Development of the utero-placental circulation in cesarean scar pregnancies: A case-control study

BACKGROUND: Cesarean scar pregnancies (CSP) are at high risk of pregnancy complications including placenta previa with antepartum hemorrhage, placenta accreta spectrum (PAS) and uterine rupture. OBJECTIVE: To evaluate the development of the utero-placental circulation in the first half of pregnancy in ongoing CSP and compare it to pregnancies implanted in the lower uterine segment above a prior cesarean section scar with no evidence of PAS at delivery. MATERIAL AND METHODS: This was a retrospective case-control study conducted in two tertiary referral centers. The study group included 27 women diagnosed with a live caesarean scar pregnancy in the first trimester of pregnancy who elected to conservative management. The control group included 27 women diagnosed with a low-lying/placenta previa at 19-22 weeks of gestation who had a first and an early second trimester ultrasound examinations. In both groups, the first ultrasound examination was carried out at 6-10 weeks to establish pregnancy location, viability and to confirm the gestational age. The utero-placental and intra-placental vasculatures were examined using color Doppler imaging (CDI) and described semi quantitatively using CDI score 1-4. The remaining myometrial thickness (RMT) was recorded in the study group whereas in the controls the ultrasound features of prior cesarean scar were noted including the presence of a niche. Both CSP and controls had also ultrasound examinations at 11-14 and 19-22 weeks of gestation. RESULTS: The mean CDI vascularity score at the 6-10 weeks ultrasound examination was significantly (P <.001) higher in the CSP group than in the controls. The high vascularity scores 3 and 4 were recorded in 20/27 (74%) cases of the CSP group. There was no vascularity score of 4 and only 3/27 (11%) controls had vascularity score of 3. In 15/27 (55.6%) CSPs the RMT was < 2 mm. At the 11-14 weeks ultrasound examination, there was no significant difference between the groups for the number of cases with increased subplacental vascularity but 12 CSPs (44%) presented with one or more placental lacunae whereas there was no case with lacunae in the controls. In the 18 CSP that progressed into the third trimester, ten were diagnosed with placenta previa creta at birth, including 4 creta and 6 increta. At the 19-22 weeks ultrasound examination, eight of the ten PAS presented with subplacental hypervascularity out of which, six showed also placental lacunae. CONCLUSION: The vascular changes in the utero-placental and intervillous circulations in CSPs are due to the loss of the normal uterine structure in the scar area and the development of placental tissue in proximity of large diameter arteries of the outer uterine wall. The intensity of these vascular changes, development of PAS and risk of uterine rupture depend on the RMT of the cesarean scar defect at the start of pregnancy. A better understanding of the pathophysiology of the utero-placental vascular changes associated with CSP should help in identifying those cases that may develop major complications and thus contribute to counselling women about the risks associated with different management strategies

A prospective evaluation of the IOTA Logistic Regression Models (LR1 and LR2) in comparison to Subjective Pattern Recognition for the diagnosis of ovarian cancer in the outpatient setting

OBJECTIVES: To determine whether IOTA diagnostic models developed for pre-operative diagnosis of ovarian cancer could also be used to differentiate between benign and malignant adnexal tumours in the population of women attending gynaecology outpatient clinics. METHODS: All women referred to our outpatient clinic were first examined by a Level II ultrasound operator. In those diagnosed with adnexal tumours the IOTA LR1/2 protocol was used to evaluate the masses. The LR1 and LR2 models were then used to assess the risk of malignancy. Subsequently women were also examined by a Level 3 examiner who used pattern recognition to differentiate between benign and malignant tumours. Women with an ultrasound diagnosis of malignancy were offered surgery whilst asymptomatic women with presumed benign lesions were offered conservative management with a minimum follow-up of 12 months. The initial diagnosis was compared with two reference standards: histological findings and/or a comparative assessment of tumour morphology on follow-up ultrasound scans. All women in whom tumour classification on follow-up changed from benign to malignant were offered surgery. RESULTS: 489 women who had either or both of the reference standards were included into the final analysis. Their mean age was 50 years (range 16-91) and 45% of them were menopausal. 342/489 (69.9%) women had surgery and 147/489 (30.1%) were managed conservatively. The malignancy rate was 137/489 (28.0%). Overall sensitivities of LR1 and LR2 for the diagnosis of malignancy were 97.1% (95% CI: 92.7-99.2) and 94.9% (95%CI: 89.8-97.9) and specificities were 77.3% (95%CI: 72.5-81.5) and 76.7% (95%CI; 71.9-81.0) respectively (p>0.05). In comparison to pattern recognition [Sensitivity 94.2% (95% CI: 88.8 to 97.4); specificity 96.3% (95% CI: 93.8 to 98.0)], the specificities of IOTA models were significantly lower. (p < 0.0001) A significantly higher number of women would have been offered surgery for suspected cancer if women were assessed using the IOTA models instead of pattern recognition [213/489 (43.6%) versus 142/489 (29.0%)] (p<0.001). CONCLUSIONS: IOTA models maintained their high sensitivity when used in the outpatient setting. Specificity was relatively low which indicates that a significant proportion of women would have been offered unnecessary surgery for suspected ovarian cancer. These findings show that IOTA models could be used as a first stage test to diagnose ovarian cancer in the outpatient setting but a different second stage test is required to minimise the number of false positive findings

Single dose systemic methotrexate versus expectant management for treatment of tubal ectopic pregnancy: A placebo-controlled randomised trial

OBJECTIVE: Methotrexate is routinely used worldwide for medical treatment of clinically stable women with tubal ectopic pregnancies. This is despite the lack of robust evidence to show its superior effectiveness over expectant management. The aim of our multicentre randomised trial study was to compare the success rates of methotrexate with placebo for the conservative treatment of tubal ectopic pregnancies. METHODS: The study was multicentre; it took place in three UK early pregnancy units between January 2006 and June 2014. Inclusion criteria were clinically stable women with a conclusive ultrasound diagnosis of a tubal ectopic pregnancy presenting with low serum β-hCG <1500IU/l. Women were randomly assigned to single systemic injection of methotrexate 50mg/m(2) or placebo. The primary outcome of the study was a binary indicator for success of conservative management, defined as resolution of clinical symptoms and decline of serum β-hCG to <20IU/l or negative urine pregnancy test without the need for any additional medical intervention. An intention to treat analysis was followed. RESULTS: We recruited a total of 80 women: 42 to methotrexate and 38 to placebo. The two arms of the study were balanced in terms of age, ethnicity, obstetric histories, pregnancy characteristics and serum β-hCG and progesterone. The proportions of successes were similar: 83% with methotrexate and 76% with placebo. On univariate analysis, this difference was not statistically significant (χ2(1df) = 0.53; P = 0.23). On multivariate logistic regression, β-hCG was the only covariate which was significantly associated with outcome. The odds of failure increased by 0.15% for each unit increase in β-hCG (OR=1.0015; 95% CI 1.0002 to 1.003; P = 0.02). In 14 women presenting with serum hCG 1000-1500IU/l the success of expectant management was 33% compared to 62% in the methotrexate arm. Although this result was not statistically significant a larger sample size would give us greater power to detect a difference in this subgroup of women, In women with successful conservative management there was no significant difference in median resolution times between methotrexate and placebo arms [17.5 days (IQR 14 - 28.0) (n = 30)] vs [14 days (IQR 7 - 29.5) (n = 25)] (P = 0.73) CONCLUSION: The results of our study do not support routine use of methotrexate for the treatment of clinically stable women diagnosed with tubal ectopic pregnancies presenting with low serum hCG <1500IU/l. Further work is required to identify a subgroup of women with tubal ectopic pregnancies and hCG≥1500IU/l in whom methotrexate may offer a safe and cost-effective alternative to surgery

Ultrasound-guided retrieval of lost intrauterine devices using very fine grasping forceps: a case series

Aim: To assess the efficacy of a novel ultrasound-guided procedure for the retrieval of intrauterine contraceptive devices (IUDs) when the threads are not visible at the external cervical os (‘lost threads’). / Methods: This was a prospective cohort study of consecutive women referred for ultrasound examination because of lost IUD threads. The procedures were performed under local anaesthesia in the outpatient setting. After injection of local anaesthetic, the anterior cervical lip was grasped with a vulsellum forceps. A 5Fr hysteroscopy grasping forceps was introduced transcervically into the uterine cavity under continuous transabdominal ultrasound guidance. The IUD was then grasped and removed from the uterus. Patients’ demographic data, gynaecological history, ultrasound findings, duration of procedure, success rate and pain score were recorded. / Results: Twenty-three consecutive women were included in the study. Ultrasound examination showed an IUD correctly sited in the centre of the uterine cavity in 20/23 (87%), in 2/23 (9%) it was partially embedded in the myometrium and in 1/23 (4%) the IUD was partially sited in the cervical canal. In 8/23 (35%) women the IUD threads were not visible on ultrasound scan. Removal of the IUD was successful in 22/23 (96%) cases with a median operating time of 3 (interquartile range 1.25–4.75) minutes. 15/23 (65%) women experienced no or minimal pain (pain score ≤3), 4/23 (17%) reported moderate pain (pain score 4–6) and 4/23 (17%) described the pain as severe (pain score 7–10). No complications were recorded during or immediately after the procedure. / Conclusions: Ultrasound-guided retrieval of lost IUDs using fine hysteroscopy grasping forceps is a highly successful technique and is well tolerated by women

The role of emotional resilience, childhood parentification, and attachment style on antisocial behaviour in adulthood: a comparison of an offender and normative population

Purpose: Despite a robust link between poor caregiver attachment and antisociality, few studies have examined the influence of parentification and emotional resilience on delinquency in later life, in groups at differing risk for antisocial conduct. Methodology: This pilot study compared the influence of parentification, attachment style (avoidant or anxious) and emotional resilience on adulthood antisocial behaviour in an offender and normative sample. Of the 137 participants in this study, 66 were supervised by the National Probation Service (age M = 36.90, SD = 13.91), and 71 were recruited from community-dwelling and student populations (age M = 31.83, SD = 13.25). Findings: In partial support of the predictions, participants in the offender group reported significantly greater levels of attachment anxiety compared to the normative group. However, emotional resilience was positively associated with antisociality in the normative sample. Research implications: This small-scale investigation indicates value in exploring these specific variables in a larger, matched samples study, to enable clearer comparisons to be made between offender and normative groups. Practical implications: The preliminary findings suggest that attachment anxiety is associated with antisociality in offender populations, which indicate a therapeutic focus on attachment anxiety as part of correctional care and offender rehabilitation. Originality: This study is novel in its aim to examine the influence of childhood parentification, attachment deficits and emotional resilience on adulthood antisociality in participants from a high-risk offender sample and non-high-risk normative sample

Clinical and ultrasound characteristics of surgically removed adnexal lesions with largest diameter ≤ 2.5 cm: a pictorial essay

Objectives: To describe the ultrasound characteristics, indications for surgery and histological diagnoses of surgically removed adnexal masses with a largest diameter of ≤ 2.5 cm (very small tumors), to estimate the sensitivity and specificity of diagnosis of malignancy by subjective assessment of ultrasound images of very small tumors and to present a collection of ultrasound images of surgically removed very small tumors, with emphasis on those causing diagnostic difficulty. Methods: Information on surgically removed adnexal tumors with a largest diameter of ≤ 2.5 cm was retrieved from the ultrasound databases of seven participating centers. The ultrasound images were described using the International Ovarian Tumor Analysis terminology. The original diagnosis, based on subjective assessment of the ultrasound images by the ultrasound examiner, was used to calculate the sensitivity and specificity of diagnosis of malignancy. Results: Of the 129 identified adnexal masses with largest diameter ≤ 2.5 cm, 104 (81%) were benign, 15 (12%) borderline malignant and 10 (8%) invasive tumors. The main indication for performing surgery was suspicion of malignancy in 22% (23/104) of the benign tumors and in all 25 malignant tumors. None of the malignant tumors was a unilocular cyst (vs 50% of the benign tumors), all malignancies contained solid components (vs 43% of the benign tumors), 80% of the borderline tumors had papillary projections (vs 21% of the benign tumors and 20% of the invasive malignancies) and all invasive tumors and 80% of the borderline tumors were vascularized on color/power Doppler examination (vs 44% of the benign tumors). The ovarian crescent sign was present in 85% of the benign tumors, 80% of the borderline tumors and 50% of the invasive malignancies. The sensitivity of diagnosis of malignancy by subjective assessment of ultrasound images was 100% (25/25) and the specificity was 86% (89/104). Excluding unilocular cysts, the specificity was 71% (37/52). Analysis of images illustrated the difficulty in distinguishing benign from borderline very small cysts with papillations and benign from malignant very small well vascularized (color score 3 or 4) solid adnexal tumors. Conclusions: Very small malignant tumors manifest generally accepted ultrasound signs of malignancy. Small unilocular cysts are usually benign, while small non-unilocular masses, particularly ones with solid components, incur a risk of malignancy and pose a clinical dilemma

ESHRE/ESGE female genital tract anomalies classification system—the potential impact of discarding arcuate uterus on clinical practice

STUDY QUESTION What would be a potential impact of implementing the new ESHRE/European Society of Gynaecological Endoscopy (ESGE) female genital anomalies classification system on the management of women with previous diagnosis of arcuate uteri based on the modified American Society for Reproductive Medicine (ASRM) criteria? SUMMARY ANSWER A significant number of women with previous diagnosis of arcuate uteri are reclassified as having partial septate uteri according to the new ESHRE/ESGE classification system which may increase the number of remedial surgical procedures. WHAT IS KNOWN ALREADY The ESHRE/ESGE classification system has defined measurement techniques, reference points and specific cut-offs to facilitate the differentiation between normal and septate uteri. These criteria have been arbitrarily defined and they rely on the measurement of uterine wall thickness and depth of distortion of uterine fundus. STUDY DESIGN, SIZE, DURATION This was a retrospective cohort study. We searched our ultrasound clinic database from January 2011 to December 2014 to identify all women diagnosed with arcuate uterus on three-dimensional ultrasound according to the modified ASRM criteria. PARTICIPANTS/MATERIALS, SETTING, METHODS For each woman, the ultrasound images were stored in our clinical database and they were re-examined according to ESHRE/ESGE specifications. The presence and location of all acquired uterine anomalies, such as fibroids or adenomyosis was noted. We applied the two diagnostic approaches as specified by the ESHRE/ESGE classification: the main option (MO) and the alternative option (AO). We used the Kappa statistic to quantify the agreement between the two approaches. We also compared the number of previous miscarriages in women with normal and partial septate uteri according to the ESHRE/ESGE classification. Non-parametric Mann–Whitney and Kruskal–Wallis tests were used for the analyses and receiver-operating characteristic curves were constructed to assess the predictive values of the calculated uterine distortion indices for the detection of women at risk of suffering multiple pregnancy losses. MAIN RESULTS AND THE ROLE OF CHANCE We included 270 women diagnosed with arcuate uterus in the study. In all, 77 women (28.5%, 95% confidence interval (CI) 23.1–33.9) had evidence of fibroids or adenomyosis. These abnormalities precluded the application of either proposed ESHRE/ESGE techniques to assess uterine morphology in 25 women (9.3%, 95% CI 5.8–12.7). When using the MO, 138/237 (58.2%, 95% CI 51.9–64.3) women were diagnosed with partial septate uterus compared to 61/230 (26.5%, 95% CI 21.2–32.6) women when using the AO. In 222 women in whom we were able to apply both MO and AO, there was agreement in the diagnosis of septate uterus between the two techniques in 146/222 cases (65.8%, 95% CI 59.3–71.7; Kappa 0.42, 95%CI 0.35–0.5). There was no statistical difference in the proportion of women with history of previous multiple miscarriages between those diagnosed with normal or partial septate uteri using either MO (6.2%, 95% CI 2.9–12.9 vs. 9.5%, 95% CI 5.6–15.6; P = 0.47) or AO (7.2%, 95% CI 4.2–12.1 vs. 11.7%, 95% CI 5.8–22.2; P = 0.29). LIMITATIONS, REASONS FOR CAUTION This study was retrospective in nature and the definition of arcuate uterus used in the study is not universally accepted. The reproductive history data were collected retrospectively and therefore may be prone to bias. WIDER IMPLICATIONS OF THE FINDINGS There are methodological weaknesses in the new ESHRE/ESGE classification system which would need to be addressed in future revisions. There was no significant difference in the past reproductive outcomes between women diagnosed with normal and anomalous uteri and the clinicians should exercise caution when offering surgical correction to women diagnosed with partial septate uteri using the new ESHRE/ESGE classification. STUDY FUNDING/COMPETING INTEREST(S) No study funding was received and no competing interests are present

Women's experiences of early pregnancy assessment unit services: a qualitative investigation

Objective: To explore the experiences of women who had used an Early Pregnancy Assessment Unit (EPAU) service in the UK and make recommendations for their improvement. Design: Qualitative interview study. Setting: Early Pregnancy Assessment Units in the UK. Sample: A maximum variation sample of women who had consented to be interviewed having attended one of 26 EPAUs involved in the VESPA study in 2018. Methods: In-depth telephone interviews with 38 women. A thematic framework analysis was conducted, with a focus on how experiences varied according to EPAU service configuration and clinical pathway. Main outcome measures: Women's experiences of EPAU services. Results: We found that EPAUs are highly valued, and women's experiences were generally positive. However, women reported a range of issues that negatively affected their experience. These included difficulties accessing the service, insensitive management of the investigation and treatment options of pregnancy loss, poor communication, insufficient information and a lack of support for their psychological health. These issues were not strongly associated with EPAU configuration or clinical pathway. Conclusions: Recommendations to improve women's experiences include the separation of EPAUs from general maternity services, and we make suggestions on how to remove barriers to access by reviewing opening hours, how to provide sensitive patient management, such as automatically cancelling appointments and scans following pregnancy loss, and how to improve communication, both with women and their partners as well as with other parts of the health service. Tweetable abstract: Early Pregnancy Assessment Units are highly valued by women but aspects of their care experiences, particularly around sensitive management of pregnancy loss, could be improved