Natural history of endometriosis in pregnancy: ultrasound study of morphology of deep endometriosis and ovarian endometrioma.

OBJECTIVE: To assess the morphological appearance of deep endometriosis and ovarian endometrioma in pregnancy using pelvic ultrasound examination. METHODS: This was a prospective observational cohort study conducted over 3 years at University College London Hospital, which is a tertiary level referral unit for early pregnancy complications and an accredited endometriosis center. All women who participated provided written consent and were invited for surveillance ultrasound examination at the time of their routine scans in pregnancy. All scans were performed by a single operator to eliminate interobserver variability. The change in size of ovarian endometrioma and nodules was reported as change in their mean diameter. Ovarian endometrioma with irregular thick inner walls, hyperechoic papillary projections and/or high vascularity and hyperechoic nodules with moderate to high vascularity were reported as decidualized. RESULTS: Sixty-five women with a live, normally sited pregnancy and concomitant ultrasound features of deep and/or ovarian endometriosis were included in the study. The median age of the study population was 34 (range, 23-44) years, and the median gestational age at presentation was 7 + 6 (range, 3 + 6 to 18 + 0) weeks. From the cohort, 47/65 (72%) were nulliparous, 48/65 (74%) had a previous diagnosis of endometriosis and 19/65 (29%) conceived via in-vitro fertilization. There were 10/65 (15% (95% CI, 7-24%)) women with ovarian endometrioma alone, 28/65 (43% (95% CI, 31-55%)) with endometriotic nodules alone and the remaining 27/65 (42% (95% CI, 30-54%)) had both. Of the women with ovarian endometrioma who underwent follow-up, 29/34 (85% (95% CI, 73-97%)) experienced cyst regression, 2/34 (6% (95% CI, 0-14%)) experienced cyst growth, and in 3/34 (9% (95% CI, 0.0-18%)) women, cyst size was unchanged. In 10/34 (29% (95% CI, 14-45%)), there was complete resolution of all cysts. Of the women with nodules who underwent follow-up, 43/51 (84% (95% CI, 74-94%)) experienced nodule regression, 2/51 (4% (95% CI, 0-9%)) experienced nodule growth and, in 6/51 (12% (95% CI, 3-21%)) women, nodule size was unchanged. In 4/51 (8% (95% CI, 0-15%)) women, there was complete resolution of all nodules. In 5/37 (14% (95% CI, 3-25%)) women who attended postnatal follow-up, complete resolution of all endometriotic lesions occurred during pregnancy. In 10/34 (29% (95% CI, 14-45%)) women with ovarian endometrioma and 27/51 (53% (95% CI, 39-67%)) women with nodules, a pattern of growth was observed in the first and second trimesters, followed by regression later in pregnancy. Features of decidualization were observed in 17/34 (50% (95% CI, 33-67%)) women with ovarian endometrioma, most commonly in the first trimester, and in 25/51 (49% (95% CI, 35-63%)) women with nodules, most commonly in the second trimester. CONCLUSIONS: For the majority of women, despite features of decidualization being common in the first and second trimesters, ovarian endometrioma and deep nodules regress during pregnancy. Morphological changes of endometriosis in pregnancy are difficult to differentiate from characteristics of malignant lesions. Better understanding of the appearance of endometriosis in pregnancy is vital to minimize intervention and help counsel women regarding their condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence of deep and ovarian endometriosis in women attending a general gynecology clinic: prospective cohort study.

OBJECTIVES: To assess using transvaginal ultrasound the prevalence of deep and ovarian endometriosis in premenopausal women attending a general gynecology clinic. We also investigated whether the presence of endometriosis was associated with various demographic factors and other pelvic abnormalities. METHODS: This was a prospective observational cohort study carried out between February 2019 and October 2020. Consecutive premenopausal women who attended our general gynecology clinic underwent pelvic ultrasound examination, performed by a single experienced operator. Pregnant women and those with a history of hysterectomy or oophorectomy were excluded. The primary outcome was the prevalence of deep and/or ovarian endometriosis. Secondary outcomes were the anatomical distribution of endometriotic lesions and the association of endometriosis with demographic characteristics and various pelvic abnormalities, which were analyzed using logistic regression and multivariable analysis. RESULTS: A total of 1026 women were included in the final study sample, of whom 194 (18.9% (95% CI, 16.6-21.4%)) had sonographic evidence of deep and/or ovarian endometriosis. Of the 194 women diagnosed with endometriosis, 106 (54.6% (95% CI, 47.4-61.8%)) were diagnosed with endometriotic nodules only, 26 (13.4% (95% CI, 9.0-19.0%)) with ovarian endometriomas only, and 62 (32.0% (95% CI, 25.5-39.0%)) women had evidence of both. There was a total of 348 endometriotic nodules in 168 women, located most frequently in the retrocervical area (166/348; 47.7% (95% CI, 42.4-53.1%)), uterosacral ligaments (96/348; 27.6% (95% CI, 23.0-32.6%)) and bowel (40/348; 11.5% (95% CI, 8.3-15.3%)). Multivariable analysis found significant positive associations between endometriosis and both adenomyosis (odds ratio (OR), 1.72 (95% CI, 1.10-2.69); P = 0.02) and pelvic adhesions (OR, 25.7 (95% CI, 16.7-39.3); P < 0.001), whilst higher parity (OR, 0.44 (95% CI, 0.24-0.81); P = 0.03) and history of Cesarean section (OR, 0.18 (95% CI, 0.06-0.52); P = 0.002) were associated with a lower occurrence of endometriosis. A total of 75/1026 women (7.3% (95% CI, 5.8-9.1%)) underwent laparoscopy within 6 months of pelvic ultrasound examination. There was very good agreement between ultrasound and surgical findings, with a kappa value of 0.84 (95% CI, 0.69-0.99). CONCLUSIONS: Deep and/or ovarian endometriosis was present in nearly one in five women attending a general gynecology clinic. There were significant positive associations with adenomyosis and pelvic adhesions and negative associations with higher parity and previous Cesarean section. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A prospective, up-down sequential allocation study investigating the effectiveness of vital capacity breaths using high-flow nasal oxygenation versus a tight-fitting face mask to pre-oxygenate term pregnant women.

BACKGROUND: The role of high flow nasal oxygenation (HFNO) for pre-oxygenation before obstetric general anaesthesia remains unclear. This study aimed to determine the number of vital capacity breaths using HFNO required to pre-oxygenate 90% of parturients to an end-tidal oxygen concentration fraction (FETO2) of ≥0.90 (termed EN90). METHODS: Using up-down, sequential allocation trial design, volunteer term parturients undergoing caesarean delivery were investigated with HFNO with their mouth closed, followed by mouth open, and if FETO2 ≥0.90 was not achieved after a maximum of 20 vital capacity breaths, pre-oxygenation was attempted with a face mask. The primary outcome was the number of vital capacity breaths required using HFNO (mouth open and closed) to achieve EN90. Secondary outcomes included assessment of EN90 using mouth open versus mouth closed and face mask pre-oxygenation, maternal satisfaction and evaluation of fetal cardiotocography. RESULTS: Twenty women at term were recruited. Successful pre-oxygenation occurred in 4 (20%), 3 (15%) and 14 (70%) women with HFNO mouth closed, HFNO mouth open, and via face mask respectively. At up to 20 vital capacity breaths, face mask pre-oxygenation was more successful at achieving EN90 compared with both HFNO with a closed (P=0.006) or open (P=0.001) mouth. Closed mouth HFNO did not outperform open mouth pre-oxygenation. CONCLUSION: Face mask pre-oxygenation is more effective at achieving EN90 compared with to HFNO within a clinically acceptable number of vital capacity breaths. Further studies are needed to determine the role of HFNO in optimising the time before desaturation and for apnoeic oxygenation in term parturients.

Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery.

BACKGROUND: Whilst validated quality-of-recovery (QoR) tools exist for general surgery, there is no specific obstetric equivalent. We aimed to develop and evaluate a modified QoR score after elective Caesarean delivery. METHODS: Twenty-two obstetric specific items were selected following review and modification of the QoR-40 survey by 16 experts and interviews with 50 stakeholders. Item selection was based on relevance to Caesarean delivery and endorsement by >66% of stakeholders. Items were tested on women pre-delivery, at 24 h, and 25 h post-delivery. An 11-item obstetric-specific QoR score (ObsQoR-11) was created based on correlation with a numerical rating scale (NRS) of global health status (r>0.20) at all time points. Reliability, responsiveness, acceptability, and feasibility were tested. RESULTS: One hundred and fifty-two women responded to the 22-item questionnaire pre-delivery (complete in 146), 100 at 24 h, and 10 at 25 h. The ObsQoR-11 correlated with the global health status NRS (r=0.53; 95% confidence interval: 0.43-0.62; P<0.0001) and discriminated good vs poor recovery (NRS score ≥70 vs <70 mm) at 24 h. There was a negative correlation between the ObsQoR-11 score at 24 h and hospital length of stay (r=-0.39; P=0.003). ObsQoR-11 was reliable (internal consistency: 0.85; split-half 0.76; test-retest intra-class correlation coefficient ri>0.6 in 82% of items) and responsive (Cohen effect size: 1.36; standardised response mean: 0.85). A longer 22-item ObsQoR had high (97%) completion rates and short (median: 2 min) completion times. CONCLUSIONS: The ObsQoR-11 provides a valid, reliable, and responsive global assessment of recovery after elective Caesarean delivery.

A Systematic Review of Postoperative Pain Outcome Measurements Utilised in Regional Anesthesia Randomized Controlled Trials.

INTRODUCTION: Regional anesthesia is a rapidly growing subspecialty. There are few published meta-analyses exploring pain outcome measures utilised in regional anesthesia randomized controlled trials (RCTs), which may be due to heterogeneity in outcomes assessed. This systematic review explores postoperative pain outcomes utilised in regional anesthesia RCTs. METHODS: A literature search was performed using three databases (Medline, Embase, and CINAHL). Regional anesthesia RCTs with postoperative pain as a primary outcome were included if written in English and published in one of the top 20 impact factor journals between 2005 and 2017. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS: From the 31 included articles, 15 different outcome measures in total were used to assess postoperative pain. The most commonly (16/31) used outcome measures were verbal numerical grading of pain out of 10, total opioid consumption, and visual analogue scale 10 cm (VAS). The need for analgesia was used as an outcome measure where studies did not use a pain rating score. Ten studies reported pain scores on activity and 27/31 studies utilised ≥2 pain outcomes. Time of measurement of pain score also varied with a total of 51 different time points used in total. CONCLUSION: Analysis of the articles demonstrated heterogeneity and inconsistency in choice of pain outcome and time of measurement within regional anesthesia studies. Identification of these pain outcomes utilised can help to create a definitive list of core outcomes, which may guide future researchers when designing such studies.

Identification and validation of QTLs conferring resistance to sorghum downy mildew (Peronosclerospora sorghi) and Rajasthan downy mildew (P. heteropogoni) in maize.

We have mapped the quantitative trait loci (QTLs) conferring resistance to sorghum downy mildew (Peronosclerospora sorghi; SDM) and Rajasthan downy mildew (P. heteropogoni; RDM), two species of DM prevalent throughout India. QTL mapping was carried out on a backcross population of 151 individuals derived from a cross between CM139 (susceptible parent) and NAI116 (highly resistant to both SDM and RDM). Heritability estimates were 0.74 for SDM and 0.67 for RDM. Composite interval mapping combined with a linkage map constructed with 80 simple sequence repeat (SSR) markers resulted in the identification of three QTLs (one each on chromosomes 2, 3 and 6) for SDM resistance and two QTLs (one each on chromosomes 3 and 6) for RDM resistance, all of which were contributed by NAI116. The significance of the major QTL on chromosome 6 (bin 6.05) that confers resistance to diverse DMs in tropical Asia, including SDM and RDM in India, was also verified. The results confirmed that some common QTLs contribute to both SDM and RDM resistance, while additional loci might specifically govern resistance to SDM. The QTL information generated in this study provide information that will aid in undertaking an integrated breeding strategy for the transfer of resistance to SDM and RDM in maize lines using marker-assisted selection.

Identification of QTLs conferring resistance to downy mildews of maize in Asia.

Downy mildew is one of the most destructive diseases of maize in subtropical and tropical regions in Asia. As a prerequisite for improving downy mildew resistance in maize, we analyzed quantitative trait loci (QTLs) involved in resistance to the important downy mildew pathogens--Peronosclerospora sorghi (sorghum downy mildew) and P. heteropogoni (Rajasthan downy mildew) in India, P. maydis (Java downy mildew) in Indonesia, P. zeae in Thailand and P. philippinensis in the Philippines--using a recombinant inbred line population derived from a cross between Ki3 (downy mildew resistant) and CML139 (susceptible). Resistance was evaluated as percentage disease incidence in replicated field trials at five downy mildew 'hotspots' in the four countries. Heritability estimates of individual environments ranged from 0.58 to 0.75 with an across environment heritability of 0.50. Composite interval mapping was applied for QTL detection using a previously constructed restriction fragment length polymorphism linkage map. The investigation resulted in the identification of six genomic regions on chromosomes 1, 2, 6, 7 and 10 involved in the resistance to the downy mildews under study, explaining, in total, 26-57% of the phenotypic variance for disease response. Most QTL alleles conferring resistance to the downy mildews were from Ki3. All QTLs showed significant QTL x environment interactions, suggesting that the expression of the QTL may be environment-dependent. A strong QTL on chromosome 6 was stable across environments, significantly affecting disease resistance at the five locations in four Asian countries. Simple-sequence repeat markers tightly linked to this QTL were identified for potential use in marker-assisted selection.