Predictors of successful ring pessary use in women with pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management. AIM: To determine any association between history, clinical and four-dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success. MATERIALS AND METHODS: From November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least three months. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success. RESULTS: Of 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty-eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty- Two (50%) were still using the pessary at a three-month follow-up. Predictors associated with failure included being pre-menopausal (P = 0.031), a previous hysterectomy (P = 0.051), increasing genital hiatus and perineal body (Gh + Pb) (P = 0.013), posterior compartment prolapse (P = 0.027) and a larger hiatal area on Valsalva on TLUS (P = 0.049). Pre-menopausal status (P = 0.003), increasing Gh + Pb (P = 0.011) and previous hysterectomy (P = 0.001) remained significant on multivariate analysis. CONCLUSIONS: A history of previous hysterectomy is a predictor of pessary failure as are Gh+Pb on Valsalva and premenopausal status.

Is there a difference in the behaviour and subsequent management of ectopic pregnancies seen at first scan compared to those ectopic pregnancies which commence as pregnancies of unknown location?

AIMS: The primary aim was to assess whether ectopic pregnancies (EPs) visualised on primary scan behave differently to EPs initially characterised as pregnancies of unknown location (PUL). The secondary aim was to assess whether the EP group is more likely to have surgical management compared to the PUL ectopic pregnancy group. MATERIALS AND METHODS: Prospective observational study. Consecutive first trimester women presenting from November 2006 to March 2012 underwent transvaginal ultrasound (TVS). Women diagnosed with an EP on TVS were divided into two groups: visualised EPs noted on the first TVS, and PULs which subsequently developed into EPs. Twenty-five historical, clinical, biochemical and ultrasonographic variables were collected. Different management strategies (expectant, medical, surgical) once an EP was confirmed on TVS were recorded. Univariate analysis was performed to compare differences between the two groups as well as rates for the three final management strategies. RESULTS: A total of 3341 consecutive women underwent TVS. On initial scan, 86.2% were classified as intrauterine pregnancy, 8.8% as PUL and 5.0% as EP (145 tubal/23 nontubal EPs). There were 194 tubal EPs in final analysis: 49 of 194 (25.3%) initially classified as PUL and 145 of 194 (74.7%) diagnosed as EP at primary TVS. When comparing the EP to the PUL EP group, the pain scores were 3.34 versus 1.91 (P-value < 0.001), the mean sac diameters were 35.2 versus 18.5 mm (P-value = 0.0327), and the volume of the EP masses were 8.21E+04 versus 1.40E+04 (P-value = 0.0341). Cumulative surgical intervention rate was significantly higher in EP compared to PUL EP group (P-value = 0.036). CONCLUSIONS: EPs seen at the first ultrasound scan appear to be more symptomatic, larger in diameter and volume compared to EPs which started as PULs. Cumulative surgical intervention rate was noted to be higher in this group with EP seen on ultrasound at the outset.

Uterine didelphys with dicavitary twin gestation: A case report.

Uterine didelphys is a rare type of congenital uterine anomaly resulting from incomplete fusion of the paramesonephric ducts during embryogenesis. We report the case of a 27-year-old multiparous woman who presented with ovulation-induced dicavitary dichorionic diamniotic twins in known uterine didelphys. At 29 + 5 weeks of gestation, the patient had preterm prelabour rupture of membranes followed by threatened preterm labour in the right uterus only, which settled with tocolysis. The pregnancy continued for a further 9 days, at which time uterine tightenings returned and the right cervix was fully dilated, resulting in successful vaginal delivery of the first twin, leaving the placenta in situ. The left uterus and cervix remained quiescent for a further 24 h before contractions returned, resulting in emergency caesarean section, with the successful delivery of the second twin. As a rare phenomenon, there is sparse literature on the management of dicavitary twin gestation in uterine didelphys. This case report adds to the evidence for independent functioning of uteri and cervices in cases of uterine didelphys which may enable interval delivery delay in this cohort with known increased risk of preterm birth.