Z. Haider

The conservative management of cervical ectopic pregnancies.

To evaluate the role of conservative management in the treatment of cervical ectopic pregnancies.

Prediction of ectopic pregnancy in women with a pregnancy of unknown location

We have previously published on the use of mathematical Model M1 to predict ectopic pregnancy in women with no signs of intra‐ or extrauterine pregnancy. The aim of this study was to improve on the performance of this model for the detection of developing ectopic pregnancies in women with pregnancies of unknown location (PULs). We therefore generated and evaluated a new logistic regression model from simple hormonal data and compared it with Model M1.

The practical application of a mathematical model to predict the outcome of pregnancies of unknown location

A logistic regression model has been developed previously to predict which pregnancies of unknown location (PULs) become ectopics. This model was based on the human chorionic gonadotropin (hCG) ratio (hCG 48 h/hCG 0 h). The aim of this study was to evaluate the model in an early pregnancy clinical setting.

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.

The simple outpatient management of Bartholin's abscess using the Word catheter: A preliminary study

Introduction:  Bartholins cysts/abscess affects 2% of women. Conventional treatment is marsupialisation under general anaesthetic. We evaluated a conservative approach in a non‐randomised prospective interventional study over 12 months.

Transvaginal Sonographic Diagnosis of Appendicitis in Acute Pelvic Pain

Received April 4, 2006, from the Early Pregnancy, Acute Gynecology, and Minimal Access Surgery Unit, St George’s Hospital, London, England. Revision requested April 10, 2006. Revised manuscript accepted for publication April 24, 2006. Address correspondence to Zara Haider, MRCOG, Acute Gynecology Unit, St George’s Hospital, Blackshaw Road, Tooting, London SW17 OQT, England. E-mail: zara.marsh@tesco.net cute pelvic pain in a 30-year-old woman is not always of gynecologic origin. Information from history, pelvic examination, and blood tests may not provide immediate answers. We present the case of a 30-year-old nonpregnant woman who attended the Accident and Emergency Department with a 1-week history of gradually worsening pelvic pain. She had a lowgrade fever of 37.4°C. Abdominal sonography showed a pelvic mass, probably due to a tubo-ovarian abscess. Blood investigations on admission revealed a C-reactive protein level of 208 mg/L, suggesting an inflammatory or infective process. She was referred to the Acute Gynecology Unit for assessment of presumed pelvic inflammatory disease. Abdominal palpation revealed tenderness with guarding in the right iliac fossa. Speculum examination findings were normal. On pelvic examination, there was cervical motion tenderness and tenderness in the right adnexum. Transvaginal sonography revealed a right-sided pelvic mass of mixed echogenicity. A “target sign” could be clearly seen within this mass (Figure 1). The right ovary could be seen separately. A diagnosis of a “likely appendicular abscess” was made, and the patient was referred back to the surgical team for an appendicectomy. On histologic examination, the appendix was described as “barely recognizable, with ulceration and transmural acute and chronic inflammation.” This case shows the ability of transvaginal sonography to diagnose the cause of acute pelvic pain due to nongynecologic conditions. Appendicitis is one of the most common nongynecologic causes of acute pelvic pain and the most common cause of right iliac fossa pain. In a proportion of cases, the clinical picture may be subtle or mis-

OC31.07: Can the hCG ratio be used to predict likelihood of success of conservative management of ectopic pregnancies?

Introduction: Little information is available about prevalence of pathology among women presenting with acute gynaecological problems. The aim of this study was to look at the prevalence of pathology in women presenting to an AGU with pelvic pain and/or vaginal bleeding. Method: All doctors examining patients were required to complete data sheets about 1000 consecutive women, detailing age, pregnancy, presenting complaints and pathology found on scan. Results: Data sheets were completed for 920/1000 (92%) women. Mean age was 31.2 years (S.D9.81). 542 (58.9%) were pregnant. 89.3% had an intrauterine pregnancy (IUP) and 32 (prevalence 3.5%) had an ectopic pregnancy (EP) visualised on transvaginal scan (TVS). Of these, 18 (56.3%) presented with pain, 10 (31.3%) with pain and bleeding and 4 (12.5%) with only bleeding. The women with pregnancies of unknown location were evenly distributed among the 3 presentations 33 (37.9%) pain, 28 (32.2%) pain and bleeding and 26 (29.9%) bleeding alone. 378 non pregnant women presented to AGU during the study period. 65.1% of those presenting with pelvic pain had a normal TVS. 31 (16.7%) had an ovarian cyst > 5 cm diameter, 6 (3.2%) had a tuboovarian abscess, 1 had a pelvic mass and 1 a pelvic abscess. 42% non pregnant women with vaginal bleeding had a normal scan. 15 (21.7%) had significant fibroids, 4 an endometrial polyp and 3 postmenopausal women had thickened endometrium (> 5 mm). 54.3% non pregnant women who presented with pain and bleeding had a normal scan. 3 had significant fibroids, 2 an ovarian cyst > 5 mm and 1 an early IUP. Conclusion: This is the first study to look at the variety of pathology presenting to an AGU. A 3.5% prevalence of EP emphasises the importance of having an ultrasound scan available at the time of initial consultation. The majority of pregnant women had an IUP and were reassured. Women with pelvic pain and/or bleeding can be efficiently triaged to appropriate management based on ultrasound findings.

P12.03: Can we improve the performance of logistic regression analysis for predicting the outcome of pregnancies of unknown location (PULs)?

Background: The aim of this study was to generate and evaluate a new logistic regression model from simple demographic, hormonal and ultrasonographic data to predict the outcome of pregnancies of unknown location (PULs). Methods: Data were collected prospectively from women classified as PUL. The final diagnoses were: failing PUL, intra-uterine pregnancy (IUP) or ectopic pregnancy (EP). The Logarithm (log) of serum human chorionic gonadotrophin (hCG) average and hCG ratio (hCG 48 hrs/hCG 0 hrs) were encoded as variables following multivariate analysis. One multi-categorical logistic regression model (M4) contained log of hCG average, hCG ratio and its quadratic effect. The performance of this model was evaluated using receiver operating characteristic (ROC) curves. M4’s performance was compared to model M1 (hCG ratio alone), which has been published previously. Results: 376/4698 (8.0%) consecutive PULs were recruited in this study – 201 in the training set and 175 in the test set. 109 (55.3%) failing PULs, 76 (38.6%) IUP and 12 (6.1%) EPs were used in the training set to develop the new models. 94 (54.3%) failing PULs, 64 (37.0%) IUP and 15 (8.7%) EPs were intest set. M4 gave an area under ROC curve 0.978 for failing PUL, 0.974 for IUP and 0.900 for EP. This performed better than M1, which gave an area under the ROC curve of 0.965, 0.969, and 0.842, respectively. Only the improvement in the detection of EPs was statistically significant (P-value = 0.0317). Conclusions: Model M4 significantly outperforms model M1 in the detection of EPs. Additional serum hCG information can improve mathematical models used to predict the outcome of PULs. In the future, the authors believe that the clinical application of this model will help to remove the need for significant experience when interpreting hormone values in the management of PULs.

P12.10: Is it possible to predict successful treatment response to methotrexate earlier than seven days?

Objective: The aim of this pilot study was to evaluate the safety and efficacy of ultrasound guided surgical evacuation of uterus compared to the conventional blind method of evacuation of retained products of conception (ERPC) currently being practised. It is not known whether routine use of intraoperative transvaginal ultrasound (TVS) improves the outcome of surgical management of first trimester miscarriage and surgical termination of pregnancy (TOP) in both primary as well as repeat procedures. Methods: A retrospective analysis over a six-month period was performed in a teaching hospital in London, UK in women who had either undergone surgical, medical or conservative management of miscarriage or TOP in the first trimester. The inclusion criteria were women who had retained products of conception (RPOC) after initial treatment of first trimester miscarriage or TOP and needed subsequent surgical evacuation of uterus. Outcome measures were the incidence of incomplete evacuation requiring further treatment and persistent vaginal bleeding. Results: Of 240 women, 30 had RPOC after initial treatment. 27% (8/30) opted for conservative management with weekly TVS, 33% (10/30) had repeat ERPC under TVS guidance and 40% (12/30) had ERPC without TVS. Amongst the TVS guided ERPC group, none required further intervention. In those who had ERPC without TVS guidance, 2 had RPOC requiring a third evacuation. Conclusion: Surgical evacuation under TVS guidance was associated with lower rate of complications compared to the conventional procedure without ultrasound. As this was a small, retrospective study, further prospective randomised controlled trials would be useful in showing further significance of these findings.

OC31.08: What is the optimal approach to accurately classifying failing pregnancies of unknown location (PULs)?

Background: Banerjee et al. (2001) have previously developed a logistic regression model to predict failing pregnancies of unknown location (PULs). In the same study, this model did not outperform serum progesterone < 20 nmol/L taken at presentation. We compare these diagnostic tests to the human chorionic gonadotrophin (hCG) ratio for the prediction of failing PULs. Methods: Retrospective observational study. We compared the performance of three models for the prediction of failing PULs. 1) Logistic regression model (Banerjee et al., incorporating vaginal bleeding, endometrial thickness; 2) serum progesterone level and serum hCG level), 2) Serum progesterone <20 nmol/L at 0 hour (hr); and 3) hCG ratio (hCG 48 hr/hCG 0 hr) < 0.8. The performance of these models was evaluated using receiver operating characteristic curves (ROC) curves. P-values for comparison of AUC curves calculated using DeLong et al.’s method. Results: 4698 consecutive women were scanned and 370 were classified as PULs. For the prediction of failing PULs, the area under the ROC (AUC) for the logistic regression model was 0.944; the AUC for serum progesterone < 20 nmol/L at 0 hr was 0.963; and the AUC for hCG ratio < 0.8 was 0.972. P-values for comparison of AUC curves (See Table 1): Conclusions: The hCG ratio is the optimal test for the prediction of failing PULs.