended. The data were stored for later analysis and theroutine investigation protocol was then adhered to and afinal diagnosis and treatment were decided upon. Results: Agreement between the diagnosis based on HyCoSyand our routine protocol was present in 74% of cases(N = 73). In 13% (N = 13) there was partial agreement. In36% the HyCoSy based protocol was considered sufficientto suggest treatment. Conclusions: A simplified approach may lead to asignificant reduction in both the time and cost of investigating aninfertile couple.