Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section.

OBJECTIVES: To investigate the prevalence and location of pelvic adhesions in women with a history of Cesarean section and to identify risk factors for their formation and symptoms associated with their presence. METHODS: This was a prospective observational study of women in whom one or more Cesarean sections had been performed > 12 months previously and who attended for a gynecological ultrasound examination. In all women, both transvaginal and transabdominal scans were performed in order to identify the presence of pelvic adhesions. Medical and surgical history was recorded and a structured questionnaire was used to enquire about any history of pelvic pain and urinary symptoms. RESULTS: A total of 308 women were recruited into the study. On ultrasound examination, 139 (45.1% (95% CI, 39.7-50.7%)) women showed evidence of adhesions within the pelvis. Adhesions in the vesicouterine pouch were the most common and were found in a total of 79 (25.6% (95% CI, 20.7-30.5%)) women. In women with a history of no surgery other than Cesarean section(s) (n = 220), an increasing number of Cesarean sections (odds ratio (OR) 3.4 (95% CI, 2.1-5.5)) and a postoperative wound infection (OR 11.7 (95% CI, 3.5-39.5)) increased the likelihood of adhesions developing in the anterior pelvic compartment. There was a significant association between the presence of anterior compartment adhesions and chronic pelvic pain. Multivariable logistic regression analysis identified anterior abdominal wall adhesions (OR 2.4 (95% CI, 1.0-5.9)) and any adhesions present on ultrasound scan (OR 2.6 (95% CI, 1.2-5.7)) as independent predictors of chronic pelvic pain. CONCLUSIONS: Pelvic adhesions are present in more than a third of women with a history of Cesarean section and they are associated with chronic pelvic pain.

Visualization of ureters on standard gynecological transvaginal scan: a feasibility study.

OBJECTIVE: To investigate the feasibility of identifying pelvic segments of normal ureters and measuring their size on standard transvaginal ultrasound examination. METHODS: This was a prospective observational study from June to July 2012. All women in the study underwent a transvaginal ultrasound examination performed for various indications either by an expert or by an intermediate-level operator. A standardized assessment of the pelvic organs was performed, recording any congenital or acquired uterine pathology and ovarian abnormalities. Visualization of pelvic segments of both ureters was attempted in all cases. The success in finding the ureters, the time required to identify them and their dimensions at rest and while exhibiting peristalsis were all recorded. RESULTS: A total of 245 consecutive women were included in the study. In all women at least one ureter was successfully identified. Both ureters were seen in 227 women (92.7% (95% CI, 89.4-96.0%)). In 17 (6.9% (95% CI, 3.7-10.1%)) the left ureter was not seen and in one woman (0.4% (95% CI, 0.0-1.2%)) the right ureter could not be visualized (P < 0.001). There were no significant differences in the median time required to visualize the right and left ureters (9.0 (interquartile range (IQR), 6.0-14.0) s vs 8.0 (IQR, 6.0 -14.0) s, respectively; P = 0.9). The median diameter of the right ureter was 1.7 (IQR, 1.4-2.2) mm at rest and 2.9 (IQR, 2.4-3.6) mm during peristalsis. The median diameter of the left ureter was 1.9 (IQR, 1.6-2.3) mm at rest and 2.9 (IQR, 2.4-3.6) mm during peristalsis. CONCLUSION: Pelvic segments of normal ureters can be identified in most women on transvaginal ultrasound examination. Visualization of the ureters could be integrated into the routine pelvic ultrasound examination, particularly in women presenting with pelvic pain or in those with suspected pelvic endometriosis.

Reproducibility of assessment of severity of pelvic endometriosis using transvaginal ultrasound.

OBJECTIVE: To examine the reproducibility of assessment of severity of pelvic endometriosis by transvaginal sonography (TVS). METHODS: This was a prospective observational study conducted from August 2006 to July 2009 in two academic departments of obstetrics and gynecology. Women with clinically suspected or proven pelvic endometriosis were invited to join the study. All patients included underwent TVS performed by two observers and a laparoscopic assessment of pelvic endometriosis. The ultrasound observers were blinded to each other's results. The reproducibility of TVS was examined by evaluation of interobserver agreement for the American Society of Reproductive Medicine (ASRM) score by Bland-Altman analysis and the stage and the diagnosis of deeply infiltrating endometriosis (DIE) by calculation of kappa coefficients. Agreement between the findings on TVS for each observer and those on laparoscopy was also evaluated. RESULTS: Thirty-four patients were recruited to the study, and TVS was performed by two ultrasound observers. Of these patients, one did not undergo laparoscopy and was therefore excluded from the final analysis. No endometriosis was found in 12 (36.4%) patients. One patient (3%) had minimal disease, one (3%) had mild disease, five (15.2%) had moderate disease and 14 (42.4%) had severe disease. Interobserver agreement was very good for disease classification on TVS (Cohen's kappa, 0.931). Agreement between TVS and laparoscopy findings was also very good (Cohen's kappa, 0.955 and 0.966 for the two examiners). For ASRM score on TVS, the interobserver 95% limits of agreement were -16.6 to 12.7, with a mean difference of -1.9 (95% CI, -4.35 to 0.71). CONCLUSION: TVS is a reproducible method for assessment of the severity of pelvic endometriosis and shows good agreement with findings on laparoscopy.

Value of transvaginal ultrasound in assessing severity of pelvic endometriosis.

OBJECTIVE: The objective of this study was to examine the ability of preoperative transvaginal ultrasound (TVS) scanning to assess the severity of pelvic endometriosis. METHODS: Consecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. The severity of endometriosis was assessed preoperatively using TVS and the findings were compared with the results obtained by laparoscopy using the American Society for Reproductive Medicine (ASRM) classification. RESULTS: In total, 201 women had preoperative TVS and laparoscopies. Of these, no endometriosis was found at laparoscopy for 62/201 (30.8%; 95% CI, 24.8-37.5), whereas 33/201 (16.4%; 95% CI, 11.9-22.2) had minimal endometriosis, 31/201 (15.4%; 95% CI, 11.1-21.1) had mild endometriosis, 27/201 (13.4%; 95% CI, 9.4-18.8) had moderate endometriosis and 48/201 (23.9%; 95% CI, 18.5-30.2) had severe endometriosis. The sensitivity and specificity of the TVS diagnosis of severe pelvic endometriosis were 0.85 (95% CI, 0.716-0.934) and 0.98 (95% CI, 0.939-0.994), respectively, and the positive and negative likelihood ratios were 43.5 (95% CI, 14.1-134) and 0.15 (95% CI, 0.075-0.295), respectively. Overall, there was a good level of agreement between ultrasound and laparoscopy in identifying absent, minimal, mild, moderate and severe disease (quadratic weighted kappa = 0.786). The mean ASRM score difference between TVS and laparoscopy in assessing severity of endometriosis was -2.398 (95% CI, -4.685 to -0.1112) and the limits of agreement were -34.62 (95% CI, -38.54 to -30.709) to 29.83 (95% CI, 25.91-33.74). CONCLUSIONS: TVS is a good test for assessing the severity of pelvic endometriosis. TVS is particularly accurate in detecting severe disease, which could facilitate more effective triaging of women for appropriate surgical care.

Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome?

OBJECTIVE: The aim of this study was to assess the natural history of ultrasonically diagnosed ovarian dermoid cysts in a large group of women who were managed expectantly, and to assess the factors that were associated with failure of expectant management. METHODS: Our database was searched for dermoid cysts diagnosed on ultrasonography by a single expert operator between 2001 and 2007 in this retrospective study. In women who opted for expectant management, demographic data including age, gravidity and parity were recorded. Indications for scan, site of cysts, dimensions and the outcomes of expectant management were also recorded. RESULTS: Two hundred and eighty-nine women were diagnosed with a total of 323 dermoid cysts by a single expert ultrasound operator. 93/289 (32.2%; 95% CI, 26.8-37.6%) women with 105/323 (32.5%; 95% CI, 27.4-37.6%) ovarian dermoid cysts were managed expectantly for longer than 3 months. The mean age at diagnosis was 33.8 (range, 13-79) years and the median duration of follow up was 12.6 (interquartile range, 7.6-29.3) months. The mean growth rate of dermoid cysts during follow up was 1.67 mm/year. There were no demographic or morphological features that could be used to predict the growth rate of dermoid cysts. After a period of expectant management, 24/93 (25.8%; 95% CI, 16.9-34.7%) women had surgical intervention. The risk of surgical intervention was significantly increased in younger women, those of parity > or = 2 and in women with bilateral cysts or larger-diameter cysts, and reduced in women with a past history of ovarian cyst. CONCLUSIONS: The success rate of expectant management of dermoid cysts is high and this approach should be considered as a viable alternative to surgical management.