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Externally validate the AAGL staging system against surgical complexity, and compare diagnostic accuracy with rASRM stage, as was done in original publication.Retrospective, diagnostic accuracy study SETTING: : Multicentre (Sydney, Australia) PATIENTS: : 317 patients (January 2016 - October 2021) were used in the final analysis INTERVENTIONS: : A database of patients with coded surgical data was analysed.Three independent observers assigned an AAGL surgical stage (1 to 4) as the index test, and surgical complexity level (A to D) as the reference standard. Results from the most accurate of the three observers were used in the final analysis.The weighted kappa score for the overall performance of AAGL stage and rASRM to predict AAGL level was 0.48 and 0.48 respectively (no difference). This was lower than the weighted kappa of 0.62 in the original paper. Diagnostic accuracy (sensitivity, specificity, PPV and NPV) for stage 1 to predict level A 98.5%, 64.3%, 66.3%, and 98.3%; stage 2 to predict level B 31.2%, 90.5%, 27.0%, and 92.1 %; stage 3 to predict level C 12.3%, 94.1%, 59.3%, and 60.7%; stage 4 to predict level D 95.65%, 88.10%, 38.60%, and 99.62%. AUROC for A vs B/C/D (cut-point 9) was 0.87, A/B vs C/D (cut-point 16) was 0.78 and A/B/C vs D (cut-point 22) was 0.94.There was weak to moderate agreement between AAGL stage and AAGL surgical complexity level. Across all key indicators, the AAGL system did not perform as well in this external validation, nor did it outperform rASRM as it did in the reference paper. Results suggest the system is not generalizable.

Objectives: A conflicting body of evidence suggests localized periodontal inflammation to spread systemically during pregnancy inducing adverse pregnancy outcomes. This systematic review and meta-analysis aimed to specifically evaluate the relationship between periodontitis and preeclampsia. Methods: Electronic searches were carried out in Medline, Pubmed, Cochrane Controlled Clinical Trial Register to identify and select observational case-control and cohort studies that analyzed the association between periodontal disease and preeclampsia. Prisma guidelines and Moose checklist were followed. Results: Thirty studies including six cohorts and twenty-four case-control studies were selected. Periodontitis was significantly associated with increased risk for preeclampsia, especially in a subgroup analysis including cohort studies and subgroup analysis with lower-middle-income countries. Conclusion: Periodontitis appears as a significant risk factor for preeclampsia, which might be even more pronounced in lower-middle-income countries., Comment: 58 pages, 13 figures

STUDY QUESTION How is endometriosis extent described by the #Enzian classification compared to the revised American Society for Reproductive Medicine (rASRM) stages in women undergoing radical surgery for deep endometriosis (DE)? SUMMARY ANSWER The prevalence and severity grade of endometriotic lesions and adhesions as well as the total number of #Enzian compartments affected by DE increase on average with increasing rASRM stage; however, DE lesions are also present in rASRM stages 1 and 2, leading to an underestimation of disease severity when using the rASRM classification. WHAT IS KNOWN ALREADY Endometriotic lesions can be accurately described regarding their localization and severity by sonography as well as during surgery using the recently updated #Enzian classification for endometriosis. STUDY DESIGN, SIZE, DURATION This was a prospective multicenter study including a total of 735 women between January 2020 and May 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS Disease extent in women undergoing radical surgery for DE at tertiary referral centers for endometriosis was intraoperatively described using the #Enzian and the rASRM classification. MAIN RESULTS AND THE ROLE OF CHANCE A total of 735 women were included in the study. Out of 31 women with rASRM stage 1, which is defined as only minimal disease, 65% (i.e. 20 women) exhibited DE in #Enzian compartment B (uterosacral ligaments/parametria), 45% (14 women) exhibited DE in #Enzian compartment A (vagina/rectovaginal septum) and 26% (8 women) exhibited DE in #Enzian compartment C (rectum). On average, there was a progressive increase from rASRM stages 1–4 in the prevalence and severity grade of DE lesions (i.e. lesions in #Enzian compartments A, B, C, FB (urinary bladder), FU (ureters), FI (other intestinal locations), FO (other extragenital locations)), as well as of endometriotic lesions and adhesions in #Enzian compartments P (peritoneum), O (ovaries) and T (tubo-ovarian unit). In addition, the total number of #Enzian compartments affected by DE lesions on average progressively increased from rASRM stages 1–4, with a maximum of six affected compartments in rASRM stage 4 patients. LIMITATIONS, REASONS FOR CAUTION Interobserver variability may represent a possible limitation of this study. WIDER IMPLICATIONS OF THE FINDINGS The #Enzian classification includes the evaluation of DE in addition to the assessment of endometriotic lesions and adhesions of the ovaries and tubes and may therefore provide a comprehensive description of disease localization and extent in women with DE. STUDY FUNDING/COMPETING INTEREST(s) No funding was received for this study. All authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER N/A.

Deep endometriosis (DE) surgery often requires advanced knowledge in laparoscopic surgery due to the location of affected organs such as the bowel, vagina, rectovaginal space including adjacent nerve structures, ureters and urinary bladder. Patients are at risk of serious complications and sequelae like anastomotic leakage, rectovaginal fistula and voiding dysfunction. Detailed knowledge of disease extent and location by transvaginal sonography (TVS) can aid the clinician to pre-operatively plan complex surgeries and estimate associated risks. Classification systems like #Enzian can be used in combination with TVS to assess surgical risk factors.

BackgroundRandomised controlled trials (RCTs) evaluating ectopic pregnancy have different outcomes which are defined and measured in diverse ways, which limits their ability to inform evidence-based clinical practice.ObjectiveTo address methodological deficiencies in published RCTs and systematic reviews, this study has developed a core outcome set to guide future research in ectopic pregnancy.DesignTo identify potential outcomes, we performed a comprehensive literature review and interviews with individuals with lived experience in ectopic pregnancy. Potential core outcomes were then entered into a three-round Delphi survey. 154 participants from six continents, comprising healthcare professionals, researchers, and individuals with lived experience in ectopic pregnancy, completed all three rounds of the Delphi survey. Outcomes were prioritised at three consensus development meetings and recommendations were developed on how to report these outcomes where possible.SubjectsHealthcare professionals, researchers, and individuals with lived experience in ectopic pregnancyResultsSix outcomes reached full consensus, including treatment success, resolution time, number of additional interventions, adverse events, mortality and severe morbidity, and treatment satisfaction.ConclusionThe core outcome set with six outcomes for ectopic pregnancy will help standardise reporting of clinical trials, facilitate implementation of findings into clinical practice, and enhance patient centred care.

Objectives Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency. Methods Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves. Results Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794–0.879) and high urgency (AUC 0.902, 95 % CI 0.860–0.945). Conclusion Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.

Objective To investigate the agreement of measurements of the three diameters of rectosigmoid deep endometriosis (DE) lesions between presurgical evaluation using transvaginal sonography (TVS) and postsurgical specimen measurement (PSM). Methods This was a prospective observational multicenter study including symptomatic women undergoing surgical treatment for DE involving the rectosigmoid, by either discoid or segmental resection, from April 2017 to December 2019. TVS was performed presurgically to evaluate lesion size (craniocaudal–midsagittal length, anteroposterior thickness and transverse diameter), in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement, and was compared with PSM. The agreement of lesion dimensions between the two methods was assessed by Bland–Altman plots and limits of agreement and additionally by the intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. Systematic and proportional bias was assessed using the paired t-test. Results A total of 207 consecutive women were eligible for inclusion. Forty-one women were excluded, leaving 166 women for final analysis. A total of 123 segmental resections and 46 discoid resections were performed (both procedures were performed in three women). The mean difference between TVS and PSM was 0.90 (95% CI, 0.85–0.95) mm for lesion length measurements, 1.03 (95% CI, 0.98–1.09) mm for lesion thickness measurements and 0.84 (95% CI, 0.79–0.89) mm for transverse diameter measurements. Bland–Altman analysis demonstrated good agreement between the two methods for measurements of lesion length. Furthermore, there was good reliability and correlation between TVS and PSM for lesion length measurements, as demonstrated by an ICC of 0.82 (95% CI, 0.75–0.87) and Pearson's correlation coefficient of 0.72 (95% CI, 0.62–0.80), moderate-to-good reliability and correlation for lesion thickness measurements, with an ICC of 0.76 (95% CI, 0.67–0.82) and Pearson's correlation coefficient of 0.61 (95% CI, 0.51–0.70), and poor-to-moderate reliability and correlation for transverse diameter measurements, with an ICC of 0.58 (95% CI, 0.39–0.71) and Pearson's correlation coefficient of 0.46 (95% CI, 0.33–0.58). Conclusion Preoperative TVS determines accurately rectosigmoid DE lesion length. TVS can thereby contribute to optimal planning of surgical treatment options in women with rectosigmoid DE. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Objectives Pouch of Douglas (POD) obliteration is a severe consequence of inflammation in the pelvis, often seen in patients with endometriosis. The sliding sign is a dynamic transvaginal ultrasound (TVS) test that can diagnose POD obliteration. We aimed to develop a deep learning (DL) model to automatically classify the state of the POD using recorded videos depicting the sliding sign test. Methods Two expert sonologists performed, interpreted, and recorded videos of consecutive patients from September 2018 to April 2020. The sliding sign was classified as positive (i.e. normal) or negative (i.e. abnormal; POD obliteration). A DL model based on a temporal residual network was prospectively trained with a dataset of TVS videos. The model was tested on an independent test set and its diagnostic accuracy including area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, and positive and negative predictive value (PPV/NPV) was compared to the reference standard sonologist classification (positive or negative sliding sign). Results In a dataset consisting of 749 videos, a positive sliding sign was depicted in 646 (86.2%) videos, whereas 103 (13.8%) videos depicted a negative sliding sign. The dataset was split into training (414 videos), validation (139), and testing (196) maintaining similar positive/negative proportions. When applied to the test dataset using a threshold of 0.9, the model achieved: AUC 96.5% (95% CI: 90.8–100.0%), an accuracy of 88.8% (95% CI: 83.5–92.8%), sensitivity of 88.6% (95% CI: 83.0–92.9%), specificity of 90.0% (95% CI: 68.3–98.8%), a PPV of 98.7% (95% CI: 95.4–99.7%), and an NPV of 47.7% (95% CI: 36.8–58.2%). Conclusions We have developed an accurate DL model for the prediction of the TVS-based sliding sign classification. Lay summary Endometriosis is a disease that affects females. It can cause very severe scarring inside the body, especially in the pelvis − called the pouch of Douglas (POD). An ultrasound test called the 'sliding sign' can diagnose POD scarring. In our study, we provided input to a computer on how to interpret the sliding sign and determine whether there was POD scarring or not. This is a type of artificial intelligence called deep learning (DL). For this purpose, two expert ultrasound specialists recorded 749 videos of the sliding sign. Most of them (646) were normal and 103 showed POD scarring. In order for the computer to interpret, both normal and abnormal videos were required. After providing the necessary inputs to the computer, the DL model was very accurate (almost nine out of every ten videos was correctly determined by the DL model). In conclusion, we have developed an artificial intelligence that can interpret ultrasound videos of the sliding sign that show POD scarring that is almost as accurate as the ultrasound specialists. We believe this could help increase the knowledge on POD scarring in people with endometriosis.

Endometriosis is a chronic benign gynaecological condition characterized by pelvic pain, subfertility and delay in diagnosis. There is an emerging philosophical shift from gold standard histopathological diagnosis through laparoscopy to establishing diagnosis through noninvasive imaging.The ENZIAN classification system was updated in 2021 to be suitable for both diagnostic imaging and laparoscopy. The accuracy of transvaginal ultrasound (TVUS) in diagnosing endometriosis varies depending on location of the lesion. A recent international pilot study found that when ultrasound is performed in accordance with the IDEA consensus, a higher detection of deep endometriosis is seen, with an overall sensitivity of 88% and specificity of 79% compared with direct surgical visualization.Although ultrasound can detect adenomyosis, deep endometriosis and endometriomas, it is not possible to reliably detect superficial endometriosis. In the instance of a negative ultrasound with persistence of symptoms despite medical therapy, laparoscopy should be considered for diagnosis and treatment.

Transvaginal ultrasonography (TVS) should be the first-line investigation in patients with suspicion of deep endometriosis and, in particular, of rectosigmoid endometriosis. TVS cannot assess the presence of intestinal nodules located proximally to the sigmoid (such as ileal or cecal endometriotic nodules), because these lesions are beyond the field of the transvaginal probe. The ultrasonographic findings of rectosigmoid endometriosis are the presence of an irregular hypoechoic nodule in the anterior wall of the rectosigmoid colon. The learning curve for diagnosing rectosigmoid endometriosis by TVS is quite short; approximately, 40 scans are required to a sonographer who trained in general gynecologic ultrasonography to become proficient at diagnosing bowel endometriosis. Several meta-analyses confirmed the high diagnostic performance of TVS in diagnosing rectosigmoid endometriosis. The presence of “soft markers” (negative sliding sign and kissing ovaries) facilitates the diagnosis of rectosigmoid endometriosis. Enhanced TVS (rectal water-contrast transvaginal ultrasonography, sonovaginography, and tenderness-guided transvaginal ultrasonography) does not improve the performance of TVS in diagnosing rectosigmoid endometriosis. These investigations, however, may be useful to ascertain the depth of infiltration of endometriosis in the intestinal wall or the presence of rectal stenosis. Magnetic resonance imaging has the same performance of TVS in diagnosing rectosigmoid endometriosis; however, it should be recommended as a second-line technique in the preoperative workup of patients with previous equivocal TVS findings.

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.

Study Objective The aim of this study was to validate temporally and externally the ultrasound-based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis. Design A multicenter, international, retrospective, diagnostic accuracy study was carried out between January 2016 and April 2018 on women with suspected pelvic endometriosis. Setting Four different centers with advanced ultrasound and laparoscopic services were recruited (1 for temporal validation and 3 for external validation). Patients Women with pelvic pain and suspected endometriosis. Interventions All women underwent a systematic transvaginal ultrasound and were staged according to the UBESS system, followed by classification of laparoscopic level of complexity according to the Royal College of Obstetricians and Gynaecologists (RCOG) levels 1 to 3. Measurements and Main Results UBESS I, II, and III were then correlated with RCOG levels 1, 2, and 3, respectively. A comparison between temporal and external sites (skipping “A”) and between each site was performed in terms of the diagnostic accuracy of UBESS to predict RCOG laparoscopic skill level. A total of 317 consecutive women who underwent laparoscopy with suspected endometriosis were included. Complete transvaginal ultrasound and laparoscopic surgical outcomes were available for 293/317 (92.4%). At the temporal site, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of UBESS I to predict RCOG level 1 were 80.0%,73.8%, 94.9%, 97.2%, 60.2%, 14.5%, and 0.3%, respectively; of UBESS II to predict RCOG level 2 were 81.0%, 70.6%, 82.0%, 26.7%, 96.8%, 3.9%, and 0.3%, respectively; of UBESS III to predict RCOG level 3 were 91.0%, 85.7%, 92.4%, 75.0%, 96.1%, 11.3%, and 0.2%, respectively. At the external sites, the results of UBESS I to predict RCOG level 1 were 90.3%, 92.0%, 88.4%, 90.2%, 90.5%, 7.9%, and 0.1% respectively; UBESS II to predict RCOG level 2 were 89.2%, 100.0%, 88.5%, 37.5%, 100.0%, 8.7%, and 0.0%, respectively; and UBESS III to predict RCOG level 3 were 86.0%, 67.6%, 98.2%, 96.2%, 82.1%, 37.8%, and 0.3%, respectively. When patients requiring ureterolysis (i.e., RCOG level 3) in the absence of bowel endometriosis were excluded (n = 54), the sensitivity of UBESS III to correctly classify RCOG level 3 increased from 85.7% to 96.7% at the temporal site (n = 42) and from 67.6% to 96.0% at the external sites (n = 12) (p Conclusion The results from this external validation study suggest that UBESS in its current form is not generalizable unless there is either or both bowel deep endometriosis and cul-de-sac obliteration present. The major limitation appears to be the misclassification of women who require surgical ureterolysis in the absence of bowel endometriosis.

BACKGROUND: There are no current standardized and accepted methods to characterize the surgical complexity of a laparoscopic hysterectomy. This leads to challenges when trying to understand the relationship between the patient and the surgical features and outcomes. The development of core feature sets for laparoscopic hysterectomy studies would enable future trials to measure the similar meaningful variables that can contribute to surgical complexity and outcomes.OBJECTIVE: The purpose of this study was to develop a core feature set for the surgical complexity of a laparoscopic hysterectomy.STUDY DESIGN: This was an international Delphi consensus study. A comprehensive literature review was conducted to identify the features that were reported in studies on laparoscopic hysterectomy complexity. All the features were presented for evaluation and prioritization to key experts in 3 rounds of online surveys. A priori consensus criteria were used to reach agreement on the final outcomes for inclusion in the core feature set.RESULTS: Experts represented North America, South America, Europe, Africa, Asia, and Oceania. Most of them had fellowship training in minimally invasive gynecologic surgery. Sixty-four potential features were entered into round 1. Experts reached a consensus on 7 features to be included in the core feature set. These features were grouped under the following domains: 1) patient features, 2) uterine features, and 3) nonuterine pelvic features. The patient features include obesity and other nonobesity comorbidities that alter or limit the ability of a surgeon to perform the basic or routine steps in a laparoscopic hysterectomy. The uterine features include the size and presence of fibroids. The nonuterine pelvic features include endometriosis, ovarian cysts, and adhesions (bladder-to-uterus, rectouterine pouch, and other adhesions).CONCLUSION: Using robust consensus science methods, an international consortium of experts has developed a core feature set that should be assessed and reported in all future studies that aim to assess the relationship between the patient features and surgical outcomes of laparoscopic hysterectomy.

To develop a model, including clinical features and ultrasound findings, to predict the need for ureterolysis (i.e., dissection of the ureter) during laparoscopy for endometriosis.A retrospective observational study of patients who had undergone transvaginal ultrasound (TVS) according to the International Deep Endometriosis Analysis consensus and subsequent laparoscopy ± excision of endometriosis between January 2017 and February 2021 was conducted.Sydney Medical School Nepean, University of Sydney, Nepean Hospital, and Blue Mountains Hospital, New South Wales, Australia.177 patients.The demographic, clinical, TVS, and intraoperative data were extracted through electronic clinical records.Multicategorical decision-tree and baseline models were built to choose the variables most correlated to the outcome under study. Receiver operating characteristic analysis was performed on the binary classification. Based on our results, we selected the variables performing with significant statistical differences (p.05). During the study period, 177 consecutive patients were recruited and divided into 2 subgroups, ureterolysis (51.4%) and nonureterolysis (48.6%). Ureterolysis was noted in 87.5% of patients in which the left ovary was immobile (p.001) and in 82.5% in which the right ovary was fixed (p.001). For patients with right uterosacral ligament (USL) deep endometriosis (DE), ureterolysis was performed in 96.2% patients (p.001) and 64.6% (p = .043) for left USL DE. Among patients with bowel DE, the proportion of patients undergoing ureterolysis was 95.5% (p.001). The prognostic variables used in the final model to predict ureterolysis included dyschezia, absence of ovarian mobility, presence of right or left USL DE, and presence of bowel DE on TVS. According to the developed model, the baseline risk for performing ureterolysis is 20% in our sample. The overall model performance demonstrated an area under the receiver operating characteristic curve 0.82.Our study demonstrates that it is possible to predict the need for ureterolysis with clinical and sonographic data. Furthermore, patients presenting with a combination of the variables of our model (dyschezia, ovarian immobility, USL, and bowel DE lesions) have a high risk of ureterolysis. In contrast, patients without these features have a low risk (approximately 20%) of needing ureterolysis.

Objective To perform a pilot diagnostic accuracy study of a novel transvaginal ultrasonography procedure called saline-infusion sonoPODography to predict superficial endometriosis in patients with suspected endometriosis. Study design A prospective single-center diagnostic accuracy study was performed from September 2019-November 2019. The index test sonoPODography was performed and the results were documented in a standardized fashion. SonoPODography was performed by installing saline into the pouch of Douglas (POD) via an intrauterine balloon catheter to create an acoustic window between the ultrasound probe and surrounding structures. The pelvis was then assessed for the presence or absence of superficial endometriosis using pre-defined features. Direct visualization at laparoscopy and histological assessment of excised endometriosis confirmed the outcome. The diagnostic performance of sonoPODography was evaluated. Results 42 consecutive participants underwent sonoPODography. Superficial endometriosis was identified by sonoPODography in 24/42 (57.1 %) and in 37/42 (88.1 %) participants by direct visualization at laparoscopy. The overall diagnostic performance of sonoPODography was: accuracy 69.1 %, sensitivity 64.9 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 27.8 %. Amongst those without deep endometriosis/endometriomas/pouch of Douglas obliteration, the diagnostic performance was: accuracy 80.0 %, sensitivity 77.7 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 33.3 %. The pouch of Douglas peritoneum was the most common site of superficial endometriosis. Conclusions SonoPODography is a novel ultrasound-based procedure that permits the direct visualization of superficial with respectable diagnostic accuracy. The findings of this pilot study are promising and justify the initiation of a larger outpatient study. SonoPODography may establish new avenues for the non-invasive diagnosis and investigation of endometriosis.

It is well-established that there is a strong association between ovarian endometriomas (OE) and deep endometriosis (DE) and rectouterine pouch (RP) obliteration. We aimed to determine the prevalence of DE and RP obliteration in the presence of normal ovaries.We conducted a multicentre retrospective cohort study from January 2009 to December 2017 using a prospective multicentre data registry. Participants included patients with signs and/or symptoms of endometriosis who underwent excisional laparoscopic surgery at one of eight hospitals. The primary outcome was the prevalence of DE and RP obliteration, which was compared between women with normal ovaries (i.e., no OE) and women with ovaries containing OE. Secondary outcomes evaluated included rates of DE by anatomic site between women with and without OE.The ovaries did not contain an OE in 319 of 410 patients (77.8%). The prevalence of DE and RP obliteration in this cohort was 25.4% and 9.7% (81 and 31 patients), respectively; whereas, in patients with OE, DE and RP obliteration prevalence was 68.1% and 60.4% (62 and 55 patients), respectively (P0.001 for both DE and RP obliteration). The uterosacral ligaments were the most common site for DE (right: 47/319 [14.7%]; left: 42/319 [13.2%]).In patients who visited a tertiary care centre with endometriosis without ovarian involvement, 1 in 4 had DE and 1 in 10 had RP obliteration. These prevalence rates should encourage knowledge and skills dissemination to improve non-invasive imaging diagnosis overall. In patients with symptoms or signs suggestive of endometriosis, a basic pelvic ultrasound that ends at evaluation for OE should not be regarded as reassuring.

ispartof: ULTRASOUND IN OBSTETRICS & GYNECOLOGY vol:55 issue:6 pages:871-878 ispartof: location:England status: published

To evaluate if a decreasing human chorionic gonadotropin (hCG) between day (D) 1 and D7 is an equal or better predictor of tubal ectopic pregnancy (EP) resolution following methotrexate (MTX) treatment than the current standard of care.This was a retrospective cohort prognostic accuracy study of women with a transvaginal ultrasound (TVS)-confirmed tubal EP (November 2006-December 2015). After single-dose MTX treatment, D4/7 hCG ratios were compared with that of D1/D7 in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to predict EP resolution.Tubal EP was diagnosed in 301/7350 (4.1%) women who underwent TVS for early pregnancy-related complaints. The patients were managed accordingly: expectant, 84/301 (27.9%); MTX, 65/301 (21.6%); surgery, 152/301 (50.5%). A D1/D7 hCG ratio ≤0.85 predicted successful resolution of tubal EPs (P0.001) treated with MTX with sensitivity 0.84 [95% confidence interval (CI), 0.69-0.94]), specificity 0.71 [95%CI, 0.48-0.89], PPV 0.84 [95%CI, 0.69-0.94], NPV 0.84 [95%CI, 0.69-0.94], which is comparable to the prognostic performance of the D4/7 protocol.In patients with tubal EP carefully selected for and treated with MTX, it may be reasonable to eliminate the D4 hCG in the follow-up algorithm.

Background: chronic pelvic pain (CPP) is a common gynaecological condition accounting for 20% of all gynaecological referrals. There are wide ranges of causes with overlapping symptomatology, therefore the management of the condition is a formidable challenge for clinicians. The aetiology of CPP is heterogeneous and in many cases, no clear diagnosis can be reached. It is in this scenario that the label of chronic pelvic pain syndrome (CPPS) can be applied. We defined women with CPPS as having a minimum duration of pain of at least 6 months, including with a diagnosis of pelvic congestion syndrome, but excluding pain caused by a condition such as endometriosis. Many surgical interventions have been tried in isolation or in conjunction with non-surgical interventions in the management with variable results. Surgical interventions are invasive and carry operative risks. Surgical interventions must be evaluated for their effectiveness prior to their prevalent use in the management of women with CPPS.Objectives: to review the effectiveness and safety of surgical interventions in the management of women with CPPS.Search methods: we searched the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase and PsycINFO, on 23 April 2021 for any randomised controlled trials (RCT) for surgical interventions in women with CPPS. We also searched the citation lists of relevant publications, two trial registries, relevant journals, abstracts, conference proceedings and several key grey literature sources.Selection criteria: RCTs with women who had CPPS. The review authors were prepared to consider studies of any surgical intervention used for the management of CPPS. Outcome measures were pain rating scales, adverse events, psychological outcomes, quality of life (QoL) measures and requirement for analgesia.Data collection and analysis: Two review authors independently evaluated studies for inclusion and extracted data using the forms designed according to Cochrane guidelines. For each included trial, we collected information regarding the method of randomisation, allocation concealment, blinding, data reporting and analyses. We reported pooled results as mean difference (MDs) or odds ratios (OR) and 95% confidence interval (CI) by the Mantel-Haenszel method. If similar outcomes were reported on different scales, we calculated the standardised mean difference (SMD). We applied GRADE criteria to judge the overall certainty of the evidence.Main results: our studies met our inclusion criteria involving 216 women with CPP and no identifiable cause. Adhesiolysis compared to no surgery or diagnostic laparoscopy We are uncertain of the effect of adhesiolysis on pelvic pain scores postoperatively at three months (MD -7.3, 95% CI -29.9 to 15.3; 1 study, 43 participants; low-certainty evidence), six months (MD -14.3, 95% CI -35.9 to 7.3; 1 study, 43 participants; low-certainty evidence) and 12 months postsurgery (MD 0.00, 95% CI -4.60; 1 study, 43 participants; very low-certainty evidence). Adhesiolysis may improve both the emotional wellbeing (MD 24.90, 95% CI 7.92 to 41.88; 1 study, 43 participants; low-certainty evidence) and social support (MD 23.90, 95% CI -1.77 to 49.57; 1 study, 43 participants; low-certainty evidence) components of the Endometriosis Health Profile-30, and both the emotional component (MD 32.30, 95% CI 13.16 to 51.44; 1 study, 43 participants; low-certainty evidence) and the physical component of the 12-item Short Form (MD 22.90, 95% CI 10.97 to 34.83; 1 study, 43 participants; low-certainty evidence) when compared to diagnostic laparoscopy. We are uncertain of the safety of adhesiolysis compared to comparator groups due to low-certainty evidence and lack of structured adverse event reporting. No studies reported on psychological outcomes or requirements for analgesia. Laparoscopic uterosacral ligament ablation or resection compared to diagnostic laparoscopy/other treatment We are uncertain of the effect of laparoscopic uterosacral ligament/nerve ablation (LUNA) or resection compared to other treatments postoperatively at three months (OR 1.26, 95% CI 0.40 to 3.93; 1 study, 51 participants; low-certainty evidence) and six months (MD -2.10, 95% CI -4.38 to 0.18; 1 study, 74 participants; very low-certainty evidence). At 12 months post-surgery, we are uncertain of the effect of LUNA on the rate of successful treatment compared to diagnostic laparoscopy. One study of 56 participants found no difference in the effect of LUNA on non-cyclical pain (P = 0.854) or dyspareunia (P = 0.41); however, there was a difference favouring LUNA on dysmenorrhea (P = 0.045) and dyschezia (P = 0.05). We are also uncertain of the effect of LUNA compared to vaginal uterosacral ligament resection on pelvic pain at 12 months (MD 2.00, 95% CI 0.47 to 3.53; 1 study, 74 participants; very low-certainty evidence). We are uncertain of the safety of LUNA or resection compared to comparator groups due to the lack of structured adverse event reporting. Women undergoing LUNA may require more analgesia postoperatively than those undergoing other treatments (P < 0.001; 1 study, 74 participants). No studies reported psychological outcomes or QoL.Authors' conclusions: we are uncertain about the benefit of adhesiolysis or LUNA in management of pain in women with CPPS based on the current literature. There may be a QoL benefit to adhesiolysis in improving both emotional wellbeing and social support, as measured by the validated QoL tools. It was not possible to synthesis evidence on adverse events as these were only reported narratively in some studies, in which none were observed. With the inadequate objective assessment of adverse events, especially long-term adverse events, associated with adhesiolysis or LUNA for CPPS, there is currently little to support these interventions for CPPS.

Ultrasound has become an invaluable tool for the workup and management of patients with symptoms and signs of endometriosis. Until the publication on the systematic approach to ultrasound in patients with suspected endometriosis by the International Deep Endometriosis Analysis (IDEA) group, there was significant heterogeneity in the scientific literature in nomenclature, definitions and components of this particular scan. Despite the concise four steps outlined in their consensus statement, the nature of this ultrasound is advanced, complex and time consuming. Without intending to oversimplify the task, we propose a practical and comprehensive approach on how to perform an ultrasound scan to assess the pelvis of a woman with potential underlying endometriosis.

This study aimed to investigate whether treatment of gingivitis in pregnant women affects pregnancy outcomes.This was a systematic review and meta-analysis of clinical trials using PRISMA guidelines to appraise the treatment of gingivitis on pregnancy outcomes, including preterm birth (less than 37 weeks), low birth weight (less than 2,500 g), gestational age and birth weight. Pooled odds ratios (OR), mean difference, and 95% confidence intervals (CI) were calculated using the random effect model. A search was conducted in databases including Medline, Pubmed, Web of Science, Google Scholar and Embase without restrictions regarding language or date of publication.Three clinical trials comprising 1,031 participants were included in this review. Treatment of gingivitis during pregnancy was associated with a decreased risk of preterm birth (OR = 0.44, 95% CI [0.20-0.98], P = 0.045) and higher birth weight (weighted mean difference (WMD) =105.36 g, 95% CI [36.72-174.01], P = 0.003). Gestational age at birth in the treatment group (WMD = 0.31 weeks, 95% CI [-0.02-0.64], P = 0.64) as well as likelihood of low birth weight (OR = 0.92, 95% CI [0.38-2.21], P = 0.851) did not reach statistical significance.The results of this meta-analysis indicate that treatment of gingivitis in pregnancy may improve pregnancy outcomes including increased infants birth weight and reduced preterm births. Future trials are warranted to validate the true effect size of gingivitis treatment on pregnancy outcomes.

Objective Emergency ultrasound (EUS) has become an integral part of emergency medicine, and the core pillars of governance, infrastructure, administration, education and quality assurance (QA) are vital for its quality and continued growth. We aimed to assess the status of these vital pillars among Australasian EDs. Methods A survey among the clinical leads in ultrasound (CLUS) in Australasian EDs from November 2020 to April 2021. Results We analysed a total of 98 responses from CLUS representing 98 EDs. Most CLUS (85%) held EUS qualifications (CCPU 57%, DDU 18%, other 9%) but 15% had none. Only 66% of CLUS had dedicated clinical support time, and a mere 5% had administrative personnel support. Up to three ultrasound machines in 62% of EDs, but only 26% of EDs had secured image archiving facilities. In-house credentialing and the Australasian College for Emergency Medicine (ACEM) trainee special skills placement were available in 50% and 32% of EDs, respectively. Only 11% of EDs had regular EUS training for FACEMs, and only 66% of EDs had regular EUS education for emergency medicine trainees. Only 20 EDs had sonographer educators. Regarding EUS QA, only 33% of EDs provided formal EUS report, 23% of EDs conducted regular image reviews and 37% of EDs audited EUS performance. Only 35% of EDs had high-level disinfection equipment, and 56% of EDs had formal transducer disinfection protocols. Conclusion Despite ACEM recommendations for the practice of EUS, Australasian EDs still lack vital governance, administrative support, infrastructure, education and QA processes. Prompt actions such as ACEM mandating these recommendations are required to improve resource allocation by health services.

STUDY QUESTION Is there an ideal imaging modality for the detection of uterosacral ligaments/torus uterinus (USL), rectovaginal septum (RVS) and vaginal deep endometriosis (DE) in women with a clinical history of endometriosis? SUMMARY ANSWER The sensitivity for the detection of USL, RVS and vaginal DE using MRI seems to be better than transvaginal ultrasonography (TVS), whilst the specificity of both were excellent. WHAT IS KNOWN ALREADY The surgical management of women with DE can be complex and requires advanced laparoscopic skills with maximal cytoreduction being vital at the first procedure to provide the greatest symptomatic benefit. Owing to a correlation of TVS findings with surgical findings, preoperative imaging has been used to adequately consent women and plan the appropriate surgery. However, until publication of the consensus statement by the International Deep Endometriosis Analysis Group in 2016, there were significant variations within the terms and definitions used to describe DE in the pelvis. STUDY DESIGN, SIZE, DURATION A systematic review and meta-analysis was conducted using Embase, Google Scholar, Medline, PubMed and Scopus to identify studies published from inception to May 2020, of which only those from 2010 were included owing to the increased proficiency of the sonographers and advancements in technology. PARTICIPANTS/MATERIALS, SETTING, METHODS All prospective studies that preoperatively assessed any imaging modality for the detection of DE in the USL, RVS and vagina and correlated with the reference standard of surgical data were considered eligible. Study eligibility was restricted to those including a minimum of 10 unaffected and 10 affected participants. MAIN RESULTS AND THE ROLE OF CHANCE There were 1977 references identified from which 10 studies (n = 1188) were included in the final analysis. For the detection of USL DE, the overall pooled sensitivity and specificity for all TVS techniques were 60% (95% CI 32–82%) and 95% (95% CI 90–98%), respectively, and for all MRI techniques were 81% (95% CI 66–90%) and 83% (95% CI 62–94%), respectively. For the detection of RVS DE, the overall pooled sensitivity and specificity for all TVS techniques were 57% (95% CI 30–80%) and 100% (95% CI 92–100%), respectively. For the detection of vaginal DE, the overall pooled sensitivity and specificity for all TVS techniques were 52% (95% CI 29–74%) and 98% (95% CI 95–99%), respectively, and for all MRI techniques were 64% (95% CI 40–83%) and 98% (96% CI 93–99%). Pooled analyses were not possible for other imaging modalities. LIMITATIONS, REASONS FOR CAUTION There was a low quality of evidence given the high risk of bias and heterogeneity in the included studies. There are also potential biases secondary to the risk of misdiagnosis at surgery owing to a lack of either histopathological findings or expertise, coupled with the surgeons not being blinded. Furthermore, the varying surgical experience and the lack of clarity regarding complete surgical clearance, thereby also contributing to the lack of histopathology, could also explain the wide range of pre-test probability of disease. WIDER IMPLICATIONS OF THE FINDINGS MRI outperformed TVS for the per-operative diagnosis of USL, RVS and vaginal DE with higher sensitivities, although the specificities for both were excellent. There were improved results with other imaging modalities, such as rectal endoscopy-sonography, as well as the addition of bowel preparation or ultrasound gel to either TVS or MRI, although these are based on individual studies. STUDY FUNDING/COMPETING INTEREST(S) No funding was received for this study. M.L. reports personal fees from GE Healthcare, grants from the Australian Women’s and Children’s Foundation, outside the submitted work. B.W.M. reports grants from NHMRC, outside the submitted work. G.C. reports personal fees from GE Healthcare, outside the submitted work; and is on the Endometriosis Advisory Board for Roche Diagnostics. REGISTRATION NUMBER Prospective registration with PROSPERO (CRD42017059872) was obtained.

Advances in preoperative diagnostics as well as in surgical techniques for the treatment of endometriosis, especially for deep endometriosis, call for a classification system, that includes all aspects of the disease such as peritoneal endometriosis, ovarian endometriosis, deep endometriosis, and secondary adhesions. The widely accepted revised American Society for Reproductive Medicine classification (rASRM) has certain limitations because of its incomplete description of deep endometriosis. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable tool for staging deep endometriosis, but does not include peritoneal or ovarian disease or adhesions. To overcome these limitations, a comprehensive classification system for complete mapping of endometriosis, including anatomical location, size of the lesions, adhesions and degree of involvement of the adjacent organs, that can be used with both diagnostic and surgical methods, has been created through a consensus process and will be described in detail—the #Enzian classification.

Objectives To determine whether ovarian fixation at transvaginal ultrasound (TVU) is a marker for need of laparoscopic pelvic sidewall surgery (ie, ureterolysis or dissection of adhesions involving the pelvic sidewall). The relationship between ovarian immobility at TVU with respect to endometriosis staging using the revised American Fertility Society (r-AFS) classification was also evaluated. Methods Retrospective diagnostic accuracy study was performed in a tertiary referral hospital and two private hospitals. Sixty-six women with pelvic pain underwent detailed TVU preoperatively followed by laparoscopic endometriosis surgery. TVU ovarian mobility findings (ie, mobile versus fixed ovary) were compared to surgical findings, the need for laparoscopic pelvic sidewall surgery and r-AFS score (I-IV). Results Complete ultrasound and surgical data were available for 66 of 77 (86%) women. Twenty-six of 66 (40%) had isolated superficial peritoneal endometriosis, 15 of 66 (23%) had ovarian endometrioma (OE), 13 of 66 (20%) had pelvic deep endometriosis (DE). Twenty-seven of 66 (41%) had ovarian fixation at TVU. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of ovarian fixation at TVU for the prediction of need for laparoscopic pelvic sidewall surgery was 71%, 61%, 86%, 85%, and 62%, respectively (P = .0002). Ovarian fixation at TVU was significantly associated with the presence of ipsilateral OE, pouch of Douglas obliteration, pelvic DE nodules, and r-AFS stage III/IV (moderate/severe) endometriosis (all P-values Conclusions Ovarian fixation at TVU appears to be a marker for moderate/severe endometriosis and the need for laparoscopic pelvic sidewall surgery. This sign may be a valuable "red flag" for identifying women at increased risk of requiring an advanced laparoscopic surgeon, and in turn, improve surgical planning.

OBJECTIVE To assess the general population's knowledge regarding the utility and availability of tools to diagnosis endometriosis, with a focus on ultrasound. DESIGN An international cross-sectional online survey study was performed between August and October 2019. SETTING AND POPULATION 5301 respondents, representing 73 countries. METHODS In all, 23 questions survey focused on knowledge of endometriosis diagnosis distributed globally via patient- and community-endometriosis groups using social media. MAIN OUTCOMES AND MEASURES Descriptive data of the knowledge of diagnostic tools for diagnosing endometriosis, including details about diagnosis using ultrasound. RESULTS In all, 84.0% of respondents had been previously diagnosed with endometriosis, 71.5% of whom had been diagnosed at the time of surgery. Ultrasound and MRI were the methods of diagnosis in 6.5% and 1.8%, respectively. A total of 91.8%, 28.8% and 16.6% of respondents believed surgery, ultrasound and MRI could diagnose endometriosis, respectively (more than one answer allowed). In those diagnosed by surgery, 21.7% knew about ultrasound as a diagnosis method, whereas in those diagnosed non-surgically, 51.5% knew (P

We performed a systematic review and meta-analysis with the aim to answer whether operative laparoscopy is an effective treatment in a woman with demonstrated endometriosis compared with alternative treatments. Moreover, we aimed to assess the risks of operative laparoscopy compared with those of alternatives. In addition, we aimed to systematically review the literature on the impact of patient preference on decision making around surgery.We searched MEDLINE, Embase, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey, and Web of Science from inception through May 2019. In addition, a manual search of reference lists of relevant studies was conducted.Published and unpublished randomized controlled trials (RCTs) in any language describing a comparison between surgery and any other intervention were included, with particular reference to timing and its impact on pain and fertility. Studies reporting on keywords including, but not limited to, endometriosis, laparoscopy, pelvic pain, and infertility were included. In the anticipated absence of RCTs on patient preference, all original research on this topic was considered eligible.In total, 1990 studies were reviewed. Twelve studies were identified as being eligible for inclusion to assess outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies of interest were identified to evaluate patient preferences. There is evidence that operative laparoscopy may improve overall pain levels at 6 months compared with diagnostic laparoscopy (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.61-4.34; p.001; 2 RCTs, 102 participants; low-quality evidence). Because the quality of the evidence was very low, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy probably yields little or no difference regarding clinical pregnancy rates compared with diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99-1.92; p = .06; 4 RCTs, 624 participants; moderate-quality evidence). It is uncertain if operative laparoscopy yields a difference in adverse outcomes when compared with diagnostic laparoscopy (RR, 1.98; 95% CI, 0.84-4.65; p = .12; 5 RCTs, 554 participants; very-low-quality evidence). No studies reported on the progression of endometriosis to a symptomatic state or progression of extent of disease in terms of volume of lesions and locations in asymptomatic women with endometriosis. We found no studies that reported on the timing of surgery. No quantitative or qualitative studies specifically aimed at elucidating the factors informing a woman's choice for surgery were identified.Operative laparoscopy may improve overall pain levels but may have little or no difference with respect to fertility-related or adverse outcomes when compared with diagnostic laparoscopy. Additional high-quality RCTs, including comparing surgery to medical management, are needed, and these should report adverse events as an outcome. Studies on patient preference in surgical decision making are needed (International Prospective Register of Systematic Review registration number: CRD42019135167).

We are proposing a shift in mindset in the field of endometriosis, whereby care for patients with endometriosis mirrors that of patients with gynaecological cancer. To achieve this, we advocate for the recognition of complex benign gynaecology as a subspecialty. Since the establishment of gynaecological oncology as a subspecialty, outcomes for patients with ovarian cancer have improved, with their care managed by multidisciplinary teams in specialized units. Despite the marked difference in the primary treatment goal between these two conditions, they share common diagnostic and therapeutic challenges. We believe that care management by a multidisciplinary team of dedicated and specialized health care professionals will lead to improved outcomes, including improved quality of life, for people living with endometriosis.