Reducing the postpartum length of stay: Implications for emergency department presentations at a tertiary women's hospital.

AIMS: Postpartum length of stay (LOS) in Australian hospitals has reduced over the past three decades. Although a reduction in LOS likely reduces hospital costs in the immediate postpartum period, there is concern that this is increasing the burden on emergency services, domiciliary staff and primary care providers. The aims were to determine whether the recent reduction in LOS at an Australian tertiary obstetric hospital resulted in a change in emergency department (ED) presentations by women in the first six weeks postpartum, and newborns within the first 28 days of life. METHODS: We conducted a cross-sectional cohort study of all newborns ≤28 days of age and women ≤6 weeks postpartum who presented to the ED during four comparable time periods (2019-2022) at an Australian tertiary obstetric hospital. Logistic regression was used to determine the relationship between neonatal and maternal postpartum ED presentations and year of birth. RESULTS: Reduced postpartum LOS was associated with a significant increase in maternal and neonatal presentations to the ED (odds ratio (OR): 1.15 (95% confidence interval (CI): 1.08-1.23), and OR: 1.11 (95% CI: 1.03-1.19), respectively). For every 100 births, an extra six women and three neonates presented to the ED for postpartum care in 2022 compared with 2019. There was no difference in maternal or neonatal admissions throughout the study periods. CONCLUSION: The increase in maternal and neonatal ED presentations associated with reduced LOS should prompt reassessment of postnatal practice and encourage further research into allocation of in-hospital resources and postpartum education.

Positron emission tomography in the evaluation of endometriosis: A systematic review.

Despite the profound impact of endometriosis worldwide, delays in diagnosis and suboptimal surveillance techniques are well-recognised issues. Case studies have reported incidental uptake of 18F-FDG PET tracer in endometriotic lesions. However, the utility of PET imaging as a non-invasive diagnostic tool for endometriosis is currently unclear. The purpose of this systematic review was to summarise the existing evidence and determine the value of available PET scanning techniques in the detection and monitoring of endometriosis. MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science were searched from conception to 05/03/23. Eligible studies included participants with a history of known or suspected endometriosis who underwent a PET scan for any indication. All PET tracers and protocols were eligible. Outcomes included correlation of PET tracer uptake with the presence of endometriosis seen at laparoscopy or confirmed on histology, sensitivity of tracer uptake, specificity of tracer uptake, site of lesions with tracer uptake, stage of lesions with tracer uptake, SUVmax of endometriosis lesions and adverse reactions to PET imaging. The protocol for this review was registered with PROSPERO (ID: CRD42023405260). Eight studies describing 110 participants were eligible for inclusion. Six studies assessed 18F-FDG with combined PET-CT, one study assessed 18F-FDG PET alone, and the remaining study assessed PET-CT with an alternative tracer, 68Ga-DOTATATE. For 18F-FDG imaging, the correlation of PET avidity with lesions or sites of endometriosis ranged from 0-55 %. Pre-operative 68Ga-DOTATATE PET-CT detected endometriosis in 33 % of cases. All included studies were cohort studies, six were assessed to have low risk of bias, one with moderate risk and one with high risk of bias. Overall, 18F-FDG PET scanning does not appear to consistently identify endometriotic lesions, and therefore its reliability and usefulness in endometriosis diagnosis is limited. The utility of 68Ga-DOTATATE PET-CT remains uncertain. Findings are constrained by limited available evidence reporting outcomes of PET imaging for endometriosis. Other existing PET tracers with biological plausibility in the detection or monitoring of endometriosis warrant further investigation.

The myometrial-cervical ratio: Can a simple sonographic measurement improve diagnosis of adenomyosis in a regional setting?

Introduction: Adenomyosis is histologically defined by the presence of endometrial glands and stroma in the myometrium. Ultrasound findings of adenomyosis are being redefined to better diagnose adenomyosis pre-operatively. Methods: A single-centre retrospective study was performed at a regional hospital. The myometrial-cervical ratio was calculated on pre-operative ultrasounds, and histopathology reviewed for each case. Logistic regression was used to estimate the association between the myometrial-cervical ratio and adenomyosis confirmed on histopathology, and the area under the receiver operating characteristic curve was calculated. Comparisons were performed based on the presence of fibroids on ultrasound. Results: Complete data were available for 136 benign hysterectomies between 1 January 2015 and 31 December 2020. When the myometrial-cervical ratio was treated as a continuous variable in a logistic regression of adenomyosis on histopathology, there was no statistical evidence (χ2(1) < 0.01, p = 0.98) of an association. When cases including fibroids in the myometrial-cervical ratio were excluded, there was a non-significant association between myometrial-cervical ratio and adenomyosis on histopathology (odds ratio = 3.435, 95% confidence interval = 0.964, 12.235; χ2(1) = 3.62, p = 0.057); area under the receiver operating characteristic = 0.637 (95% confidence interval = 0.504, 0.770). The optimal myometrial-cervical ratio cutpoint was 1.875 (95% confidence interval = 1.698, 2.051), which achieved 71.43% sensitivity and 60.00% specificity. There was strong statistical evidence (χ2(1) = 9.02, p = 0.003) that the myometrial-cervical ratio outperformed standard pre-operative ultrasound identification of adenomyosis. Conclusion: While accuracy remains suboptimal, the myometrial-cervical ratio outperformed standard ultrasound diagnostic features of adenomyosis in a regional setting. The myometrial-cervical ratio may offer a simple imaging measurement for adenomyosis in inexperienced hands when fibroids are absent.

The relationship between sleep disturbances and endometriosis: A systematic review.

OBJECTIVE: Endometriosis is associated with a range of symptoms that can negatively impact a person's quality of life. While pain and infertility have received at lot of attention, sleep disturbances in individuals with endometriosis has been overlooked in both clinical practice and research. Therefore, the primary aim of this systematic review was to gather evidence from the current literature to illustrate the association between sleep disturbances and endometriosis. STUDY DESIGN: A literature search was conducted using three electronic databases (OVID EMBASE, MEDLINE, and Web of Science). Observational studies, published in English, that involved participants aged 18 years or older that compared sleep outcomes between endometriosis patients and those without a history of endometriosis were included. The quality of each study was assessed using the Joanna Briggs Institute critical appraisal tools. RESULTS: Nine studies (six case-control and three cross-sectional) were included in this review; 7 with low risk of bias and 2 with moderate risk of bias. The studies demonstrated heterogeneity in the assessment of sleep disturbances. However, 7 studies reported a significant positive association between endometriosis and sleep disturbances. Moreover, this impact on sleep was further complicated by the complex interaction between pain, fatigue and quality of life. CONCLUSION: Current studies suggest an association between sleep disturbances and endometriosis, which may provide a blueprint for future clinical recommendations to screen and treat sleep disturbances in individuals with endometriosis to improve their quality of life. Future studies should aim to standardise the methods of assessing sleep disturbances and explore potential contributing factors.

When you see nothing at all: Outcomes following a negative laparoscopy. A systematic review.

BACKGROUND: Persistent pelvic pain (PPP) is a complex and often debilitating condition. While widely accepted to be multifactorial in nature, the precise aetiology of PPP remains elusive. In many cases, women who undergo laparoscopy for PPP will have no visible pathology identified (a 'negative' laparoscopy). Currently, there are no consensus guidelines which outline the recommended management following a negative laparoscopy, and the woman's experiences and outcomes are not widely known. AIMS: This review aims to identify and summarise the literature surrounding the experiences of women with PPP who have a negative laparoscopy; specifically, their outcomes of pain, quality of life (QoL), satisfaction with care, and their overall management. MATERIALS AND METHODS: A systematic search of the electronic databases Ovid Medline, PubMed and Embase was performed. Studies in English exploring the outcomes of women with PPP following a negative laparoscopy were included. RESULTS: Four studies consisting of a total of 200 women were included. Results were inconsistent. Three studies concluded that the majority of women with PPP had persistent pain following a negative laparoscopy. A single study found that pain significantly improved after negative laparoscopy. QoL outcomes varied, with two studies reporting a positive impact and two studies reporting a deleterious impact on QoL following a negative laparoscopy. CONCLUSIONS: The impact on pain outcomes and QoL following a laparoscopy that does not diagnose pathology remains unknown, and the available evidence is insufficient to guide evidence-based practice. This review highlights a significant gap in our understanding of surgical management for PPP.

Evidence for the role of multidisciplinary team care in people with pelvic pain and endometriosis: A systematic review.

BACKGROUND: Endometriosis is a chronic, inflammatory condition characterised by the presence of endometrial-like tissue outside the uterine cavity. Given the multi-system nature of the disease and the potential for significant negative impact on quality of life, there has been a long-standing recognition of the need for multidisciplinary care for people with endometriosis. However, there is paucity to the data supporting this approach, and much of the evidence is anecdotal. AIM: This systematic review aims to describe recent evidence-based models and patient-centred perspectives of multidisciplinary care for endometriosis, to improve understanding of the role of an integrated, multidisciplinary team in effectively addressing patients' care needs. MATERIALS AND METHODS: PubMed, Medline, Embase and Web of Science were searched for relevant articles published between 1 January 2010 to 7 July 2022. RESULTS: Nineteen studies met the inclusion and exclusion criteria and pinpointed a multidisciplinary team consisting of gynaecologists, pain specialists, nurses, physiotherapists, psychologists, sex therapists, nutritionists, complementary medicine practitioners, and social workers to be most commonly utilised in holistically managing people with pelvic pain and endometriosis. Furthermore, patient perspectives on care highlighted the need for reliable information, respect and validation of experiences or preferences, discussion of long-term treatment plans and social and emotional supports. CONCLUSION: The trend for multidisciplinary team care for people with endometriosis is growing. Further consumer-driven clinical studies and outcome evaluations need to be conducted to determine the effect of multidisciplinary care on improvements to quality of life for people living with endometriosis and or pelvic pain.

Does weight loss in women with obesity induce regression of endometrial hyperplasia? A systematic review.

Obesity is a leading risk factor for endometrial cancer and its precursor, endometrial hyperplasia (EH). Currently, weight loss is recommended for people with EH and obesity, but evidence to guide weight management as primary or adjunctive therapy is limited. This systematic review aims to assess the role of weight loss in inducing histopathological regression of EH in women with obesity. A systematic search of Medline, PubMed, Embase and The Cochrane Library databases was conducted in January 2022. Studies reporting on participants with EH who underwent weight loss interventions, incorporating comparisons of pre- and post-intervention histology, were included. Studies were limited to those published in English with full text available. Six studies met the inclusion criteria, all of which reported outcomes after bariatric surgery. Three studies reported outcomes for the same group of participants, therefore only one outcome set was included. Pre-operative endometrial biopsy results were available for 167 women, and 81 had post-operative biopsies reported. Nineteen women (11.4% of those biopsied) had EH pre-operatively; 17 underwent repeat sampling post-operatively. Twelve (71%) had complete histological resolution, 1 (6%) had partial regression from complex hyperplasia to simple hyperplasia, 1 (6%) had persistent atypical hyperplasia, and 3 (18%) had persistent simple hyperplasia. One patient with a normal pre-intervention biopsy had simple hyperplasia post-operatively. Due to poor quality and overall scarcity of data, the role of weight loss in the primary or adjunctive treatment of EH is unknown. Future studies should prospectively assess weight loss modalities and targets, as well as use of concurrent therapies.

Medical management of retained products of conception: A prospective observational study.

OBJECTIVE(S): To measure the success rate of primary medical therapy in managing retained products of conception (RPOC) in women with secondary postpartum haemorrhage (PPH) and to identify factors associated with need for surgical management. STUDY DESIGN: Postpartum patients presenting to a tertiary women's hospital Emergency Department between July 2020 and December 2022 with secondary PPH and evidence of RPOC on ultrasound were recruited. Clinical information relating to the presentation was collected prospectively. Antenatal and intrapartum data were collected from medical record and Birthing Outcome System database review. The primary outcome was the success of medical management for RPOC, defined by the implementation of medical or expectant management without subsequent need for surgical intervention. RESULTS: Forty-one patients with RPOC underwent primary medical or expectant management. Twelve patients (29%) were managed successfully with medical management, while twenty-nine (71%) proceeded to surgical management. Medical management involved antibiotics (n = 37, 90%), prostaglandin E1 analogue (n = 14, 34%) and other uterotonics (n = 3, 7%). A greater endometrial thickness on ultrasound was significantly associated with a requirement for secondary surgical intervention (p < 0.05). There was an association approaching statistical significance between a higher sonographic volume of RPOC and the failure of medical management (p = 0.07). There was no statistically significant association between the mode of delivery or the number of days postpartum with the success of medical management. CONCLUSION(S): For patients presenting with secondary PPH and sonographic RPOC, over two thirds required surgical management. Increased endometrial thickness was associated with an increased requirement for surgical management.

Economic cost of secondary postpartum haemorrhage: A case-control study at a tertiary hospital in Australia.

BACKGROUND: Secondary postpartum haemorrhage (PPH) is a condition which affects 0.2-3.0% of women. Despite its impact on maternal morbidity, there is a lack of understanding of the cost burden of disease. AIMS: To determine the economic cost of secondary PPH in the postpartum period, compared to the costs for women without this diagnosis. MATERIALS AND METHODS: Data were prospectively collected on a cohort of 97 women who presented with secondary PPH to the emergency department (ED) between July 2020 and February 2021. A case-control design was then used to compare postpartum cost data from these patients to a group of 97 controls who were matched to maternal demographics, and who did not present with secondary PPH. RESULTS: For women with secondary PPH, there were significantly more hospital attendances, and postpartum costs were higher for all cost subcategories across ED, admissions, and outpatient attendances (P < 0.0001), compared to controls. The total cost of postpartum care for 97 patients with secondary PPH was $254 377.62 with an average cost per patient of $2622.45, compared to $26 670.46 for 97 controls with an average cost of $274.95 per patient (P < 0.0001). This demonstrates a 9.5-fold increase in postpartum costs per woman with secondary PPH. CONCLUSIONS: Secondary PPH is an under-researched condition which presents a significant cost burden for the health system. Evidence-based guidelines addressing the prevention and management of secondary PPH may assist in minimising this cost burden for both the health service and the patient.

Management of secondary postpartum haemorrhage: A systematic review.

Secondary postpartum haemorrhage is a significant cause of postnatal morbidity and admission to hospital. It can be managed medically, surgically or with interventional radiological techniques, however, there is limited evidence to inform the most appropriate use of these treatments. This review aimed to summarise the existing evidence and evaluate the effectiveness and safety of the management options available for secondary postpartum haemorrhage. MEDLINE, EMBASE, CENTRAL, SCOPUS, Clinicaltrials.gov and ICTRP were searched from conception to August 2021. Eligible studies described the management of participants with secondary postpartum haemorrhage occurring between 24 h and 12 weeks after a pregnancy of at least 20 weeks gestation. All treatment interventions were eligible. Outcomes included reduction of bleeding, hospital admissions, re-presentations to hospital, secondary surgical procedures, blood transfusions, adverse effects of treatment, surgical complications, hysterectomy, ICU admissions, severe morbidity and mortality. The protocol for this review was registered with PROSPERO (ID: CRD42021274146). Eleven studies, describing 834 participants, were eligible for inclusion. Five studies reported outcomes of a single intervention and six studies reported outcomes of more than one treatment modality. Assessed interventions included medical management, surgical procedures, and radiological techniques. Resolution of bleeding was seen in 8.2-84.6 % of participants following medical management, 89.3-100 % following surgical management and 87.5-100 % post transcatheter arterial embolisation. When considering only studies published in the last 30 years, these results are 71.9-73.7 %, 89.3-92.0 % and 87.5-100 % respectively. All included studies were small and retrospective observational in design with poor methodological quality leading to a serious or critical risk of bias. This review has highlighted the deficiencies in evidence for the management of secondary PPH. Future, well designed, prospective studies are needed to provide guidance to clinicians managing this condition.

Medical management of secondary postpartum haemorrhage: A prospective cohort study.

BACKGROUND: Secondary postpartum haemorrhage (PPH) complicates ~1% of pregnancies and can cause serious maternal morbidity. However, evidence guiding optimal management is scarce and often based on case series and expert opinion. AIMS: To measure the success of primary medical therapy in managing secondary PPH and to identify factors associated with need for surgical management. MATERIALS AND METHODS: Postpartum patients presenting to a tertiary women's hospital emergency department between July 2020 and October 2021 with secondary PPH were recruited. Data from the acute presentation were prospectively collected. Antenatal and intrapartum data were collected from medical record review. The primary outcome was the success of medical management for secondary PPH, defined by the implementation of medical or expectant measures without subsequent need for surgical intervention. RESULTS: One-hundred and twenty patients underwent primary medical management for secondary PPH. Ninety-eight (82%) were managed successfully with medical management and 22 (18%) required surgery. Medical management involved misoprostol (n = 33; 27.5%), antibiotics (n = 108; 90%), and less commonly other uterotonics (n = 6; 5%). Factors associated with lower rates of successful medical management included: antecedent manual removal of placenta (MROP) (odds ratio (OR) 0.2, P = 0.047), primary PPH ≥500 mL (OR 0.39, P = 0.048) or ≥1 L (OR 0.24, P = 0.009), >200 mL blood loss at presentation (OR 0.17, P = 0.015), increasing time post-delivery (OR 0.84, P = 0.044), retained products of conception (RPOC) on ultrasound (OR 0.024, P = 0.001) and vaginal birth (OR 0.27, P = 0.027). CONCLUSION: Medical management was highly successful. Vaginal birth, MROP, primary PPH, RPOC on ultrasound and increasing time post-delivery were associated with increased need for surgical management.

Determining a threshold measurement of endometrial thickness for asymptomatic postmenopausal women: A tertiary centre case series.

BACKGROUND: An incidental finding of a thickened endometrium on ultrasound in the postmenopausal patient without bleeding is a common presentation to gynaecological services; however there is limited evidence to guide clinical practice as to when hysteroscopic evaluation and endometrial sampling is required. AIMS: To determine the endometrial thickness at which endometrial sampling is indicated in asymptomatic postmenopausal women referred with thickened endometrium on ultrasound. MATERIALS AND METHODS: A single-centre retrospective case series of postmenopausal women without bleeding undergoing hysteroscopy was conducted. Logistic regression was used to examine the association between a range of variables and pre-malignant or malignant pathology and endometrial thickness. The optimal endometrial thickness threshold was identified to maximise model sensitivity. RESULTS: A total of 404 postmenopausal women were included in this study, having undergone a hysteroscopy at the study site between 1 July 2008 and 30 June 2018. The mean (SD) age of patients at presentation was 65 (9.09) years and the mean body mass index was 29.86 kg/m2 (6.52). Of these women, nine (2.2%) were diagnosed with endometrial carcinoma and seven (1.7%) had endometrial hyperplasia with atypia. The most common histopathological finding was of a benign endometrial polyp (153: 37.9%). When including hyperplasia with or without atypia in histopathology of interest, a cut-off of ≥9 mm provides the greatest sensitivity (83.3%) and specificity (63.8%) for a diagnosis of pre-malignant or malignant pathology (classification accuracy of 64.8%; area under the receiver operating characteristic: 0.7358, 95% CI: 0.6439, 0.8278) in this cohort. CONCLUSIONS: Using an endometrial thickness of ≥9 mm can be used as a cut-off for endometrial sampling in postmenopausal women without bleeding.

Virtual clinics in gynaecology - Can we shorten the wait? A randomised controlled trial implementing a novel care pathway for postmenopausal bleeding.

BACKGROUND: Postmenopausal bleeding (PMB), a common symptom of endometrial cancer, necessitates prompt clinical and sonographic assessment, often followed by hysteroscopy. Unfortunately, due to traditional gynaecology outpatient clinic paradigms, unnecessary patient-clinician encounters are common and may lead to delays in diagnosis. AIM: The aim was to assess a novel clinic model for the management of women with PMB based on virtual assessment and routine use of the outpatient hysteroscopy clinic. METHODS: An unblinded pragmatic randomised controlled trial was performed, comparing a 'virtual clinic' to routine outpatient clinical care. The primary outcome for assessment was time, measured as the interval (days) between referral triage and discharge for definitive management or to the general practitioner. Demographical and clinical data were collected. After discharge from the system, patients completed a satisfaction and feedback questionnaire. Log-rank tests were used to compare the equality of time-to-event functions across randomised groups. RESULTS: There were 96 participants, 46 in the intervention arm and 50 controls. The total time spent in the gynaecology system differed between groups (Χ2 (1) = 6.94, P = 0.008), with a median total time of 55 days (95% confidence interval (CI): 37-66 days) for the intervention group compared to a median of 84 days (95% CI: 54-101 days) for the control group. The number of in-person gynaecology encounters differed between those randomised to intervention (P < 0.001). Overall, 96% of respondents indicated a positive score for overall satisfaction. CONCLUSIONS: The proposed clinic model resulted in a significant reduction in the time between referral and discharge, without compromising patient satisfaction.

We live in a virtual world: Training the trainee using an integrated visual reality simulator curriculum.

BACKGROUND: Gynaecology trainees struggle to obtain adequate procedural experience. Training programs integrating virtual reality simulators (VRS) have been suggested as a solution. AIMS: The study aimed to assess if a VRS training program (LapSim® , Surgical Sciences, Göteborg, 2017) improved live operating performance at six months for novice and experienced trainees. Additional outcomes included the association between LapSim® logged time and live operating performance at six months, LapSim® scores and live operating performance at zero and sixmonths and the difference in benefit for novice and experienced gynaecology trainees. METHODS: A prospective intervention study was conducted. Novice and experienced trainees were enrolled, and comparisons made at zero- and six-month time points. The intervention groups were provided with a laparoscopic gynaecology curriculum incorporating VRS. Controls underwent routine training only. Assessment of live operating performance was conducted after six months training. RESULTS: Thirty-five trainees participated, and 25 had access to the VRS curriculum (17 novice and eight experienced trainees). Access to the VRS curriculum and time spent training on the LapSim® made no difference to live operating ability for either intervention group (P > 0.05). The median (interquartile range) hours of VRS usage were 7.9 (4.5-10.8) and 6.0 (4.0-6.8) for novice and experienced trainees respectively. The intervention group provided positive feedback on the utility of VRS in their laparoscopic skill development. CONCLUSION: Optimal utilisation of VRS in Australian training paradigms remains incompletely understood. Further research is required to establish the most effective integration of VRS into training models to ensure uptake and transferability to the operating theatre.

The use of the myometrial-cervical ratio in the ultrasound diagnosis of adenomyosis - A validation study.

BACKGROUND: Adenomyosis is a benign disorder defined by ectopic endometrial glands within the uterine myometrium. A study by Mooney et al reported the myometrial-cervical ratio (MCR), a novel ultrasound measurement that was found to improve the preoperative diagnosis of adenomyosis. AIMS: To validate the association between sonographic MCR and adenomyosis confirmed on histopathology in an independent patient group. MATERIALS AND METHODS: Single-centre retrospective cohort study including women who underwent hysterectomy between 1 January 2016 and 31 December 2018 for a benign, non-obstetric indication with an ultrasound at the study centre prior to surgery. Clinical details and histopathology were extracted. Ultrasound images were reviewed by a gynaecology ultrasound subspecialist blinded to histological findings. RESULTS: Eight hundred eighty-seven patients underwent hysterectomy in the study period for eligible indications; 317 had an ultrasound at the study centre and were included. There was no statistically significant association between the MCR and adenomyosis on histology when all patients were included; however, increased MCR was associated with adenomyosis when those with fibroids on ultrasound were excluded. The area under the receiver operating characteristic for this model was 0.614 (95% CI: 0.53 to 0.69). The optimal MCR cut-point in this subgroup was 1.79, which achieved 55.6% sensitivity and 62.8% specificity, with 58.5% correctly classified. There was no significant difference in MCR compared to traditional ultrasound markers of adenomyosis. CONCLUSIONS: In a population undergoing hysterectomy for benign and non-obstetric indications, the MCR applied to preoperative ultrasound was only weakly associated with a histological diagnosis of adenomyosis.

Telehealth for gynaecology outpatients during the COVID-19 pandemic: Patient and clinician experiences.

BACKGROUND: The COVID-19 pandemic has necessitated alterations in provision of health care and how patients access it. Telehealth has replaced traditional face-to-face outpatient clinics in an unprecedented manner. This study aimed to assess overall patient and clinician satisfaction with telehealth consultations, to establish acceptability of telehealth during pandemic and non-pandemic times, and document feedback. MATERIALS AND METHODS: A prospective observational study involving women presenting to a general gynaecology outpatient department was performed. Women who attended for consultation between 13 July and 4 September 2020 were invited to participate in a questionnaire following their telehealth appointment. Clinicians consulting in the outpatient department were invited to complete a questionnaire at the end of the eight-week study period. Satisfaction, utility and acceptability data were obtained using visual analogue scales (VAS). RESULTS: Twenty-six out of 56 (46.4%) clinicians and 124/870 (14.3%) patients completed the questionnaire. Patients who responded were older and more likely to have been born in Australia than women who did not (P = 0.0355 and P = 0.005, respectively). Overall patient satisfaction with telehealth was high (median VAS (interquartile range), 8.6 (5.6-9.8)). More women found telehealth to be acceptable during a pandemic than afterward (8.9 vs 6.6, P < 0.0001). Clinicians were less satisfied with telehealth than patients (7.1 vs 8.6, P = 0.02); however, most would be happy to continue using telehealth in non-pandemic times (7.0 (6.2-9.8)). CONCLUSION: Telehealth consultations allow provision of gynaecological care at a time when reducing risk of infection to patients and staff is paramount. Telehealth gynaecology consultations are efficient and convenient without significant detriment to patient or clinician satisfaction.

Preoperative Imaging in Patients with Deep Infiltrating Endometriosis: An Important Aid in Predicting Depth of Infiltration in Rectosigmoid Disease.

STUDY OBJECTIVE: To determine the diagnostic accuracy of specialist-performed transvaginal ultrasound (TVUS) and pelvic magnetic resonance imaging (MRI) modalities in predicting depth of deep infiltrating endometriosis (DIE) of the rectosigmoid by comparison with histologic specimens obtained at surgery. DESIGN: A retrospective analysis, which met the Standards for Reporting of Diagnostic Accuracy Studies (2015) guidelines for a diagnostic accuracy study. SETTING: Tertiary teaching hospital. PATIENTS: A total of 194 cases who underwent preoperative discussion at the gynecologic endosurgery unit multidisciplinary meeting between January 2012 and December 2019 were eligible for inclusion. INTERVENTIONS: Retrospective assessment of the accuracy of TVUS and MRI in predicting histologic depth of rectosigmoid DIE after operative management. MEASUREMENTS AND MAIN RESULTS: Al total of 135 surgeries were performed for DIE; 20 underwent a rectal shave, 14 had a disc/wedge resection, 38 an anterior/segmental resection, and 63 had no rectosigmoid surgery. Of the 52 patients with full-thickness rectal wall excision, all patients had at least one imaging modality available for review; 42 (81%) had both. At least one imaging modality was in agreement with histologic depth in 48 cases (92%) (sensitivity, 94%; specificity, 50%; positive predictive value [PPV], 97.9%; negative predictive value [NPV], 25.0%; area under the receiver operating curve, 0.720; 95% confidence interval, 0.229-1.000). When TVUS was assessed in isolation, the test remained sensitive for any rectal wall involvement (sensitivity, 93.6%; specificity, 50.0%; PPV, 97.8%; NPV, 25.0%; area under the receiver operating curve, 0.718; 95% confidence interval, 0.227-1.000). When only MRI was assessed, the test demonstrated both high sensitivity and specificity for rectal wall disease (sensitivity, 86.4%; specificity, 100%; PPV, 100%; NPV, 14.2). CONCLUSION: Specialist-performed TVUS and MRI are accurate in predicting depth of disease in rectosigmoid endometriosis. These modalities were similar in their diagnostic performance at assessing depth of rectal wall involvement, and their use is justified in the preoperative planning of these gynecologic surgeries.

When pain is not the whole story: Presenting symptoms of women with endometriosis.

BACKGROUND: Endometriosis affects one in nine Australian women of reproductive age, and is often associated with pain and infertility. However, many women may be asymptomatic, or present with alternative symptoms. AIM: To identify reasons for initial specialist referral among patients with endometriosis. MATERIAL AND METHODS: Patients were identified as having endometriosis intraoperatively based on International Classification of Diseases coding. Operation reports were reviewed and graded for severity of disease. This cohort was then retrospectively audited to identify reasons for initial referral to the general gynaecology, endosurgery, gynae-oncology, reproductive medicine outpatient departments (OPD) at the Mercy Hospital for Women in Melbourne between 1 February 2015 and 31 December 2016. RESULTS: Three hundred patients were identified as having endometriosis at laparoscopy, including 90 women with Stage IV disease. Patients were a mean (SD) age of 33.1 (7.6) years. While pain remained a common reason for referral (61.7% of referrals), 36.7% of women with Grade IV disease did not have pain included in their referral letter. Severe disease was associated with increased age (regression coefficient 0.05; 95% CI: 0.03-0.07, P < 0.01), but not with pain symptoms. Women referred with ovarian cysts or masses were more likely to be diagnosed with severe disease (regression coefficient 0.69; 95% CI: 0.37-1.01, P < 0.01). CONCLUSION: Although pelvic pain is not a good predictor for a diagnosis of endometriosis, it remains a common symptom among women with the disease. However, more than one in three patients with Grade IV endometriosis presented without mention of pain symptoms, encouraging clinicians to adopt a broader approach to the presenting symptoms of endometriosis.