The use of power Doppler colour scoring to predict successful expectant management in women with an incomplete miscarriage.

OBJECTIVE: To evaluate whether the use of power Doppler to confirm the presence or absence of blood flow within retained products of conception (RPC) in women with an incomplete miscarriage can predict subsequent successful expectant management. METHODS: Prospective observational study in the Acute Gynaecology and Early Pregnancy Unit (AGEPU) at Nepean Hospital from November 2006 to February 2009. Incomplete miscarriage was defined by the presence of a measurable focus of hyperechoeic material, in three planes, within the endometrial cavity using two-dimensional greyscale transvaginal ultrasound (TVS). Subjective qualitative power Doppler colour scoring (PDCS) of the RPC was performed. The vascularization of the RPC was scored using the colour scoring system of the International Ovarian Tumour Analysis (IOTA) group. PDCS 1 meant absence of vascularity, PCDS 2 represented minimal vascularity, PDCS 3 rather strong vascularity and PDCS 4 very strong vascularity. The correlation between the PDCS and successful expectant management of miscarriage was analysed. The volume of RPC was calculated using the ellipsoid formula and then compared with both the PDCS and the outcome of expectant management. Successful expectant management was defined as the resolution of symptoms and the absence of RPC on follow-up TVS. RESULTS: A total of 1395 consecutive pregnant women underwent TVS. Of them, 198 women were diagnosed with an incomplete miscarriage; 172 were managed expectantly. Complete data were available on 158 cases. In total 84.8% (134/158) were managed successfully whilst 15.2% (24/158) failed expectant management. Of the total, 89% (121/136) of women with a PDCS 1 had successful expectant management compared with 57.1 (8/14) with PDCS 2 and 62.5% (5/8) with PDCS 3. Comparing absence of flow (PDCS 1) to presence of flow (PDCS 2 or more), the rate of success was significantly higher in the first group (89 versus 60.9%, Fisher's exact test P= 0.00136). In the prediction of success, the absence of flow showed a sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio of 90.3, 37.5, 89, 40.9% and 1.445 (95% confidence interval: 1.055-1.979), respectively. There was no correlation between the volume of RPC and the PDCS; and there was no relationship between the volume of RPC and the success of expectant management. CONCLUSIONS: PDCS can predict the likelihood of successful expectant management of incomplete miscarriage. The absence of flow on power Doppler is associated with a significant improvement in the rate of successful expectant management. This new approach may be helpful in quantifying the chances of successful expectant management in those women with an incomplete miscarriage at the primary scan.

Mirena intra-uterine system: does it improve long term symptoms in women with chronic pelvic pain and/or endometriosis after laparoscopy? A multicentre randomized controlled trial.

BACKGROUND: Chronic pelvic pain (CPP) is a complex clinical scenario, which affects 15% of women. The published literature lacks a consistent definition of CPP. However according to Vercillini et al., CPP is defined by the duration and type of pelvic pain. CPP is present if the pelvic pain persists for more than 3 months duration and is constant or intermittent, cyclical or noncyclical in nature. Four types of pelvic pain have also been described and these include: cyclical pain during menstruation (dysmenorrhoea), deep dyspareunia, dyschezia and noncyclical pelvic pain. Therefore for the purposes of this study, CPP will be defined by these aforementioned types of pelvic pain and duration. METHODS: Multi-centre randomised controlled trial comparing Mirena IUS versus expectant management in women with CPP and/or dysmenorrhoea who undergo laparoscopic surgery. All women aged 18 - 45 years with CPP scheduled for laparoscopy will be eligible for inclusion. Women with a non-gynecological cause of pelvic pain, contraindications to the use of Mirena IUS, previous hysterectomy, contraindications to laparoscopy and/or general anesthesia, use of hormonal treatment in the preceding three months, underlying gynaecological malignancies or known ovarian cysts other than endometriomata will be excluded. Importantly, all randomised women with endometriosis noted at the time of surgery will have the disease excised laparoscopically. Routine excision of endometriosis at laparoscopy will be performed according to the anatomical location and type (superficial or deep infiltrating endometriosis (DIE)). Women will be followed for up to 24 months after laparoscopic surgery. RESULTS: The primary outcome measure is improvement of pelvic pain and/or of dysmenorrhoea post-laparoscopic surgery for women. Assuming a 30% reduction in pain for the expectantly managed group in order to detect a reduction in pain in the study group of 50% with an alpha of 0.05 and a beta of 0.20, the sample size was estimated at a minimum of 103 women per trial arm. DISCUSSION: This trial will provide evidence to validate the effectiveness or otherwise of progestogen-releasing IUS in treating women with CPP who undergo laparoscopy surgery. The pros and cons of both trial arms will offer guidance to clinicians in making the right treatment choice.

The value of laparoscopic skills courses.

OBJECTIVES: To evaluate the effectiveness of 'hands-on' laparoscopic skills course. METHODS: A prospective observational study conducted between May 2005 and June 2006. All gynaecologists who attended 'hands-on' laparoscopic skills course held over a five-day period were assessed initially and at the end of the intensive course. Subjective assessment involved each attendee self-scoring their own knowledge in laparoscopy in different fields; this was done using visual analog scoring (VAS). Objective assessment was done through multiple choice questions (MCQs) and motor skill tasks. The difference between the performances of each of the candidates at pre- and post-course periods was evaluated using the Wilcoxon signed rank test. P-values < 0.05 represented statistical significance. SETTING: Centre for Advanced Reproductive Endosurgery (CARE), Royal North Shore Hospital, University of Sydney, Sydney, Australia. RESULTS: Twenty-four consecutive gynaecologists have been enrolled in the study - 14 were specialists and ten were obstetrics and gynaecology trainees. Mean age was 44.4 years (range 35-58 years). Pre- and post-course subjective assessment measuring VAS improved significantly for all variables. Objective measurements of pre- and post-course mean MCQ results also improved significantly from 71% to 84.5%, respectively (P-value < 0.0001). There was dramatic improvement in the performing of motor skills in the dry laboratory. CONCLUSIONS: Laparoscopic skills workshops can improve both knowledge base and motor skills. Such courses result in a short-term measurable improvement. Future studies should focus on assessing the impact of such 'hands-on' courses to see if these skills are transferred to the operating room.

Diagnosing twins in early pregnancy.

Multiple pregnancy has increased in frequency as a result of the ageing maternal population as well as the advent and wider availability of assisted reproductive technologies. Higher-order pregnancies are associated with increased morbidity and mortality for both the foetuses and mother. The introduction of transvaginal ultrasound has made accurate diagnosis of twin pregnancy, determination of chorionicity and subsequent planning of these high-risk pregnancies a common part of obstetric care. In this article, we critically evaluate the role of transvaginal ultrasound in the diagnosis of twin pregnancies.

Recognising gestational trophoblastic disease.

Gestational trophoblastic disease (GTD) is a group of interrelated tumours originating from the placenta. Hydatidiform molar (HM) pregnancy is the most common form of GTD; this includes both partial hydatidiform molar (PHM) and complete hydatidiform molar (CHM) pregnancies. The importance of such a condition derives from its potential for persistent trophoblastic disease; this is noted to be more common after a CHM (10-20%) compared to a PHM (0.1-11%). The recent routine use of high-resolution trans-vaginal ultrasound (TVS) in early pregnancy has improved the recognition and thus pre-surgical diagnosis of molar pregnancy. Pre-surgical recognition aids planning of surgery, decreases intra-operative complications and identifies women with potential persistent trophoblastic disease. Despite the introduction of TVS, its performance in preoperative diagnosis is quite poor. This is primarily because of the histomorphometric features of the hydropic villi. A significant proportion of HM cases demonstrates minimal hydropic change in the first trimester and therefore is likely to remain unidentifiable by ultrasound examination prior to surgical evacuation, even with improved sonographer expertise. The overall sensitivity for the ultrasound diagnosis of HM is 50-86%. Ultrasound diagnosis of CHM can be made in approximately 80% of the cases, whilst ultrasound diagnosis of PHM is less accurate and nearly 70% of cases will be missed. Correlation of the ultrasonographic findings with human chorionic gonadotropin levels can further improve the recognition of HM pregnancy pre-surgery. Although ultrasound can be helpful in the diagnosis of molar pregnancies, histological confirmation is mandatory. Histological confirmation post-curettage is still the gold standard for the diagnosis of GTD. In this article, we critically evaluate the role of TVS in the pre-surgical recognition of GTD.

What determines the need to morcellate the uterus during total laparoscopic hysterectomy?

STUDY OBJECTIVE: To identify factors associated with the need to perform uterine morcellation during total laparoscopic hysterectomy (TLH). A secondary aim was to establish new cut-offs based on uterine weight for the probability of morcellation. DESIGN: Prospective observational study (Canadian Task Force Classification II-2). SETTING: Tertiary referral laparoscopic unit. PATIENTS: All women scheduled to undergo TLH in the study period were included. INTERVENTIONS: Age, parity, operating time, estimated blood loss, and final uterine weight at histology were recorded. Logistic regression analysis was performed to determine the factors associated with the need to perform uterine morcellation at the time of TLH. Multiple imputation (MI) was used to impute missing values. MEASUREMENTS AND MAIN RESULTS: A total of 112 consecutive women underwent TLH and were included in the final analysis. In all, 56 (50%) of 112 women underwent TLH without morcellation (i.e., it was possible to deliver the uterine specimen vaginally) and 56 (50%) of 112 women underwent TLH with morcellation (i.e., it was not possible to deliver the uterine specimen vaginally and, therefore, morcellation was performed). Median age in each group was 45 and 46 years, respectively. Sixteen (70%) of 23 nulliparous women underwent morcellation compared with 40 (45%) of 89 parous women. Multivariable logistic regression analysis revealed that nulliparity (OR = 6.45, 95% CI = 1.74-23.9) and uterine weight (OR/100-g increase = 4.97, 95% CI = 2.13-11.6) increased the odds of morcellation. All 20 women with a uterine weight of at least 350 g required morcellation. Based on the MI analysis results, uterine weight was at least 350 g in 1 of 5 patients, with 99.5% of the women having uterine weight of 350 g or more that required morcellation. CONCLUSION: Nulliparity and increasing uterine weight are associated with the need to perform uterine morcellation in TLH. Studies are needed to find a reliable method for estimating uterine weight preoperatively.

The hCG ratio can predict the ultimate viability of the intrauterine pregnancies of uncertain viability in the pregnancy of unknown location population.

BACKGROUND: To determine whether hCG ratio at 48 h can predict ultimate viability of intrauterine pregnancies of uncertain viability (IPUVs) in the pregnancy of unknown location (PUL) population. METHODS: Prospective observational study from June 2001 to October 2004. All women classified with PUL had serum hCG levels measured at 0 and 48 h to calculate hCG ratio (hCG 48/hCG 0 h). All women were followed up until final diagnosis: failing PUL, viable and non-viable intrauterine pregnancy (IUP), ectopic pregnancy. Those PULs found to have an IPUV at follow-up transvaginal ultrasound scan (TVS) were included in final analysis. RESULTS: During the study period, 12,572 consecutive first trimester women were scanned. One thousand and three (8%) women were classified PULs. Three hundred and seventy-nine (37.8%) PULs were confirmed IPUVs at follow-up scan. Complete data from 334 IPUVs were analyzed: 82.6% (276/334) viable IUPs and 17.4% (58/334) non-viable IUPs. Median hCG ratio was greater in viable IUPs [2.32, inter-quartile range (IQR) 1.16-4.77] compared with non-viable IUPs 1.83 (IQR 0.97-4.60). Sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratios of an hCG ratio >2.00 for the prediction of a viable IUP are 77.2%, 95.8%, 86.6%, 90.9%, 15.5, 0.24, respectively. In our population, an hCG ratio >2.00 increases the odds for a viable IUP from 0.42 to 6.46 post-test. CONCLUSIONS: The hCG ratio is significantly higher in those IPUVs which become viable IUPs compared with non-viable IUPs. New cut-offs for the hCG ratio need to be evaluated for the prediction of viability in the IPUV group of PULs.

Is ultrasound the new gold standard for the diagnosis of ectopic pregnancy?

Ultrasound technology and in particular the use of transvaginal imaging has taken the guesswork out of ectopic pregnancy diagnosis. The vast majority of ectopic pregnancies can and should be diagnosed with a high degree of certainty before management is commenced. More and more women with ectopic pregnancy are eligible for nonsurgical intervention because ultrasound has enabled clinicians to make the diagnosis much earlier in its natural history. We believe that laparoscopy, traditionally the gold standard in diagnosis of ectopic pregnancy, should not be used in modern management. There is more and more evidence to support the use of transvaginal ultrasound as the primary diagnostic tool for ectopic pregnancy. In this review we hoped to demonstrate that transvaginal ultrasound is the new gold standard for the diagnosis of ectopic pregnancy.