V. H. Eisenberg

Prenatal prediction of survival in isolated left-sided diaphragmatic hernia

To investigate the potential value of antenatally determined intrathoracic herniation of the liver and the ratio of fetal lung area to head circumference (LHR) in the prediction of postnatal survival in isolated, left‐sided congenital diaphragmatic hernia (CDH).

Is there an association between autoimmunity and endometriosis

Endometriosis is a benign gynecologic disorder that affects 5-10% of women of reproductive age worldwide. It is characterized by the presence of ectopic endometrial cells and stroma in various locations outside the endometrium. In some of these women there are also a chronic local inflammatory process and presence of autoantibodies. It is not known whether this process is part of the etiology or is a secondary response to the ectopic cells. Furthermore, endometriosis shares similarities with several autoimmune diseases, which include elevated levels of cytokines, decreased apoptosis, and cell-mediated abnormalities. Our aim in this paper was to review the association between autoimmunity and endometriosis. For this purpose we conducted a thorough literature review in the MEDLINE/PubMed database using the keyword endometriosis crossed with: autoimmune disease, autoimmune diseases, autoimmunity, autoantibodies, immunity, immune-modulation, endometrial antibodies, etc.

Prenatal Sonographic Diagnosis of Hemivertebra

Objective. To describe our experience in prenatal diagnosis of hemivertebra. Methods. This is a case series of patients referred to our tertiary medical center over a 3‐year period. All fetuses were scanned by high‐resolution real‐time scanners. The apparent vertebral anomaly was assessed in a real‐time manner by a joint team of obstetricians, sonographers, and pediatric orthopedic surgeons. A complete anomaly survey of other fetal organs was performed on each fetus. All patients were given proper counseling by the same joint team. All patients had detailed obstetric and neonatal follow‐up. Prenatal sonograms, neonatal medical records, and clinical courses were evaluated retrospectively. Results. During the 3 years, 6 cases of hemivertebra were identified in our department. Gestational age at diagnosis was 14 to 23 weeks. Two patients had conception by assisted reproductive technology. Associated anomalies included VATER syndrome (vertebral defects, imperforate anus, tracheoesophageal fistula, and radial and renal dysplasia), gastroschisis, and pyelectasis. Outcomes in fetuses without major associated anomalies were fair. Conclusions. Diagnosis of isolated hemivertebra might be associated with a favorable outcome. The 3 key factors in achieving an optimal spine at maturity, early diagnosis, anticipation, and prevention of deterioration, might be enhanced by our joint multidisciplinary approach to the diagnosis of skeletal anomalies.

Pelvic inflammatory disease in women with endometriosis is more severe than in those without

To determine the incidence and severity of acute pelvic inflammatory disease (PID) or tubo‐ovarian abscess (TOA) in hospitalised women with and without a history of endometriosis.

Three-dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy.

To characterize, using three‐dimensional (3D) transperineal ultrasound, the appearance, position and dimensions of mesh implants following minimally invasive abdominal sacrocolpopexy.

OP34.05: Obstetric anal sphincter injury—how does a subsequent delivery affect long term outcome?

group women. Right-sided injury was seen twice as often as left, 32% vs. 16%; injury was bilateral in 2 patients (4%). In controls, 44/247 (18%) showed signs of levator ani disruption (P < 0.01); none were bilateral. Conclusions: III◦ or IV◦ anal sphincter tears pose increased risk for trauma of the anterior compartment. Although this risk factor cannot be modified to prevent LAM injury, it is a possible indication for thorough sonographic evaluation of the anterior compartment.

OC29.04: Risk factors for levator avulsion trauma in women with obstetric anal sphincter injuries

Objectives: In 10–30% of women, vaginal birth results in levator ani tears which are associated with female pelvic organ prolapse and reduced contraction strength in later life. This study was undertaken to determine whether women notice such changes after childbirth. Methods: This is a retrospective analysis of two perinatal imaging studies. Patients were followed up 3–6 months postpartum. They were asked to estimate pelvic floor strength relative to strength just before childbirth, using a percentage. Translabial 4D pelvic floor ultrasound was performed to determine structure and function of the levator ani muscle. Imaging analysis was performed offline, using proprietary software, blinded against all clinical data. Levator avulsion was diagnosed on tomographic imaging in the axial plane. Results: 513 primiparous women were seen for follow-up in the context of two prospective trials, at a median of 129 days postpartum. They had given birth to a singleton at a mean gestation of 40.0 (range, 36+0 to 42+5). There were 351 vaginal deliveries (27 Forceps, 60 Vacuum and 264 NVD) and 162 Caesareans (31.6%). At follow-up, 482 were able to rate their pelvic floor strength relative to the situation prior to childbirth, reporting an average strength of 89%. This reduction was associated with delivery mode (P < 0.001), length of 2nd stage (P = 0.017) and episiotomy (P = 0.019). 45 women were diagnosed with levator avulsion which was associated with a greater reduction (no avulsion, 90% vs., unilateral avulsion, 86%, bilateral avulsion 80%, P= 0.007 on ANOVA). Conclusions: Many women notice altered pelvic floor function after childbirth. Vaginal childbirth, episiotomy, perineal tears and length of 2nd stage are associated with subjectively reduced pelvic floor strength after first delivery. Women who have suffered a levator avulsion notice a significantly greater reduction in subjective strength.

OP23.04: Validation of transperineal ultrasound examination in the evaluation of urogynecological patients

Objectives: To evaluate the correlation between levator ultrasound morphology and pelvic floor pathology. Methods: A standardized pelvic floor questionnaire, physical examination (Baden–Walker classification), and multi-channel urodynamic testing (MMS, Holland). 2D, 3D and 4D transperineal ultrasound with a 4–8-MHz transabdominal probe, at rest, maximal Valsalva, and maximal contraction. Statistical analysis using SPSS software. Results: Forty-eight women were analyzed, median age 53 years. Levator avulsion defects were found in 79%, 19% right, 8% left and 52% bilaterally. In cases of bilateral avulsion, 28% had a larger avulsion defect on the right. Levator biometric indices are given in the Table. Levator ballooning (hiatal area ≥ 300 mm2) was observed in 4.5% of women at rest and 46.8% of women at maximal Valsalva. Levator ballooning at Valsalva correlated weakly with prolapse sensation (r = 0.32, 0.04 Fisher exact test) and voiding difficulty (r = 0.31, P = 0.04), but not with prolapse grading. Range and median of the ratios of the various biometric indices between maximum Valsalva and rest are shown in the Table. The Valsalva to rest ratio for the levator area at the genital hiatus was significantly larger than the other ratios. The Valsalva to rest ratio for area showed a weak correlation with prolapse sensation (r = 0.41, P = 0.01, Fisher exact test) and rectocele grading (r = 0.4, P = 0.012, Pearson Chi square). Conclusions: Levator ani defects are very common in patients with pelvic floor problems. The ratio between the levator areas at maximal Valsalva and at rest correlates with several prolapse symptoms and physical findings, and may represent the tissue elasticity of the levator ani. More research is needed to establish its significance to patient management and outcome.

OC05.04: Avulsion defect and cystocele - is there a link?

Objectives: Much data relating to ovarian pathology is based on masses selected for surgery. However optimal management of small and asymptomatic cysts such as dermoids is unknown. Our objective was to assess the natural history of dermoid cysts with reference to torsion and malignancy rates. Methods: A retrospective review of 304 contemporaneous electronic records was performed of consecutive women characterized as having a dermoid cyst from classical TVS features. The natural history was followed for up to 11yr through electronic scan and hospital records. Histopathological outcomes were correlated with TVS findings. Results: 84 (28%) women presented with pelvic pain and the remaining 220 were diagnosed incidentally during investigation of other gynae/nongynaecological problems. Median age was 32.8 (15.5–74.4). Median mean cyst diameter was 47.3mm (4-197mm) and 15 (4.9%) were bilateral. In 83 (27%) cases surgery was indicated at first presentation. In those patients the mean cyst diameter was 55cm and 31 (37.3%) presented with pain. In 3 women (1%) torsion was confirmed. Of the 221 (73%) women initially managed expectantly, 56 (25%) subsequently underwent surgery, for pain or other indications. Of the total 129 undergoing surgical management in our unit, 109 were confirmed dermoids. 19/20 of the non-dermoids were benign. For the 1 histological finding of stage 1a granulosa cell tumour review of the images suggests classical dermoid TVS features were not present even at 1st presentation. Dermoid recurrence occurred in 16 (5.2%) cases. In the remaining 165 (75%) with ongoing expectant management (mean follow up 318 days) no further cases of torsion or malignancy were found during the median 7.0 yr following discharge. Conclusion: Our data suggest the rate of malignancy and torsion in masses with typical features of dermoids using modern TVS is lower than reported in existing literature. The data suggests that expectant management may be safe except in cases of diagnostic uncertainty or pain.

OC30.04: Does the levator ani change in appearance?

Objective: Several mechanisms are believed to be in play maintaining anal continence, one of them being voluntary squeezing using the pelvic muscles. Here we study the effect of squeeze on the anal channel position and dimensions. Method: 20 healthy 0-gravida and 24 women with anal incontinence were recruited after written consent for 3D vaginal ultrasound measurements of angles and diameters during rest and squeeze. The anovaginal angle was defined as the angle between the posterior vaginal wall and the anterior wall of the channel assessed in a sagittal section. The anorectal angle was defined as the angle between the posterior wall of the anal channel and that of the rectal wall above the level of the puborectal muscle. Diameter and area of the mucosa were measured in the middle of the anal channel (lower level) and at the level of the puborectal muscle (upper level). Results: The 0-gravida had a mean age of 26 years with an incontinence score 0 on a scale 0–24. The incontinent women had a mean age of 59 years and their score was mean 11 (range 3–22). The ultrasound measurement results are presented in the table. Conclusion: Voluntary squeeze augments the bend of the anal and rectal tube at the level of the puborectal muscle and compresses the mucosal cuff at this level in young 0-gravida women. In incontinent women of a higher age, the anal tube is straighter, the mucosal cuff in the lower anal channel is smaller, and the effect of squeeze is less prominent or lacking.