A 24-months Follow-up Study of Individuals with Endometriosis using Transvaginal Ultrasound.

STUDY OBJECTIVE: To investigate the progression of deep infiltrating endometriosis using transvaginal ultrasound surveillance of patients undergoing conservative management. DESIGN: Retrospective single cohort. SETTING: Australian tertiary university hospital PATIENTS: One hundred twenty two women with endometriosis proven on transvaginal ultrasound who had not undergone surgical management. INTERVENTIONS: The progression of endometriosis lesions demonstrated on transvaginal ultrasound in women receiving conservative management over the course of 24 months. MEASUREMENTS AND MAIN RESULTS: A total of 122 patients fulfilled the inclusion criteria. All women had 2 ultrasounds that were performed at least 6 months apart. The median follow-up time was 490.5 days (255.4-725.6). At second scan, 22% (95% CI: 15-30%) of cohort experienced an increase in the number of endometriosis nodules compared to first scan, with 51% (95% CI: 42-60%) remaining static while 27% (95% CI: 19-35%) experienced a decrease. While there was no statistically significant difference in the volumes of uterosacral ligament, retro cervical, and bowel endometriosis, endometrioma volumes were significantly lower at second scan (Median = 3.24 mL, IQR = 0.6-16.87) as compared to the first scan (Median = 7.41 mL, IQR = 2.04-28.95), p <.001. CONCLUSION: Individuals with deep infiltrating endometriosis are unlikely to see significant disease progression over time. Both surgical and nonsurgical interventions are effective in managing endometriosis in terms of endometriotic nodule size and number, as measured by ultrasound.

Diagnostic Accuracy of Transvaginal Ultrasound and Magnetic Resonance Imaging for Adenomyosis: Systematic Review and Meta-Analysis and Review of Sonographic Diagnostic Criteria.

We aim to first systematically review and perform a meta-analysis of the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) and, second, to evaluate the accuracy of various sonographic diagnostic criteria for adenomyosis. A search of PubMed and Embase yielded 32 eligible studies. In diagnosing adenomyosis, the diagnostic performance of TVUS was found to be high and comparable to the performance of MRI. Of the eight sonographic criteria, only five were assessable. The best individual criterion was echogenic subendometrial lines and buds. Limited data exist for the various sonographic criteria, and further studies are required to compare their performance.

Biparietal diameter measurements using the outer-to-outer versus outer-to-inner measurement: A question of pedantry?

OBJECTIVES: To compare two methods of measuring fetal biparietal diameter (BPD) - outer-to-inner (BPDoi) vs. outer-to-outer (BPDoo) calliper placement - and to compare the differences in EFW calculated using the Hadlock 4 formula and other common EFW formulae. METHODS: A total of 543 fetuses underwent a single ultrasound prospectively performed by 40 sonographers between 14 and 40 weeks of gestation, taking into account the intra- and inter-observer variability. The measurements for each fetus consisted of BPDoi and BPDoo, and EFW is calculated from HC, AC and FL measurements. The difference between BPDoo and BPDoi was estimated, and this difference was compared with gestational age using linear regression. Translational equations that allow interconversion of the two parameters were derived. EFW calculated from four different formulae using various combinations of biometric measurements was compared. RESULTS: The difference between BPDoi and BPDoo increases with gestational age, although this difference was small. For BPDoo, the regression equation is BPDoo = 0.555934 + 1.027318 × BPDoi. Similarly, for BPDoi, the regression equation is BPDoi = -0.403458 + 0.9714153 × BPDoo. There is a minimal difference in the EFW calculated from the four formulae, except for gestations prior to 27-28 weeks. EFW derived from INTERGROWTH-21st formulae plot is higher than that from Hadlock 3 or Hadlock 4 before 27-28 weeks. CONCLUSIONS: Although the absolute difference between BPDoo and BPDoi increased across gestational age, this difference was small. The method of BPD measurement should follow that as prescribed in the EFW equation used in the local context. Estimation of fetal weight using Hadlock 3, Hadlock 4 and INTERGROWTH-21st is similar, with slight differences at gestations less than 27-28 weeks.

Myomectomy: technique and current indications.

Uterine fibroids are the commonest benign tumor of the female genital tract. They affect a significant proportion of reproductive aged women and may cause excessive menstrual bleeding, pelvic pain or pressure, and adversely affect reproductive outcomes. However, many women remain asymptomatic. Fibroids are the first indication for hysterectomy, but myomectomy is the most suitable surgical option for women who desire preservation of their fertility potential. Only a selected group of women of childbearing age will benefit from a myomectomy, as the consequences of myomectomy on reproductive function have remained controversial. The purpose of this paper was to review the main surgical approaches for myomectomy, and discuss evidence-based indications for myomectomy in women with fibroids, especially with regards to its impact on fertility and reproductive outcomes. A critical review of the literature pertaining to the surgical approaches of myomectomy and the indications for myomectomy was performed, focusing on their impact on fertility and reproductive outcomes. Myomectomy is useful for the treatment of symptomatic fibroids and in selected women with infertility. Symptomatic submucosal fibroids are classically treated by hysteroscopic resection. Symptomatic intramural and subserosal fibroids may be treated by myomectomy, either by laparotomy or laparoscopy depending on their number and size. Prophylactic myomectomy is not recommended for preventing obstetrical complications or the risk of leiomyosarcoma. Although fibroids may have a negative effect on fertility, only the removal of submucosal fibroids has been consistently shown to improve spontaneous fertility or outcomes of assisted reproduction technology.

Decidualized ovarian mass mimicking malignancy.

Deciduosis classically occurs in the context of known endometriosis in the pelvis, most commonly in the ovaries, but also in the peritoneum. However, ovarian deciduosis outside the context of endometriosis is rare and makes diagnosis difficult, especially as the sonographic appearance suggests a malignant process. We report a case of decidualized ovarian mass in a patient without prior history of endometriosis that mimicked an ovarian malignancy. MRI may be a useful imaging modality to monitor these lesions and guide management. Consultation with a multidisciplinary team accustomed to such conditions will help to tailor the management to each individual.

Three-dimensional imaging of the uterus: The value of the coronal plane.

Advent in three-dimensional (3D) imaging technology has seen 3D ultrasound establish itself as a useful adjunct complementary to traditional two-dimensional imaging of the female pelvis. This advantage largely arises from its ability to reconstruct the coronal plane of the uterus, which allows further delineation of many gynecological disorders. 3D imaging of the uterus is now the preferred imaging modality for assessing congenital uterine anomalies and intrauterine device localization. Newer indications include the diagnosis of adenomyosis. It can also add invaluable information to delineate other endometrial and myometrial pathology such as fibroids and endometrial polyps.

Regimens of fetal surveillance for impaired fetal growth.

BACKGROUND: Policies and protocols for fetal surveillance in the pregnancy where impaired fetal growth is suspected vary widely, with numerous combinations of different surveillance methods. OBJECTIVES: To assess the effects of antenatal fetal surveillance regimens on important perinatal and maternal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 February 2012). SELECTION CRITERIA: Randomised and quasi-randomised trials comparing the effects of described antenatal fetal surveillance regimens. DATA COLLECTION AND ANALYSIS: Review authors R Grivell and L Wong independently assessed trial eligibility and quality and extracted data. MAIN RESULTS: We included one trial of 167 women and their babies. This trial was a pilot study recruiting alongside another study, therefore, a separate sample size was not calculated. The trial compared a twice-weekly surveillance regimen (biophysical profile, nonstress tests, umbilical artery and middle cerebral artery Doppler and uterine artery Doppler) with the same regimen applied fortnightly (both groups had growth assessed fortnightly). There were insufficient data to assess this review's primary infant outcome of composite perinatal mortality and serious morbidity (although there were no perinatal deaths) and no difference was seen in the primary maternal outcome of emergency caesarean section for fetal distress (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.35 to 2.63). In keeping with the more frequent monitoring, mean gestational age at birth was four days less for the twice-weekly surveillance group compared with the fortnightly surveillance group (mean difference (MD) -4.00; 95% CI -7.79 to -0.21). Women in the twice-weekly surveillance group were 25% more likely to have induction of labour than those in the fortnightly surveillance group (RR 1.25; 95% CI 1.04 to 1.50). AUTHORS' CONCLUSIONS: There is limited evidence from randomised controlled trials to inform best practice for fetal surveillance regimens when caring for women with pregnancies affected by impaired fetal growth. More studies are needed to evaluate the effects of currently used fetal surveillance regimens in impaired fetal growth.

Rapid hypnosis as an anaesthesia adjunct for evacuation of postpartum vulval haematoma.

Hypnosis can be a useful therapeutic adjunct to pharmacological analgesia or anaesthesia in obstetrics. However, it is rarely considered a primary anaesthetic technique and is seldom employed in the acute surgical setting. Few obstetricians and anaesthetists currently utilise this technique in their clinical practice. We present a case report of a 34-year-old woman who successfully underwent evacuation of a large vulval haematoma using the simple hypnosis technique of 'believed-in imagination' as the principal anaesthetic technique with only minimal adjunctive pharmacological analgesia.

Gathering the evidence: cord gases and placental histology for births with low Apgar scores.

BACKGROUND: Acute intrapartum hypoxia is an uncommon cause of cerebral palsy. The exclusion of acute intrapartum hypoxia utilizes two vital pieces of information that can be obtained at the time of birth: (i) cord blood gas to exclude a severe metabolic acidosis, and (ii) placental histology to suggest an alternative aetiology other than acute intrapartum hypoxia. Although recommendations exist to encourage this practice in high-risk deliveries, their compliance in an Australian setting is not known. AIMS: To evaluate the frequency and utility of cord blood gases and placental histology following delivery with an Apgar score ≤6 at five minutes. METHODS: A retrospective study of 12,887 consecutive deliveries at a tertiary obstetric centre, of which 100 live births had Apgar scores ≤6 at five minutes. Cord blood gases and placental histology were examined. There were also 132 stillbirths where placental histology was sought. RESULTS: Cord gases were measured in 52 of 100 live births with a low Apgar score. Seven of these had severe metabolic acidaemia and 26 had normal cord gases. Placental histology was requested in 40 of these births and 30 showed abnormal histology, suggesting alternative aetiologies. Of the 132 stillbirths, placental histology was available in 50. Abnormal histology was present in 39 of these stillbirths. CONCLUSIONS: Cord gases and placental histology should be sought in all babies with low Apgar scores for the benefit of understanding causation, counselling of the parents, research and professional liability assessment. Heightened awareness for adverse perinatal outcomes is required by health care professionals when a neonate requires resuscitation.

Regimens of fetal surveillance for impaired fetal growth.

BACKGROUND: Policies and protocols for fetal surveillance in the pregnancy where impaired fetal growth is suspected vary widely, with numerous combinations of different surveillance methods. OBJECTIVES: To assess the effects of antenatal fetal surveillance regimens on important perinatal and maternal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2008). SELECTION CRITERIA: Randomised and quasi-randomised trials comparing the effects of described antenatal fetal surveillance regimens. DATA COLLECTION AND ANALYSIS: R Grivell and L Wong independently assessed trial eligibility and quality and extracted data. MAIN RESULTS: One trial of 167 women and their babies was included. This trial was a pilot study recruiting alongside another study, therefore a separate sample size was not calculated. The trial compared a twice-weekly surveillance regimen (biophysical profile, nonstress tests, umbilical artery and middle cerebral artery Doppler and uterine artery Doppler) with the same regimen applied fortnightly (both groups had growth assessed fortnightly). There were insufficient data to assess this review's primary infant outcome of composite perinatal mortality and serious morbidity (although there were no perinatal deaths) and no difference was seen in the primary maternal outcome of emergency caesarean section for fetal distress. In keeping with the more frequent monitoring, mean gestational age at birth was four days less for the twice-weekly surveillance group compared with the fortnightly surveillance group. Women in the twice-weekly surveillance group were 25% more likely to have induction of labour than those in the fortnightly surveillance group. The risk ratio was 1.25 (95% confidence interval 1.04 to 1.50). AUTHORS' CONCLUSIONS: There is limited evidence from randomised controlled trials to inform best practice for fetal surveillance. regimens when caring for women with pregnancies affected by impaired fetal growth. More studies are needed to evaluate the effects of currently used fetal surveillance regimens in impaired fetal growth.

Potential interactions between prescription drugs and complementary and alternative medicines among patients in the emergency department.

STUDY OBJECTIVE: To determine the nature and prevalence of potential interactions between prescription drugs and complementary and alternative medicines (CAMs) and the reasons some patients do not advise their physicians of CAM use. DESIGN: Cross-sectional survey. SETTING: The emergency department of the Royal Melbourne Hospital, a tertiary referral center. PATIENTS: Four hundred four adult patients (>or= 18 yrs) who visited the emergency department between February 1, 2002, and March 31, 2003. Intervention. A specifically designed, self-administered questionnaire, available in seven languages. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were the prevalence of potential prescription drug-CAM interactions and the reasons some patients do not advise their physicians of CAM use. Mean +/- SD patient age was 50.6 +/- 20.0 years; 220 patients were men (54.5%, 95% confidence interval [CI] 49.5-59.4%). When asked about use during the previous year, 275 patients (68.1%, 95% CI 63.2-72.5%) reported having taken a CAM; of these, 138 were also taking a prescription drug. We identified 15 documented potential drug-CAM interactions in nine patients (3.3% of CAM users, 95% CI 1.6-6.3%) and 97 theoretical potential drug-CAM interactions in 51 patients (18.6% of CAM users, 95% CI 14.2-23.8%). Aspirin and warfarin were the most commonly involved drugs. Of CAM users, 197 (71.6%, 95% CI 65.9-76.8%) never informed their physician about CAM use, most frequently because they were not asked. CONCLUSION: The prevalence of potential drug-CAM interactions among patients in the emergency department is considerable, and some of these interactions could be clinically significant. Practitioners should increase their awareness of potential drug-CAM interactions, and education initiatives aimed at encouraging patient-physician discussion of CAM use are recommended, such as a CAM history in their patient evaluation. Further research is required to better determine the clinical significance of drug-CAM interactions.

Use and toxicity of complementary and alternative medicines among emergency department patients.

OBJECTIVE: To determine the prevalence and type of complementary and alternative medicines (CAM) used by ED patients, to identify patient subgroups more likely to use CAM, the conditions for which they were taken, and the prevalence of side-effects and toxicity associated with CAM use. METHODS: This was an analytical cross-sectional survey of patients at a large tertiary referral ED. Consenting patients completed a specifically designed study questionnaire, in their preferred language if required. Information was collected on CAM use on the day of presentation and within the previous week and previous year. RESULTS: Four hundred and four patients were enrolled (participation rate 97.1%). Fifty (12.4%, 95% CI 9.4, 16.1) patients had taken a CAM on the day of presentation, 203 (50.2%, 95% CI 45.3, 55.2) within the previous week and 275 (68.1%, 95% CI 63.2, 72.5) within the previous year. CAM users were significantly younger, better educated and more likely to be female than non-CAM users (P < 0.01). 103 different CAM had been taken for a wide variety of reasons. Side-effects were experienced in 53 of the 1182 CAM courses taken (side-effect rate of 4.5%). One patient presented suffering specifically from CAM toxicity. CONCLUSION: Complementary and alternative medicines are used by a considerable proportion of ED patients. The potential for side-effects, toxicity and interaction with traditional medication indicates the need for consideration of CAM use in patient assessment.