Diagnostic laparoscopy in pre-surgical planning for higher stage endometriosis: Is it still relevant?

It has become necessary to re - examine the relevance of diagnostic laparoscopy in the two-stage approach to surgical management of symptomatic women with higher stage endometriosis following emerging evidence demonstrating acceptable diagnostic performance of alternative less invasive and less expensive imaging modalities. We highlight the relative merits of these presurgical diagnostic imaging modalities and propose strategies that address the challenge of transitioning to a new diagnostic paradigm in the management of symptomatic women with higher stage endometriosis.

Systematic evaluation of women with suspected endometriosis using a 5-domain sonographically based approach.

In recent years, knowledge has evolved regarding the role of transvaginal sonography in the assessment of the pouch of Douglas status and the preoperative prediction of extraovarian endometriosis in specific locations. Despite these advances in transvaginal sonography, the challenge of developing a comprehensive, cost-effective, and reproducible preoperative classification system for endometriosis remains. Critical to this classification system should be a sonographically based evaluation protocol that is systematic, evidence based, and reproducible with clearly defined end points. To date, no structured evaluation protocol exists for the assessment of the pelvis in women with suspected endometriosis. In this article, we propose a domain-based evaluation protocol for the assessment of women with suspected endometriosis using transvaginal sonography.

Managing Caesarean Scar Pregnancy in low Resource Settings: 2 Case Reports and a Description of Transrectal Ultrasound guided Surgical Approach (TRUGA).

Caesarean scar pregnancy (CSP) occurs when an embryo implants in a previous caesarean section scar. It has a reported incidence of 1 in 1800. Various surgical and medical techniques have been described in case reports for the management of CSP. These techniques are usually undertaken in tertiary level units with significant resource availability. In this paper, we present a new clinical perspective for the management of CSP in low resource settings and describe the steps involved in a transrectal ultrasound guided approach with dilatation of uterine cervix and subsequent evacuation of uterine contents (TRUGA with D&C).

Relating historical variables at first presentation with operative findings at laparoscopy for endometriosis.

OBJECTIVES: To determine the correlation between historical variables at presentation with the phenotype and location of biopsy proven endometriosis at laparoscopy. METHODS: Prospective observational study. Consecutive women had laparoscopic surgery following clinical suspicion of endometriosis. Standardised history and clinical examination were taken, and the presenting complaints were evaluated within four subsets of women: (i) primary laparoscopy for endometriosis (ii) previous laparoscopically confirmed endometriosis (iii) biopsy positive for endometriosis and (iv) all biopsies negative for endometriosis. Historical pain variables within the four subsets were compared with disease location and phenotype (superficial, deep infiltrating, endometriomata) at laparoscopy. A stringent P-value of 0.01 was used as the cut-off for significance. RESULTS: Overall 104 consecutive women were included: mean age 34.3 years, 66/104 (63.5%) had reoperation and 38/104 (36.5%) had primary laparoscopy. 89/104 (85.6%) were biopsy positive for endometriosis, and 11/104 (10.6%) were biopsy negative. Superficial endometriosis was most common phenotype. Site of pain did not correlate with ipsilateral location of disease. Significant correlations included as follows: dyspareunia and endometrioma (P = 0.0009) in women undergoing reoperation; dyspareunia and posterior compartment (P = 0.0086) and lateral compartment (P = 0.0004) disease in women with histology proven endometriosis; left iliac fossa pain and biopsy proven posterior compartment endometriosis (P = 0.0041). CONCLUSIONS: Although a history of dyspareunia in women with previous endometriosis was significantly correlated with endometrioma, site-specific locations of pain symptoms did not correlate with ipsilateral locations of endometriosis at laparoscopy. The phenotype - combined deep and superficial endometriosis - was associated with dyspareunia among women with previous history of endometriosis.

A retrospective comparison of water birth and conventional vaginal birth among women deemed to be low risk in a secondary level hospital in Australia.

BACKGROUND: Water birth involves the complete birth of the baby under warm water. There is a lack of consensus regarding the safety of water birth. AIM: This study aimed to describe the maternal and neonatal outcomes associated with water birth among labouring women deemed at low risk for obstetric complications and compare these outcomes against women of similar risk who had a standard land birth. METHOD: A retrospective audit and comparison of women giving birth in water with a matched cohort who birthed on land at Bankstown hospital over a 10 year period (2000-2009). RESULTS: In total 438 childbearing women were selected for this study (N=219 in each arm). Primigravida women represented 42% of the study population. There was no significant difference in mean duration of both first and second stages of labour or postpartum blood loss between the two birth groups. There were no episiotomies performed in the water birth arm which was significantly different to the comparison group (N=33, p<0.001). There were more babies in the water birth group with an Apgar score of 7 or less at 1min (compared to land births). However, at 5min there was no difference in Apgar scores between the groups. Three of eight special care nursery admissions in the water birth group were related to feeding difficulties. CONCLUSION: This is the largest study on water birth in an Australian setting. Despite the limitations of a retrospective audit the findings make a contribution to the growing body of knowledge on water birth.

The 'sliding sign' in conjunction with sonovaginography: is this the optimal approach for the diagnosis of Pouch of Douglas obliteration and posterior compartment deep infiltrating endometriosis?

Introduction: Endometriosis is a chronic peritoneal disease that may progress as a deep infiltrating lesion involving the posterior compartment of the pelvis. Efforts to improve pre-operative knowledge of the location and extent of these lesions have resulted in the development of Transvaginal ultrasound (TVS) as the first-line imaging modality for extra-ovarian endometriosis. However, various techniques of TVS have been described in the literature for this purpose. Methods: In this review we will detail the evolution of TVS as the primary imaging modality in the pre-operative diagnosis of posterior compartment deep infiltrating endometriosis (DIE). We will also discuss the potential of an emerging new real-time diagnostic ultrasound-based technique known as the 'sliding sign' in combination with office gel sonovaginography for the pre-operative diagnosis of Pouch of Douglas obliteration and posterior compartment DIE. Conclusion: Implementation of the new real-time dynamic, reproducible and simple 'sliding sign' in conjunction with SVG has the potential to challenge the current concept that traditional laparoscopy is the 'gold standard' modality for the diagnosis of women with posterior compartment DIE.

Rationalising the change in defining non-viability in the first trimester.

Introduction: With the publication of four papers in late 2011, international cut-offs for definitions of non-viability in the first trimester of pregnancy were challenged. These definitions were inconsistent across different international guidelines. For example, a gestational sac with absent yolk sac or embryo and a mean diameter of ≥ 16 mm would be classified as a miscarriage in the USA, whereas the same sac would have to measure ≥ 20 mm in the UK or Australia to meet this definition. Likewise, an embryo with no detectable heartbeat and a CRL of ≥ 5 mm would also meet criteria for missed miscarriage in the USA, compared to a CRL ≥ 6 mm in the UK or Australia. Methods: Later in 2011 and then in 2012, guidelines across the three countries were updated and are now consistent, defining an empty gestational sac with a mean diameter of > 25 mm as a non-viable pregnancy and/or an embryo with CRL > 7 mm and no detectable heartbeat. In this paper we explore the rationale that led to these changes in order to potentially avoid wrongly diagnosing miscarriage at the decision boundary measurements and in turn avoiding inadvertent termination of potentially viable pregnancies. Conclusion: Although reducing women's anxiety and making a definitive diagnosis as early as possible is desirable, the need for absolute certainty is paramount before diagnosis of the death of an early pregnancy is made.

A case-control study of risk factors for male infertility in Nigeria.

AIM: To evaluate the association between selected potential socio-demographic and behavioral risk factors and infertility in Nigerian men. METHODS: There were two groups in this study. One group consisted of 150 men with proven male infertility, and the other consisted of 150 fertile men with normal semen parameters. Both were matched for age, place of residence and key socio-demographic variables. They were compared for sexual history, past medical and surgical history, past exposures to sexually transmitted infections and treatment, past and current use of drugs as well as smoking and alcohol intake history. RESULTS: Infertile men were significantly more likely than fertile men to report having experienced penile discharge, painful micturition and genital ulcers, less likely to seek treatment for these symptoms and more likely to seek treatment with informal sector providers. Multivariate analysis showed that male infertility was significantly associated with bacteria in semen cultures, self-reporting of previous use of traditional medications and moderate to heavy alcohol intake, but not with smoking and occupational types. CONCLUSION: INFERTILITY is associated with various proxies of sexually transmitted infections (STIs) and poor healthcare-seeking behavior for STIs in Nigerian men.