Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study.

BACKGROUND: In rural Nepal, where women face financial and geographic barriers in accessing ultrasound scans, the government initiated a Rural Obstetric Ultrasound Program (ROUSG) to train skilled birth attendants (SBAs) in rural birthing centers and expand access to routine ultrasound scans for local pregnant women. This study explores the perceived benefits and limitations of the training and implementation of this program. METHODS: A qualitative study was conducted in 15 primary care facilities in Bhojpur and Dhading, two rural districts of Nepal. The research team conducted in-depth interviews with 15 trained SBAs and focus group discussions with 48 service recipients and 30 FCHVs to gain insight into their perceptions. All interviews and focus group discussions were recorded, reviewed, and manually coded into MS Excel. RESULTS: Overall, our findings indicated that the ROUSG program was very well received among all our study participants, though critical gaps were identified, mostly during the training of the SBAs. These included insufficient guidance or practice opportunities during training and the challenges of implementing the mobile obstetric ultrasound service. Most importantly, though, our results suggest that the implementation of the ROUSG program increased access to prenatal care, earlier identification and referrals for abnormal scans, as well as reduced pregnancy-related stress. There was also a notable anecdotal increase in antenatal care utilization and institutional deliveries, as well as high satisfaction in both service providers and recipients. CONCLUSION: Our findings highlighted that while the training component could use some strengthening with increased opportunities for supervised practice sessions and periodic refresher training after the initial 21-days, the program itself had the potential to fill crucial gaps in maternal and newborn care in rural Nepal, by expanding access not only to ROUSG services but also to other MNH services such as ANC and institutional deliveries. Our findings also support the use of ultrasound in areas with limited resources as a solution to identify potential complications at earlier stages of pregnancy and improve timely referrals, indicating the potential for reducing maternal and neonatal morbidities. This initial study supports further research into the role ROUSG can play in expanding critical MNH services in underserved areas and improving broader health outcomes through earlier identification of potential obstetric complications.

Saliva microRNA signature to diagnose endometriosis: A cost-effectiveness evaluation of the Endotest®.

OBJECTIVE: To evaluate a saliva diagnostic test (Endotest®) for endometriosis compared with the conventional algorithm. DESIGN: A cost-effectiveness analysis with a decision-tree model based on literature data. SETTING: France. POPULATION: Women with chronic pelvic pain. METHODS: Strategy I is the French algorithm, representing the comparator. For strategy II, all patients have an Endotest®. For strategy III, patients undergo ultrasonography to detect endometrioma and patients with no endometrioma detected have an Endotest®. For strategy IV, patients with no endometrioma detected on ultrasonography undergo pelvic magnetic resonance imaging (MRI) to detect endometrioma and/or deep endometriosis. An Endotest® is then performed for patients with a negative result on MRI. MAIN OUTCOMES MEASURES: Costs and accuracy rates and incremental cost-effectiveness ratios (ICERs). Three analyses were performed with an Endotest® priced at €500, €750, and €1000. Probabilistic sensitivity analysis was conducted with Monte Carlo simulations. RESULTS: With an Endotest® priced at €750, the cost per correctly diagnosed case was €1542, €990, €919 and €1000, respectively, for strategies I, II, III and IV. Strategy I was dominated by all other strategies. Strategies IV, III and II were, respectively, preferred for a willingness-to-pay threshold below €473, between €473 and €4670, and beyond €4670 per correctly diagnosed case. At a price of €500 per Endotest®, strategy I was dominated by all other strategies. At €1000, the ICERs of strategies II and III were €724 and €387 per correctly diagnosed case, respectively, compared with strategy I. CONCLUSION: The present study demonstrates the value of the Endotest® from an economic perspective.

Intervenções psicológicas necessárias: a prática como residente no serviço de medicina fetal / Necessary psychological interventions: the practice as a resident in the fetal medicine service / Intervenciones psicológicas necesarias: la práctica como residente en el servicio de medicina fetal

Com os avanços tecnológicos e o aprimoramento da prática médica via ultrassonografia, já é possível detectar possíveis problemas no feto desde a gestação. O objetivo deste estudo foi analisar a prática do psicólogo no contexto de gestações que envolvem riscos fetais. Trata-se de um estudo qualitativo sob formato de relato de experiência como psicólogo residente no Serviço de Medicina Fetal da Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ). Os registros, feitos por observação participante e diário de campo, foram analisados em dois eixos temáticos: 1) intervenções psicológicas no trabalho em equipe em consulta de pré-natal, exame de ultrassonografia e procedimento de amniocentese; e 2) intervenções psicológicas em casos de bebês incompatíveis com a vida. Os resultados indicaram que o psicólogo nesse serviço é essencial para atuar de forma multiprofissional na assistência pré-natal para gravidezes de alto risco fetal. Ademais, a preceptoria do residente é relevante para sua formação e treinamento para atuação profissional no campo da psicologia perinatal.(AU)

Face to the technological advances and the improvement of medical practice via ultrasound, it is already possible to detect possible problems in the fetus since pregnancy. The objective of this study was to analyze the psychologist's practice in the context of pregnancies which involve fetal risks. It is a qualitative study based on an experience report as a psychologist trainee at the Fetal Medicine Service of the Maternity School of UFRJ. The records, based on the participant observation and field diary, were analyzed in two thematic axes: 1) psychological interventions in the teamwork in the prenatal attendance, ultrasound examination and amniocentesis procedure; and 2) psychological interventions in cases of babies incompatible to the life. The results indicated that the psychologist in this service is essential to work in a multidisciplinary way at the prenatal care for high fetal risk pregnancies. Furthermore, the resident's preceptorship is relevant to their education and training for professional performance in the field of Perinatal Psychology.(AU)

Con los avances tecnológicos y la mejora de la práctica médica a través de la ecografía, ya se puede detectar posibles problemas en el feto desde el embarazo. El objetivo de este estudio fue analizar la práctica del psicólogo en el contexto de embarazos de riesgos fetal. Es un estudio cualitativo basado en un relato de experiencia como residente de psicología en el Servicio de Medicina Fetal de la Escuela de Maternidad de la Universidade Federal do Rio de Janeiro (UFRJ). Los registros, realizados en la observación participante y el diario de campo, se analizaron en dos ejes temáticos: 1) intervenciones psicológicas en el trabajo en equipo, en la consulta prenatal, ecografía y los procedimientos de amniocentesis; y 2) intervenciones psicológicas en casos de bebés incompatibles con la vida. Los resultados señalaron como fundamental la presencia del psicólogo en este servicio trabajando de forma multidisciplinar en la atención prenatal en el contexto de embarazos de alto riesgo fetal. Además, la tutela del residente es relevante para su educación y formación para el desempeño profesional en el campo de la Psicología Perinatal.(AU)

Effect of Timing by Endometrial Receptivity Testing vs Standard Timing of Frozen Embryo Transfer on Live Birth in Patients Undergoing In Vitro Fertilization: A Randomized Clinical Trial.

Importance: Endometrial receptivity testing is purported to improve live birth following frozen embryo transfer by identifying the optimal embryo transfer time for an individual patient; however, data are conflicting. Objective: To compare live birth from single euploid frozen embryo transfer according to endometrial receptivity testing vs standardized timing. Design, Setting, and Participants: Double-blind, randomized clinical trial at 30 sites within a multicenter private fertility practice in the Eastern US. Enrollment was from May 2018 to September 2020; follow-up concluded in August 2021. Participants underwent in vitro fertilization, preimplantation genetic testing for aneuploidy, endometrial receptivity testing, and frozen embryo transfer. Those with euploid blastocyst(s) and an informative receptivity result were randomized. Exclusion criteria included recurrent pregnancy loss, recurrent implantation failure, surgically aspirated sperm, donor egg(s), and unmitigated anatomic uterine cavity defects. Interventions: The intervention group (n = 381) underwent receptivity-timed frozen embryo transfer, with adjusted duration of progesterone exposure prior to transfer, if indicated by receptivity testing. The control group (n = 386) underwent transfer at standard timing, regardless of receptivity test results. Main Outcomes and Measures: The primary outcome was live birth. There were 3 secondary outcomes, including biochemical pregnancy and clinical pregnancy. Results: Among 767 participants who were randomized (mean age, 35 years), 755 (98%) completed the trial. All randomized participants were analyzed. The primary outcome of live birth occurred in 58.5% of transfers (223 of 381) in the intervention group vs 61.9% of transfers (239 of 386) in the control group (difference, -3.4% [95% CI, -10.3% to 3.5%]; rate ratio [RR], 0.95 [95% CI, 0.79 to 1.13]; P = .38). There were no significant differences in the intervention vs the control group for the prespecified secondary outcomes, including biochemical pregnancy rate (77.2% vs 79.5%, respectively; difference, -2.3% [95% CI, -8.2% to 3.5%]; RR, 0.97 [95% CI, 0.83 to 1.14]; P = .48) and clinical pregnancy rate (68.8% vs 72.8%, respectively; difference, -4.0% [95% CI, -10.4% to 2.4%]; RR, 0.94 [95% CI, 0.80 to 1.12]; P = .25). There were no reported adverse events. Conclusions and Relevance: Among patients for whom in vitro fertilization yielded a euploid blastocyst, the use of receptivity testing to guide the timing of frozen embryo transfer, compared with standard timing for transfer, did not significantly improve the rate of live birth. The findings do not support routine use of receptivity testing to guide the timing of embryo transfer during in vitro fertilization. Trial Registration: ClinicalTrials.gov Identifier: NCT03558399.

Log (Lactobacillus crispatus/ Gardnerella vaginalis): a new indicator of diagnosing bacterial vaginosis.

To explore a new marker which can detect bacterial vaginosis (BV) with high sensitivity and specificity quantitatively. According to the Nugent Score, vaginal secretions from study participants were divided into BV, healthy, and BV-intermediate groups. First, we compared the obvious differences and high abundance of bacteria in the three groups using 16S rRNA-sequencing, and screened out candidate markers. Then, quantitative detection of these candidate markers from the three groups was done using real-time reverse transcription-quantitative polymerase chain reaction (RT-qPCR), followed by evaluation of the sensitivity and specificity. Finally, we verified the new markers using clinical cases. Gardnerella vaginalis, Atopobium vaginae, Lactobacillus, Megasphaera were screened out by 16S rRNA-sequencing. RT-qPCR data were transformed and analyzed through ROC curves. PCR results for these bacteria were log-transformed using Lactobacillus crispatus as the numerator and other BV-related bacteria as the denominator. Four new indicators were found. Of these, log L. crispatus/G. vaginalis (L/G) <0 was the best indicator. The sensitivity, specificity, positive predictive value, and negative predictive value of our system were 93.5%, 97.2%, 96.6 and 94.6%, respectively. Combination of data for 16S rRNA-sequencing and RT-qPCR revealed four indicators for BV detection. Of these, log L/G < 0 was the best indicator. Creating a molecular-diagnostic system independent of the Nugent Score for BV could have an important impact on the clinical management of BV.Abbreviation: log L. crispatus/G. vaginalis (logL/G); Bacterial vaginosis (BV); vaginal secretions (VSs); polymerase chain reaction (PCR); rRNA-sequencing (rRNA-seq); real-time reverse transcription-quantitative polymerase chain reaction (RT-qPCR); operational taxonomic unit (OTU); non-metric multidimensional scaling (NMDS); receiver operating characteristic (ROC).

Pathogenesis Based Diagnosis and Treatment of Endometriosis.

Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.

Competencia obstétrica en la atención prenatal: una mirada desde el trabajo interprofesional / Obstetric competence in prenatal care: a look from inter-professional work

RESUMEN Introducción: las actividades extensionistas en la educación médica tributan a la formación integral del estudiante y a la solución de los principales problemas de salud de la sociedad. Objetivo: describir los saberes de la competencia obstétrica en la atención prenatal, desde una mirada interprofesional en estudiantes de Licenciatura en Enfermería. Materiales y métodos: se realizó una investigación cualitativa con enfoque fenomenológico en 10 estudiantes de la ayudantía en Ginecobstetricia. Se aplicaron entrevistas y guías de observación validadas por expertos. El estudio se diseñó en tres fases: experiencias vividas en la sostenibilidad del Programa de Atención Materno Infantil, necesidades de aprendizaje sobre la atención prenatal y determinación de saberes obstétricos con enfoque interprofesional. Resultados: los estudiantes manifestaron como experiencia vivida la necesidad de superación continua. Se reforzaron valores como el humanismo y la responsabilidad en la práctica profesional. Se identificaron las necesidades de aprendizaje: valoración de exámenes y pruebas diagnósticas, orientación psicofísica y nutricional, sistemas de apoyo a la familia, medidas de seguridad a la gestante, e identificación y toma de conducta ante las complicaciones. Se determinaron los saberes a considerar en la competencia obstétrica a partir de un modelo con enfoque interprofesional. Conclusiones: el modelo propuesto permitirá el adecuado desempeño de los estudiantes de Licenciatura en Enfermería, al integrarse como agentes activos en las diferentes acciones de salud comunitaria, y al apropiarse de los saberes necesarios para un adecuado seguimiento de la embarazada en el nivel primario de salud (AU).

ABSTRACT Introduction: the extension activities in medical education contribute to the integral training of the student and to the solution of the main health problems of the society. Objective: to describe the knowledge of obstetric competence in prenatal care, from an inter-professional perspective in the students of Bachelor's degree in Nursing. Materials and methods: a qualitative research with a phenomenological approach was carried out in 10 students of the assistantship in Gynecobstetrics. Expert-validated interviews and observation guides were applied. The study was designed in three phases: experiences in the sustainability of the Maternal and Child Care Program, learning needs on prenatal care and identification of obstetric knowledge with an inter-professional approach. Results: the students expressed as lived experience the need for continuous improvement. Values such as humanism and responsibility in professional practice were reinforced. Learning needs were identified: assessment of examinations and diagnostic tests, psychophysical and nutritional counseling, family support systems, safety measures for pregnant women, and identification and behavior in the face of complications. The knowledge to be considered in obstetric competence was determined from a model with an inter-professional approach. Conclusions: the proposed model will allow the appropriate performance of the students of Bachelor´s degree in Nursing, while integrating them as active agents in the different community health actions, and by appropriating the necessary knowledge for an adequate follow-up of the pregnant woman at the primary health level (AU).

Cost effectiveness of the sFlt1/PlGF ratio test as an adjunct to the current practice of evaluating suspected preeclampsia in the United States.

OBJECTIVE: Preeclampsia is a major obstetric disorder that can lead to severe maternal, fetal and infant outcomes. In women with suspected preeclampsia, measurement of the soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) ratio has been shown to have a high negative predictive value (>97%). Our aim was to estimate the value to the US healthcare system of adopting this test into clinical practice. STUDY DESIGN: An economic model was developed for the evaluation of suspected preeclampsia from a US payer perspective using data from a US observational study of 459 women evaluated between 23 and 34.6 weeks. Test results were not available to clinicians. The model compares two strategies for managing suspected preeclampsia: standard care versus a biomarker-informed pathway utilizing the sFlt1/PlGF ratio. RESULTS: Utilization of the sFlt1/PlGF ratio test reduced the number of women admitted for suspected preeclampsia by 34-49%. Despite fewer admissions, a higher proportion of women admitted to hospital subsequently developed preeclampsia, and the proportion of women not admitted who would subsequently develop preeclampsia remained low (3.2%-6.7%). Cost savings arising from a reduction in admissions are estimated to be $1050 in the base case; varying the hospitalization cost ±25% would lead to savings in the range $771 to $1330 per patient at 2020 prices. CONCLUSION: Adopting the sFlt1/PlGF ratio test as an adjunct to clinical criteria improves the assessment of risk in women presenting with suspicion of preeclampsia and has the potential to safely reduce unnecessary admissions and save costs.

The Value of Anti-Müllerian Hormone in the Prediction of Spontaneous Pregnancy: A Systematic Review and Meta-Analysis.

Objective: To determine whether serum anti-Müllerian hormone (AMH) level is a predictor of clinical pregnancy in women trying to achieve a natural conception. Methods: The PubMed, Embase, and Cochrane Library databases were searched for articles published until August 2020. Studies that met the inclusion and exclusion criteria were included in the meta-analysis; no language limitations were imposed. Quality was appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 checklist. Heterogeneity due to the threshold effect was identified; thus, we plotted a summary receiver operating characteristic curve and calculated its area under the summary receiver operating characteristic curve (AUC) and Cochran's Q index to assess whether AMH level is a predictor of spontaneous pregnancy. Publication bias and sensitivity were also assessed. Results: Eleven studies (4,388 women) were ultimately included in this meta-analysis. The AUC and Cochran's Q indices were 0.5932 and 0.5702, respectively. For women younger than 35 years, the AUC was 0.6355 and the Q index was 0.6025. For those older than 35 years, the AUC was 0.5536 and the Q index was 0.5403. Subgroup analyses by study type and population characteristics showed results similar to the overall outcome. No publication bias was identified, and the sensitivity analysis confirmed the robustness of the final result. Conclusions: Serum AMH levels have poor predictive value for natural pregnancy. The predictive value of AMH was poor in the younger and older subgroups. Our findings suggest that low serum AMH levels are not associated with reduced fertility. Introduction: This study investigated the predictive value of anti-Müllerian hormone (AMH) level for natural pregnancy. Other than age, few factors can predict the chances of natural fertility. AMH is an established biomarker of ovarian reserve that is widely used to predict oocyte yield in cases of in vitro fertilization (IVF) and menopause. In clinical practice, the applications of AMH are increasing. However, its predictive value for natural conception remains controversial. In this study, since AMH is closely related with ovarian reserve, we evaluated whether it has predictive value for natural pregnancy. Our findings will fine-tune the clinical application of AMH in pre-pregnancy counseling. The topic should be of wide interest to investigators in the reproductive endocrinology and gynecology fields. Systematic Review Registration: PROSPERO 2020 CRD42020216265, Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020216265.

Métodos de estudio de pacientes con sangrado uterino posmenopáusico: recomendaciones prácticas / Study methods of patients with postmenopausal uterine bleeding: practical recommendations

Resumen El sangrado uterino posmenopáusico se define como aquel sangrado que ocurre después del cese definitivo de la menstruación en la etapa reproductiva de la mujer como consecuencia de la claudicación biológica de los ovarios, o como un sangrado no esperado en mujeres con terapia de reposición hormonal sistémica de la menopausia. Representa el 5% de las consultas ginecológicas y, si bien su origen suele ser por causas benignas, puede requerir una evaluación minuciosa para descartar patologías malignas del endometrio. El objetivo de este trabajo es establecer un flujograma diagnóstico basado en la evidencia para la evaluación de las pacientes con sangrado uterino posmenopáusico.

Abstract Postmenopausal uterine bleeding is defined as the bleeding that occurs after the last menstruation due to loss of ovarian function, or a non-scheduled bleeding in patients with hormonal therapy. It represents 5% of the gynecologic visits, and even though its origin is often benign, it requires a thorough evaluation to discard malignant diseases. The objective of these review is to propose a diagnostic algorithm based on the available evidence for the evaluation of patients with postmenopausal uterine bleeding.

Cervical cancer screening "see and treat approach": real-life uptake after invitation and associated factors at health facilities in Gondar, Northwest Ethiopia.

BACKGROUND: Although cervical cancer is a preventable disease, screening coverage in Ethiopia is far below the target. There is limited evidence on uptake among the general population in Ethiopia. Thus, this study was conducted to assess uptake and associated factors with the cervical cancer screening "see and treat approach" among eligible women in public health facilities in Gondar town, Northwest Ethiopia. METHOD: A facility-based, cross-sectional study was conducted. The total sample size was 493. A consecutive sampling method was applied. Participants were informed about and invited to cervical cancer screening using visual inspection with acetic acid. Crude and adjusted odds ratios were calculated to determine statistical association with socio-demographic variables. Multivariable logistic regression was used to determine factors of cervical cancer screening uptake. RESULT: Out of 464 women advised for screening, 76 (16.4, 95% CI [13, 19.8%]) attended the screening. Primary education and above (AOR = 5.3, 95% CI [2.20, 13.0]), knowledge about the disease (AOR = 8.4, 95% CI [3.33, 21.21]), perceived susceptibility (AOR = 6.5, 95% CI [2.72, 15.51]), fewer perceived barriers (AOR = 6.4, 95% CI [2.30, 17.80]), cues to action (AOR = 4.6, 95% CI [1.86, 11.32]), perceived self-efficacy (AOR = 5, 95% CI [2.14, 11.73]), and previous recommendation for screening (AOR = 2.7, 95% CI [1.15, 6.51]) were significantly associated with screening uptake. CONCLUSION: The actual uptake of screening offered in this study was high relative to only 3% national screening coverage. There is a need to implement active invitation for screening with special focus on less-educated women. Repeated invitation may facilitate future screening uptake.

Prevalence of T-shaped uterus among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria.

RESEARCH QUESTION: What is the prevalence of T-shaped uteri among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria? DESIGN: A prospective cohort study of 258 women of reproductive age with a history of at least one natural pregnancy resulting in live birth. Participants were recruited from the family planning clinic between January 2018 and March 2020. The ESHRE/ESGE classification of congenital anomalies of the female genital tract was used for describing abnormal findings. CUME criteria were also used for diagnosing T-shaped uterus. Uterine cavity volume was measured. RESULTS: Mean age of participants was 35.4 ± 6.2 years. Participants were diagnosed with the following: congenital uterine abnormality (n = 9 [3.6%]); partial septate uterus (n = 5 [2.0%]) and hemiuterus (n = 2 [0.8%]). Two women (0.8%) were diagnosed with T-shaped uterus and borderline T-shaped uterus based on the ESHRE/ESGE criteria and CUME. Mean lateral indentation angle, lateral indentation depth and T-angle were 156.2° ± 9.53°, 2.85 ± 0.93 mm and 73.3° ± 9.85° in patients with normal uterine cavity. In patients with T-shaped and borderline T-shaped uteri, respective figures were 115° versus 121°, 10 mm versus 7.6 mm and 27.5° versus 70°. Median volume of the uterine cavity in patients with normal uterine cavity and T-shaped uterus was 3.71 ml (minimum 2.0 to maximum 9.03 ml, interquartile range 1.93) and 3.2 ml (2.9 and 3.62 ml), respectively. CONCLUSIONS: The prevalence of T-shaped uteri in fertile women is low, which corresponds to previous reports of women with poor reproductive history.

Hysteroscopic detection of chronic endometritis: Evaluating proposed hysteroscopic features suggestive of chronic endometritis.

PURPOSE: To evaluate the proposed criteria in a large sample and in additional subgroups in order to test the validity of the hysteroscopic features widely-accepted as suggestive of CE. METHOD(S): All patients (n: 2675) underwent outpatient hysteroscopy, with the vaginoscopic approach technique. Hysteroscopic features such as, stromal oedema, diffuse or focal hyperaemia, "strawberry aspect", micropolyposis and endometrial polyps, are often indicate the presence of chronic endometritis. All hysteroscopic features, alone and in combination were applied in 7 (seven) different subgroups of the sample: total sample, women in reproductive age, women with infertility issues/IVF screening, women with history of recurrent miscarriages, menopausal women, and women with hysteroscopic indication of Abnormal Uterine Bleeding (AUB) in women of reproductive age and postmenopausal bleeding (PMB). From each case, endometrial samples were obtained and immunohistochemistry, identifying CD-138, was applied in order to diagnose CE. RESULT(S): A total of 2675 patients were included of which, 1444 women were found with at least one of the proposed hysteroscopic features mentioned above. Stromal oedema, focal or diffuse hyperaemia and "strawberry aspect" in combination with micropolyposis demonstrated higher rates of diagnostic accuracy in the detection of CE correlated to histologic confirmation. Micropolyposis, stromal oedema, focal or diffuse hyperaemia and "strawberry aspect" offer great diagnostic accuracy in the hysteroscopic detection of Chronic Endometritis, regardless reproductive status and/or clinical presentation. Endometrial polyps are not valid hysteroscopic features in cases of suspected CE. CONCLUSION(S): Diagnostic hysteroscopy can accurately diagnose cases of CE, based on stromal oedema, focal or diffuse hyperaemia and "strawberry aspect", in combination with micropolyposis. In subgroups of infertile women, higher diagnostic accuracy based on the hysteroscopic features mentioned, was more likely to be achieved. Whether endometrial polyps are suggestive of CE, when identified during office hysteroscopy, remains controversial.

Prediction Models of Adnexal Masses: State-of-the-Art Review.

IMPORTANCE: Several predictive models and scoring systems have been developed to differentiate between benign and malignant ovarian masses, in order to guide effective management. These models use combinations of patient characteristics, ultrasound markers, and biochemical markers. OBJECTIVE: The aim of this study was to describe, compare, and prioritize, according to their strengths and qualities, all the adnexal prediction models. EVIDENCE ACQUISITION: This was a state-of-the-art review, synthesizing the findings of the current published literature on the available prediction models of adnexal masses. RESULTS: The existing models include subjective assessment by expert sonographers, the International Ovarian Tumor Analysis models (logistic regression models 1 and 2, Simple Rules, 3-step strategy, and ADNEX [Assessment of Different NEoplasias in the adneXa] model), the Risk of Malignancy Index, the Risk of Malignancy Ovarian Algorithm, the Gynecologic Imaging Reporting and Data System, and the Ovarian-Adnexal Reporting and Data System. Overall, subjective assessment appears to be superior to all prediction models. However, the International Ovarian Tumor Analysis models are probably the best available methods for nonexpert examiners. The Ovarian-Adnexal Reporting and Data System is an international approach that incorporates both the common European and North American approaches, but still needs to be validated. CONCLUSIONS: Many prediction models exist for the assessment of adnexal masses. The adoption of a particular model is based on local guidelines, as well as sonographer's experience. The safety of expectant management of adnexal masses with benign ultrasound morphology is still under investigation.

A patient-specific model combining antimüllerian hormone and body mass index as a predictor of polycystic ovary syndrome and other oligo-anovulation disorders.

OBJECTIVE: To determine whether a patient-specific predictive model combining antimüllerian hormone (AMH) levels and body mass index (BMI) can aid in the diagnosis of polycystic ovary syndrome (PCOS) and other ovulatory dysfunction disorders (OVDYS) among infertile women. DESIGN: Retrospective cohort study. SETTING: Academic fertility center. PATIENT(S): One thousand and ten infertile women undergoing 3,160 intrauterine insemination (IUI) cycles, stratified by diagnosis in three groups: PCOS, OVDYS, and other etiologies. INTERVENTION(S): Ovulation induction followed by IUI or ultrasound-monitored natural cycles. MAIN OUTCOME MEASURE(S): The probability of either PCOS or OVDYS diagnosis based on AMH levels alone and a patient-specific predictive model that combines serum AMH and patient's BMI. RESULT(S): Median and interquartile range (IQR) for the serum AMH levels (ng/mL) were the highest in women with PCOS, and lowest in those with other infertility causes. Overall, for every 1 ng/mL increase in AMH, the odds of PCOS and OVDYS versus other causes increased by 55% and 24%, respectively. Postestimation from multivariate logistic regression models showed that PCOS diagnosis can be predicted with lower AMH values in women with a higher BMI compared with the AMH values predicting PCOS in normal-weight or underweight patients. The receiver operating characteristic curves reinforced these findings, and the best cutoffs for PCOS diagnosis were 7.5, 4.4, and 4.1 ng/mL for women belonging to the BMI groups 18.5-24.9, 25.0-29.9, and ≥30.0 kg/m2, respectively. CONCLUSION(S): Taking into account AMH and BMI, we developed a model that predicts the probability of an oligo-anovulation diagnosis, thus facilitating patient-specific counseling in the infertility setting.

2020 Hong Kong College of Obstetricians and Gynaecologists guideline on investigations of premenopausal women with abnormal uterine bleeding.

Abnormal uterine bleeding in premenopausal women is a common gynaecological symptom and composes of abnormality in the frequency, duration, regularity, and flow volume of menstruation. It could constitute the presentation of various gynaecological malignancies. An appropriate history and physical examination are mandatory to ascertain the diagnosis. Depending on the clinical condition, a complete blood picture, thyroid function test, clotting profile, chlamydia test, cervical smear, and pregnancy test can be performed. Ultrasound should be performed in cases with a pelvic mass, unsatisfactory physical examination, persistent symptoms, or no response to medical treatment. In women aged ≥40 years, an out-patient endometrial biopsy with Pipelle should be performed. In women aged <40 years with risk factors for endometrial cancer, persistent symptoms, or no response to medical treatment, an endometrial biopsy should be performed to rule out endometrial cancer. Hysteroscopy or saline infusion sonohysterography is more sensitive than ultrasound for diagnosing endometrial pathology. Details of the above recommendations are presented.