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Objective: To report the outcome of cesarean scar pregnancy (CSP) undergoing treatment. Methods: MEDLINE, Embase and CINAHL databases were searched. Inclusion criteria were women with CSP undergoing treatment. The primary outcome was successful treatment for CSP, defined as no need for additional medical or surgical strategies. Secondary outcomes were the type of additional treatment (surgical or medical), need for blood transfusion, emergency laparotomy, hysterectomy, post-treatment complications. All these outcomes were explored in women undergoing single and compound treatments for CSP. Furthermore, we performed a separate sub-group analysis only including studies which reported on the outcomes of elective treatments. Random effects meta-analyses were used to analyze the data and results reported as pooled proportions or odd ratio (OR). Results: 176 studies (13431 women with CSP undergoing treatment) were included. Successful treatment after primary intervention was achieved in 86.2% (95% CI 82.3–89.7) of women with CSP undergoing treatment with ultrasound guided suction curettage, 72.4% (95% CI 64.8-79.3) with systemic MTX, 81.6% (95% CI 72.3–89.3) with local MTX, 83.9% (95% CI 66.7–95.6) with interventional radiology, 90.42% (95% CI 82.9–96.0) with hysteroscopy, 96.1% (95% CI (92.3–98.6) with laparoscopy and 92.6 with high intensity focused ultrasound (95% CI 78.2–99.6). Post-treatments complications were reported in 3.5% (95% CI 1.7–6.0) of women treated with systemic MTX, 5.9% (95% CI 0.8–15.1) with local MTX or KCl, 1.2% (95% CI 0.1–3.5) with interventional radiology, 1.4% (95% CI 0.4–2.9) with hysteroscopy, 5.5% (95% CI 0.4–25.7) with high intensity focused ultrasound and in none of the cases treated with ultrasound guided suction curettage. When considering compound treatments, successful resolution of CSP was achieved in 91.9% (95% CI 88.0–95.10) of women treated with interventional radiology followed by curettage, 83.3% (95% CI 68.8–93.8) with systemic MTX and curettage, 79.4% (95% CI 56.3–95.2) with local MTX and curettage, 96.2% (95% CI 92.3–98.7) with curettage followed by single or double balloon insertion in the uterine cavity, 98.3% (95% CI 95.9–99.7) with high intensity focused ultrasound followed by curettage, 91.1% (95% CI 3.4–97.0) with interventional radiology followed by removal of CSP with hysteroscopy, 64.3% (95% CI 13.8–99.2) with interventional radiology and systemic MTX and in 95.5% (95% CI 92.9–97.5) with curettage and hysteroscopy. When considering studies reporting a comparison between different treatments, there was no difference between systemic vs local MTX in the primary outcome. Curettage was associated with a higher chance of achieving a successful treatment. Conclusions: A multitude of treatments for CSP have been reported in the published literature. All treatments described for CSP are apparently equally effective in treating this condition. The findings from this systematic review highlight the need for adopting a common definition and outcome reporting of CSP to better elucidate its natural history, estimate the magnitude of maternal complication after treatment and design appropriately powered RCT to elucidate the optimal treatment of CSP according to its ultrasound phenotype and gestational age at treatment, in terms of effective resolution of the condition and risk of post-intervention complications. [ABSTRACT FROM AUTHOR]

STUDY QUESTION Is acute haemoperitoneum that is managed conservatively a precursor of deep endometriosis? SUMMARY ANSWER Our study provides evidence to suggest that acute haemoperitoneum may lead to the development of deep endometriosis in a significant proportion of cases. WHAT IS KNOWN ALREADY A recent pilot study was the first to suggest that acute haemoperitoneum could be a precursor of deep endometriosis. However, the sample size was small, and the follow-up was not standardized owing to unknown rates of clot absorption and development of endometriosis. STUDY DESIGN, SIZE, DURATION This was a prospective observational cohort study conducted at a single centre over a 31-month period. A required sample size of 30 was calculated using results from a previous study, with a minimum of 15 women each in the groups with and without significant haemoperitoneum (study and control groups, respectively). A total of 59 women were recruited to the study and eight were lost to follow-up. The final sample comprised 51 women, 15 in the study group and 36 in the control group. PARTICIPANTS/MATERIALS, SETTING, METHODS All non-pregnant, premenopausal women aged 18–50 years who consecutively presented to our dedicated gynaecological diagnostic unit with severe acute lower abdominal pain were eligible for this study. We only included women who were clinically stable and were suitable for conservative management. Those with prior history or evidence of endometriosis on their initial ultrasound scan, previous hysterectomy, or bilateral oophorectomy were excluded. Participants had standardized follow-up visits for 6 months, with pelvic ultrasound scans and the British Society of Gynaecological Endoscopy pelvic pain questionnaires completed at each visit. The primary outcome was the sonographically confirmed presence of newly formed endometriosis. Secondary outcomes were the presence and change of pelvic pain symptoms and health-related quality of life (HR-QOL). MAIN RESULTS AND THE ROLE OF CHANCE After completion of follow-up, 7/15 (47%; 95% CI 21.3–71.4%) women presenting with acute haemoperitoneum (study group) developed sonographic evidence of deep endometriosis, compared to 0/36 (0%; 97.5% CI 0.0–9.7%) women in the control group. A ruptured functional haemorrhagic cyst was the most common cause of haemoperitoneum, occurring in 13/15 cases (87%). The time from the initial event to sonographic evidence of endometriosis varied from 2 to 6 months. The EuroQol visual analogue scores were not significantly different at baseline between the groups that developed and did not develop endometriosis [28 (interquartile range (IQR) 15–40, n = 6) vs 56 (IQR 35–75, n = 44), P  =   0.09], while the EuroQol-5D values were lower in the endometriosis group [−0.01 (IQR −0.07 to 0.19, n = 6) vs 0.62 (IQR 0.24–0.73, n = 44), P  =   0.002]. At 6 months, the EuroQol-5D scores were improved in both groups, but remained significantly lower in the endometriosis group compared to the no endometriosis group [0.69 (IQR 0.66–0.80, n = 6) vs 0.85 (IQR 0.76–1.00, n = 44), P  =   0.03]. There was no clinically relevant difference in the pelvic pain scores at either time point. LIMITATIONS, REASONS FOR CAUTION It remains uncertain whether minimal, superficial endometriosis existed at commencement of the study and had a role in the development of deep endometriosis. Although the ultrasound findings were in keeping with deep endometriosis, this was not confirmed histologically. The pelvic pain and HR-QOL findings could have been influenced by the baseline scores being taken when the patient was admitted with acute pain. Also, the sample size was too small to draw reliable conclusions regarding the impact of newly developed endometriosis on QoL. WIDER IMPLICATIONS OF THE FINDINGS Our study provides further evidence showing that significant haemoperitoneum may be a precursor of deep endometriosis. Haemodynamically stable women presenting with acute pelvic pain and significant haemoperitoneum should be counselled about the risk of developing deep endometriosis. Interventional studies should be carried out in the future to see whether laparoscopy and pelvic washout could prevent development of deep endometriosis. Preventative strategies, including treatment to suppress ovulation and formation of functional cysts, should be further investigated. This includes the combined and progesterone-only contraceptive pills. Larger future studies are also required to assess women over a longer period of time, with adjustment for confounding factors, to evaluate a possible effect on HR-QOL and pain symptoms. STUDY FUNDING/COMPETING INTEREST(S) Funding was obtained from The Gynaecology Ultrasound Centre, London, UK. TT received personal fees from GE, Samsung, Medtronic, and Merck for lectures on ultrasound. TT also received a postdoctoral grant from the South-Eastern Norwegian Health Authority (grant number 2020083). TRIAL REGISTRATION NUMBER researchregistry6472. [ABSTRACT FROM AUTHOR]

Introduction: The natural history of endometriosis is poorly understood, and despite numerous studies, the rate of the disease progression and optimal treatment planning in women who are asymptomatic or experience mild symptoms not requiring treatment are unknown. The aim of this study was to assess the behavior of deep endometriosis in women who are managed expectantly without any medical or surgical intervention. Material and methods: A retrospective cohort study of women diagnosed with deep endometriosis on transvaginal ultrasound scan at the Department of Gynecology, University College London Hospitals and The Gynecology Ultrasound Centre, London, UK, from April 2007 to April 2022. All women attended for at least two ultrasound scans which were carried out by a single expert ultrasound examiner and at least 6 months apart. The number and position of endometriotic nodules were recorded, and the mean diameter of each nodule was calculated from measurements taken in three orthogonal planes. Results: During the study period, 1922 women were found to have moderate or severe deep endometriosis on pelvic ultrasound examination. A total of 135 premenopausal women who were managed expectantly fitted the inclusion criteria. The median number of endometriotic nodules per woman at the initial visit was 2 (range: 0–7), and the median follow‐up time was 666 days (181–2984). In the follow‐up period, 50/135 women (37%, 95% CI: 29–46) developed additional nodules or experienced an increase in nodule size, and 17/135 women (13%, 95% CI: 8–19) had a regression in the number or size of the nodules. In the remaining 68/135 women (50%, 95% CI: 42–59) the disease remained static during the follow‐up. The median change in mean diameter of nodules during the study period per woman was +0.13 mm (−11.67 − +5.83), with an annual growth rate of +0.09 mm/year (−6.65 − +6.45). Conclusions: In our study we found evidence of deep endometriosis progression in just over a third of women. In view of this, asymptomatic or mildly symptomatic women diagnosed with deep endometriosis could be reassured that their disease is unlikely to worsen with time. [ABSTRACT FROM AUTHOR]

Study Objective: To retrospectively evaluate the ability of routinely collected preoperative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis.Design and Setting: Patients at the University College London Hospital who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (British Society for Gynaecological Endoscopy) database. Imaging data were collected and analyzed to determine associations with the requirement for bowel resection.Patients: We evaluated 228 consecutive women undergoing bowel surgery (shave, disc resection, or segmental resection) for rectovaginal endometriosis.Interventions: The patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection, and segmental resection of the bowel. All patients underwent a preoperative transvaginal ultrasound to assess the extent of endometriosis.Measurements and Main Results: There were 206 rectal shaves (90.4%), 2 disc resections (0.9%), and 20 segmental bowel resections (8.8%). A multivariable analysis demonstrated an association between bowel resection and ≥2 nodules located in the rectovaginal space (odds ratio [OR] 6.85; 95% confidence interval [CI], 1.37-34.2), nodules in the vesicouterine pouch (OR 5.87; 95% CI, 1.03-33.3), and increasing nodule size (OR 2.39 per 1 cm increase per 1 cm diameter increase; 95% CI, 1.56-3.64).Conclusion: Ultrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counseling and surgical planning in the preoperative setting for women with rectovaginal endometriosis. [ABSTRACT FROM AUTHOR]

Objective: To compare the diagnostic accuracies of ultrasound and magnetic resonance imaging (MRI) for deep (=50%) myometrial invasion (DMI) and cervical stromal invasion (CSI) in women with endometrial cancer. Methods: This was a prospective study at a gynecology clinic for women with postmenopausal bleeding. Between October 2015-October 2018, consecutive women with suspected endometrial cancer based on ultrasound subjective pattern recognition were simultaneously assessed for DMI and CSI on ultrasound. Subsequently, they also underwent preoperative MRI. We compared the diagnostic accuracies of ultrasound and MRI in predicting DMI and CSI with the final histology as the gold standard. Results: We included 51 women. The prevalence of DMI and CSI were 22/51 (43%) and 7/51 (14%), respectively. The majority of malignancies were of endometrioid histological subtype (38/51, 75%) and FIGO stage 1 or 2 (40/51, 78%). Ultrasound diagnosed more cases of DMI compared to MRI (19/22 vs. 17/22), however, the difference was not statistically significant. The sensitivities and specificities of ultrasound and MRI for DMI were 86% vs. 77% and 66% vs. 76%, respectively. For CSI, ultrasound and MRI correctly diagnosed the same number of cases (5/7, 71%); their respective false-positive rates were low, 0/44 (0%) and 1/44 (2%). Ultrasound and MRI had a moderate agreement for DMI (k=0.49; 95% confidence interval [CI]=0.26-0.73), whereas the agreement for CSI was substantial (k=0.69; 95% CI=0.36-1.00). Conclusion: Endometrial cancer can be simultaneously diagnosed and staged at women's initial ultrasound assessment. The accuracies of ultrasound for DMI and CSI are comparable to MRI. [ABSTRACT FROM AUTHOR]

STUDY QUESTION What recommendations can be provided to improve terminology for normal and ectopic pregnancy description on ultrasound? SUMMARY ANSWER The present ESHRE document provides 17 consensus recommendations on how to describe normally sited and different types of ectopic pregnancies on ultrasound. WHAT IS KNOWN ALREADY Current diagnostic criteria stipulate that each type of ectopic pregnancy can be defined by clear anatomical landmarks which facilitates reaching a correct diagnosis. However, a clear definition of normally sited pregnancies and a comprehensive classification of ectopic pregnancies are still lacking. STUDY DESIGN, SIZE, DURATION A working group of members of the ESHRE Special Interest Group in Implantation and Early Pregnancy (SIG-IEP) and selected experts in ultrasound was formed in order to write recommendations on the classification of ectopic pregnancies. PARTICIPANTS/MATERIALS, SETTING, METHODS The working group included nine members of different nationalities with internationally recognised experience in ultrasound and diagnosis of ectopic pregnancies on ultrasound. This document is developed according to the manual for development of ESHRE recommendations for good practice. The recommendations were discussed until consensus by the working group, supported by a survey among the members of the ESHRE SIG-IEP. MAIN RESULTS AND THE ROLE OF CHANCE A clear definition of normally sited pregnancy on ultrasound scan is important to avoid misdiagnosis of uterine ectopic pregnancies. A comprehensive classification of ectopic pregnancy must include definitions and descriptions of each type of ectopic pregnancy. Only a classification which provides descriptions and diagnostic criteria for all possible locations of ectopic pregnancy would be fit for use in routine clinical practice. The working group formulated 17 recommendations on the diagnosis of the different types of ectopic pregnancies on ultrasound. In addition, for each of the types of ectopic pregnancy, a schematic representation and examples on 2D and 3D ultrasound are provided. LIMITATIONS, REASONS FOR CAUTION Owing to the limited evidence available, recommendations are mostly based on clinical and technical expertise. WIDER IMPLICATIONS OF THE FINDINGS This document is expected to have a significant impact on clinical practice in ultrasound for early pregnancy. The development of this terminology will help to reduce the risk of misdiagnosis and inappropriate treatment. STUDY FUNDING/COMPETING INTEREST(S) The meetings of the working group were funded by ESHRE. T.T. declares speakers' fees from GE Healthcare. The other authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER N/A DISCLAIMER This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation. ESHRE's GPRs should be used for informational and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. Furthermore, ESHRE's GPRs do not constitute or imply the endorsement, recommendation or favouring of any of the included technologies by ESHRE. [ABSTRACT FROM AUTHOR]

Objective: The majority of complete hydatidiform moles (CHM) are detected on ultrasound examination by the end of the first trimester when they present as multiple sonolucent cysts. To better understand the pathophysiology of this unique placental pathology and improve its prenatal diagnosis and management we have reviewed the ultrasound features of CHM before the appearance of cystic changes.Study Design: We searched our database to identify all women diagnosed with a complete hydatidiform mole confirmed by histopathology who had an ultrasound examination before 9 weeks' gestation. We reviewed their ultrasound reports and all the corresponding images.Results: The study group included 39 women with a positive pregnancy test and vaginal bleeding, 36 of whom had at least two ultrasound examinations before 9 weeks' gestation. At the first scan (mean gestation age 7 + 1 weeks; SD 1.1), 29 out 39 (74.4%) of CHM presented as a heterogeneous hyperechogenic mass with or without gestational sac and the remaining ten (25.6%) cases as a regular 4-week gestational sac. Cystic molar changes became apparent from the end of the second month of gestation.Conclusion: The development of a CHM follows a well-defined pattern starting with a macroscopically normal gestation sac at 4 weeks, which transforms into a polypoid mass between 5 and 7 weeks of gestation. The hydropic changes of the villous tissue is progressive and rarely visible in utero on ultrasound before 8 weeks of gestation. These findings should allow an earlier diagnosis and assist in the management counselling of women with CHM. [ABSTRACT FROM AUTHOR]

This study aimed to assess the accuracy of the International Ovarian Tumour Analysis (IOTA) logistic regression models (LR1 and LR2) and that of subjective pattern recognition (PR) for the diagnosis of ovarian cancer.This was a prospective single-center study in a general gynecology unit of a tertiary hospital during 33 months. There were 292 consecutive women who underwent surgery after an ultrasound diagnosis of an adnexal tumor. All examinations were by a single level 2 ultrasound operator, according to the IOTA guidelines. The malignancy likelihood was calculated using the IOTA LR1 and LR2. The women were then examined separately by an expert operator using subjective PR. These were compared to operative findings and histology. The sensitivity, specificity, area under the curve (AUC), and accuracy of the 3 methods were calculated and compared.The AUCs for LR1 and LR2 were 0.94 [95% confidence interval (CI), 0.92-0.97] and 0.93 (95% CI, 0.90-0.96), respectively. Subjective PR gave a positive likelihood ratio (LR+ve) of 13.9 (95% CI, 7.84-24.6) and a LR-ve of 0.049 (95% CI, 0.022-0.107). The corresponding LR+ve and LR-ve for LR1 were 3.33 (95% CI, 2.85-3.55) and 0.03 (95% CI, 0.01-0.10), and for LR2 were 3.58 (95% CI, 2.77-4.63) and 0.052 (95% CI, 0.022-0.123). The accuracy of PR was 0.942 (95% CI, 0.908-0.966), which was significantly higher when compared with 0.829 (95% CI, 0.781-0.870) for LR1 and 0.836 (95% CI, 0.788-0.872) for LR2 (P < 0.001).The AUC of the IOTA LR1 and LR2 were similar in nonexpert’s hands when compared to the original and validation IOTA studies. The PR method was the more accurate test to diagnose ovarian cancer than either of the IOTA models. [ABSTRACT FROM AUTHOR]

The management of incidental or unusual site venous thrombosis (VT) is challenging and is often extrapolated from studies on symptomatic deep venous thrombosis (DVT). There is a tendency to treat with anticoagulation, due to the theoretical risk of propagation and embolism; however, this is not without risk. Furthermore, there is little guidance on how to monitor incidental VT. The aim of this study was to describe the natural history of incidental uterine venous plexus thrombosis (UVPT) and provide a structured approach to its overall management. A prospective study was conducted in a university teaching hospital over a 16-month period. Women diagnosed with UVPT on transvaginal ultrasound (TVS) were followed up over a six-month period and managed based on an individualised risk assessments, in conjunction with haematologists. Fifty women were diagnosed with UVPT during the study period, of which 38 were managed expectantly. The resolution was documented in 70% of women. There were no cases of symptomatic DVT or pulmonary embolisms in either the expectant or treatment groups. Our study has shown that in a high proportion of women, incidental UVPT could be managed successfully without the need for anticoagulation. The overall management of UVPT should be based on individualised clinical risk assessments. [ABSTRACT FROM AUTHOR]

Background and aims: Postmenopausal endometrial polyps are commonly managed by surgical resection; however, expectant management may be considered for some women due to the presence of medical co-morbidities, failed hysteroscopies or patient's preference. This study aimed to identify patient characteristics and ultrasound morphological features of polyps that could aid in the prediction of underlying pre-malignancy or malignancy in postmenopausal polyps. Methods: Women with consecutive postmenopausal polyps diagnosed on ultrasound and removed surgically were recruited between October 2015 to October 2018 prospectively. Polyps were defined on ultrasound as focal lesions with a regular outline, surrounded by normal endometrium. On Doppler examination, there was either a single feeder vessel or no detectable vascularity. Polyps were classified histologically as benign (including hyperplasia without atypia), pre-malignant (atypical hyperplasia), or malignant. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed with a range of demographic, clinical, and ultrasound variables as independent, and the presence of pre-malignancy or malignancy in polyps as dependent variables. A 10-fold cross-validation method was used to estimate the model's misclassification risk. Results: There were 240 women included, 181 of whom presented with postmenopausal bleeding. Their median age was 60 (range of 45–94); 18/240 (7.5%) women were diagnosed with pre-malignant or malignant polyps. In our decision tree model, the polyp mean diameter (≤13 mm or >13 mm) on ultrasound was the most important predictor of pre-malignancy or malignancy. If the tree was allowed to grow, the patient's body mass index (BMI) and cystic/solid appearance of the polyp classified women further into low-risk (≤5%), intermediate-risk (>5%–≤20%), or high-risk (>20%) groups. Conclusions: Our decision tree model may serve as a guide to counsel women on the benefits and risks of surgery for postmenopausal endometrial polyps. It may also assist clinicians in prioritizing women for surgery according to their risk of malignancy. [ABSTRACT FROM AUTHOR]

To determine whether obstetric outcomes differ between women with endometriosis and those without, where all women undergo first-trimester screening for endometriosis. A prospective observational cohort study. The Early Pregnancy Unit at University College London Hospital, United Kingdom. Women with a live pregnancy progressing beyond 12 weeks' gestation and concurrent endometriosis (n = 110) or no endometriosis (n = 393). All women underwent a pelvic ultrasound examination in early pregnancy to examine for the presence of endometriosis and uterine abnormalities. The primary outcome of interest was preterm birth, defined as delivery before 37 completed weeks' gestation. Secondary outcomes included late miscarriage, antepartum hemorrhage, placental site disorders, gestational diabetes, hypertensive disorders of pregnancy, neonates small for gestational age, mode of delivery, intrapartum sepsis, postpartum hemorrhage, and admission to the neonatal unit. Women with a diagnosis of endometriosis did not have statistically significantly higher odds of preterm delivery (adjusted odds ratio [aOR] 1.85 [95% confidence interval {CI} 0.50–6.90]), but they did have higher odds of postpartum hemorrhage during cesarean section (aOR 3.64 [95% CI 2.07–6.35]) and admission of their newborn infant to the neonatal unit (aOR 3.24 [95% CI 1.08−9.73]). Women with persistent or recurrent deep endometriosis after surgery also had higher odds of placental site disorders (aOR 8.65 [95% CI 1.17–63.71]) and intrapartum sepsis (aOR 3.47 [95% CI 1.02–11.75]). We observed that women with endometriosis do not have higher odds of preterm delivery, irrespective of their disease subtype. However, they do have higher odds of postpartum hemorrhage during the cesarean section and newborn admission to the neonatal unit. [ABSTRACT FROM AUTHOR]

Our study examined the impact of adenomyosis on the chance of clinical pregnancy after IVF and embryo transfer (IVF–ET). This was a prospective multicentre study from April 2013 to October 2015. We included 375 women with history of infertility who attended for a 3D scan prior to IVF–ET. A total of 150/375 (40.0%, 95% confidence interval [CI] 35.2–45.0) women had clinical pregnancy. Women with any feature of adenomyosis had a lower clinical pregnancy rate (21/72 [29.2%, 95% CI 18.6–39.6] versus 129/303 [42.6%, 95% CI 37.1–48.2], P = 0.044, relative risk (RR) 0.68 [95% CI 0.47–1.00]). Logistic regression selected an adenomyosis score of 4 or higher as an independent predictor of clinical pregnancy (odds ratio [OR] 0.35 [95% CI 0.15–0.82]). Estimated probability of clinical pregnancy decreased from 42.7% (95% CI 37.1–48.3) for women with no adenomyosis features to 22.9% (95% CI 13.4–32.6) for those with four and 13.0% (95% CI 2.2–23.9) for those with all seven. Women with adenomyosis have lower clinical pregnancy rate after IVF–ET. Condition severity expressed as a number of morphological features on ultrasound scan increases the magnitude of the effect. [ABSTRACT FROM AUTHOR]