Intra- and interobserver reproducibility of pelvic ultrasound for the detection and measurement of endometriotic lesions

STUDY QUESTION: What is the interobserver and intraobserver reproducibility of pelvic ultrasound for the detection of endometriotic lesions? SUMMARY ANSWER: Pelvic ultrasound is highly reproducible for the detection of pelvic endometriotic lesions. WHAT IS KNOWN ALREADY: Transvaginal ultrasound (TVS) has been widely adopted as the first-line assessment for the diagnosis and assessment of pelvic endometriosis. Severity of endometriosis as assessed by ultrasound has been shown to have good concordance with laparoscopy (kappa 0.79). The reproducibility of TVS for assessment of ovarian mobility and pouch of Douglas obliteration using the 'sliding sign' has already been described in the literature. However, there is no available data in the literature to demonstrate the intraobserver repeatability of measurements for endometriotic cysts and nodules. STUDY DESIGN SIZE DURATION: This was a prospective observational cross-sectional study conducted over a period of 12 months. We included 50 consecutive women who were all examined by two operators (A and B) during their clinic attendance. PARTICIPANTS/MATERIALS SETTING METHODS: The study was carried out in a specialist endometriosis centre. We included all consecutive women who had ultrasound scans performed independently by two experienced operators during the same visit to the clinic. The outcomes of interest were the inter- and intraobserver reproducibility for the detection of endometriotic lesions. We also assessed repeatability of the measurements of lesion size. MAIN RESULTS AND THE ROLE OF CHANCE: There was a good level of agreement between operator A and operator B in detecting the presence of pelvic endometriotic lesions (k = 0.72). There was a very good level of agreement between operators in identifying endometriotic cysts (k = 0.88) and a good level of agreement in identifying endometriotic nodules (k = 0.61). The inter- and intraobserver repeatability of measuring endometriotic cysts was excellent (intra-class correlation (ICC) ≥ 0.98). There was good interobserver measurement repeatability for bowel nodules (ICC 0.88), but the results for nodules in the posterior compartment were poor (ICC 0.41). The intraobserver repeatability for nodule size measurements was good for both operators (ICC ≥0.86). LIMITATIONS REASONS FOR CAUTION: Within this cohort, there was insufficient data to perform a separate analysis for nodule size in the anterior compartment. All examinations were performed within a specialised unit with a high prevalence of deep endometriosis. Our findings may not apply to operators without intensive ultrasound training in the diagnosis of pelvic endometriosis. WIDER IMPLICATIONS OF THE FINDINGS: These findings are important because ultrasound has been widely accepted as the first-line investigation for the diagnosis of pelvic endometriosis, which often determines the need for future investigations and treatment. The detection and measurement of bowel nodules is essential for anticipation of surgical risk and planning surgical excision. STUDY FUNDING/COMPETING INTERESTS: The authors have no conflict of interest. No funding was obtained for this work

Ultrasound diagnosis of endometrial cancer by subjective pattern recognition in women with postmenopausal bleeding: a prospective inter-rater agreement and reliability study

OBJECTIVES: The objective of our study was to assess the inter-rater agreement and reliability of using subjective pattern recognition to diagnose endometrial cancer on ultrasound in women with postmenopausal bleeding. METHODS: This was a prospective cross-sectional study at a gynaecological rapid access clinic, between Oct 2016 - Dec 2017, where consecutive women with postmenopausal bleeding and endometrial thickness of ≥4.5mm on transvaginal ultrasound scan were included. We excluded women on hormone replacement therapy, tamoxifen or with a history of primary gynaecological malignancy. Two raters independently performed ultrasound examinations, blinded to each other's findings, and classified women into having uniformly thickened endometrium, benign polyp or endometrial cancer, by subjective pattern recognition. Inter-rater reliability of the ultrasound diagnoses was assessed by using Cohen's kappa statistics. All women subsequently underwent either outpatient endometrial biopsy, hysteroscopy or hysterectomy. RESULTS: Forty women were included in the study with a median age of 61 (IQR 57-69) and a median endometrial thickness of 11.0mm (IQR 6.2-20.3). Final histological analysis confirmed 16 (40%) women with endometrial cancer, 16 (40%) endometrial polyps, 4 (10%) atrophic endometrium, 3 (7%) proliferative endometrium and 1 (3%) endometrial hyperplasia. Inter-rater agreement for the ultrasound diagnoses of uniformly thickened endometrium, polyp and cancer, were 14/16 (87.5%), 22/30 (73.3%) and 28/34 (82.4%), respectively; the inter-rater reliability was good (κ = 0.69, 95% C.I. 0.49-0.88). When the ultrasound diagnoses were combined as either cancer or no cancer, the inter-rater agreement was 85% and the inter-rater reliability was also good (κ = 0.78, 95% C.I. 0.61-0.95). Rater A correctly identified 14/16 cancers and Rater B identified 15/16. Endometrial cancers were misdiagnosed as benign polyps on ultrasound in two women by Rater A, and in one woman by Rater B. The overall accuracies of Rater A and Rater B in differentiating between benign endometrial pathologies and malignancy were 90% and 85%, respectively. CONCLUSIONS: Our results showed good inter-rater reliability of subjective pattern recognition in diagnosing uniformly thickened endometrium, polyp and cancer on ultrasound in women with postmenopausal bleeding. Our findings should facilitate wider use of subjective pattern recognition in routine clinical practice

Physical resolution of tubal ectopic pregnancy on ultrasound imaging following successful expectant management

RESEARCH QUESTION What is the time required for complete physical resolution of tubal ectopic pregnancies diagnosed on ultrasound imaging in women undergoing successful expectant management? DESIGN A prospective observational cohort study of 177 women who had successful expectant management of tubal ectopic pregnancy, who attended a single Early Pregnancy Unit between January 2014 and December 2018. All participants were monitored until their serum β-hCG dropped to non-pregnant levels and with two-weekly follow-up ultrasound scans until resolution of the pregnancy. RESULTS 112/177 (63.8%, 95% CI 56.3-70.9) of tubal ectopic pregnancies were indiscernible on ultrasound 2 weeks after serum β-hCG had returned to non-pregnant levels. In 8/177 (4.5%, 95% CI 2.0-8.7) physical resolution took longer than 78 days. There was a positive correlation between biochemical and physical resolution of tubal ectopic pregnancy (r=0.21, p=0.006). CONCLUSIONS Physical resolution of tubal ectopic pregnancy is often prolonged and is positively correlated with initial and maximum β-hCG levels. Our results indicate that β-hCG resolution cannot be used as the end-point of expectant management of tubal ectopic pregnancy, which should be considered when counselling women and planning for future pregnancies. KEY MESSAGE In a significant proportion, physical resolution of tubal ectopic pregnancy takes several weeks following the return of serum β-hCG to non-pregnant levels. Women should be advised to delay trying for another pregnancy for three months, to avoid resolving pregnancies being misdiagnosed as new ones and to reduce the theoretical risk of recurrent ectopic, due to temporary tubal blockage by the resolving trophoblast

Risk prediction of major haemorrhage with surgical treatment of live cesarean scar pregnancies

Objective: To evaluate the association between demographic and ultrasound variables and major intra-operative blood loss during surgical transcervical evacuation of live caesarean scar pregnancies. Study Design: This was a retrospective cohort study conducted in a tertiary referral center between 2008 and 2019. We included all women diagnosed with a live caesarean scar ectopic pregnancy who chose to have surgical management in the study center. A preoperative ultrasound was performed in each patient. All women underwent transcervical suction curettage under ultrasound guidance. Our primary outcome was the rate of postoperative blood transfusion. The secondary outcomes were estimated intra-operative blood loss (ml), rate of retained products of conception, need for repeat surgery, need for uterine artery embolization and hysterectomy rate. Descriptive statistics were used to describe the variables. Univariate and multivariable logistic regression models were constructed using the relevant covariates to identify the significant predictors for severe blood loss. Results: During the study period, 80 women were diagnosed with a live caesarean scar pregnancy, of whom 62 (78%) opted for surgical management at our center. The median crown-rump length was 9.3 mm (range 1.4–85.7). Median blood loss at the time of surgery was 100 ml (range, 10–2300), and six women (10%; 95%CI 3.6–20) required blood transfusion. Crown-rump length and presence of placental lacunae were significant predictive factors for the need for blood transfusion and blood loss > 500 ml at univariate analysis (p < .01); on multivariate analysis, only crown-rump length was a significant predictor for need for blood transfusion (OR = 1.072; 95% CI 1.02–1.11). Blood transfusion was required in 6/18 (33%) cases with the crown-rump length ≥ 23 mm (≥9+0 weeks of gestation), but in none of 44 women presenting with a crown-rump length < 23 mm (p < .01). Conclusion: The risk of severe intraoperative bleeding and need for blood transfusion during or after surgical evacuation of live caesarean scar pregnancies increases with gestational age and is higher in the presence of placental lacunae. One third of women presenting at ≥ 9 weeks of gestation required blood transfusion and their treatment should be ideally arranged in specialized tertiary centers

Predictive value of presence of amniotic sac without visible embryonic heartbeat in diagnosis of early embryonic demise

OBJECTIVES: This study aimed to assess the diagnostic value and impact on management of early embryonic demise of visualising an amniotic sac without a live embryo on ultrasound imaging. We also examined the potential effect this finding would have on the rate of follow up visits in early pregnancy units if incorporated into current diagnostic algorithms. METHODS: This was a prospective cohort study assessing all pregnant women who attended a single specialist early pregnancy unit from July 2017 to November 2018 with symptoms of pain and/or bleeding, or with a history of ectopic pregnancy or miscarriage, at less than 14 weeks' gestation. The detailed initial ultrasound findings were documented including whether an amniotic sac was present in normally sited intrauterine pregnancies in the absence of a live embryo. Women were followed-up until a conclusive diagnosis was made. RESULTS: The study included 6012 women attending with early pregnancy complications during the study period. A conclusive diagnosis was reached on the initial scan in 4221 (70.2%), whilst 1135 (18.9%) had pregnancies of uncertain viability and 656 (10.9%) had pregnancies of unknown location. All women with pregnancies of uncertain viability required follow up ultrasound scans to differentiate between live pregnancies and early embryonic demise. An amniotic sac in the absence of a live embryo was found in 174/1135 (15.3%) of women with pregnancies of uncertain viability at their initial ultrasound scan. In all cases the diagnosis of early embryonic demise was confirmed in all 134 of these women who attended their follow-up scans. The presence of amniotic sac without live embryo at the initial visit had a specificity of 100% (95% CI 98.53-100.00) and positive predictive value of 100% CI 87.37-88.24) in the diagnosis of early embryonic demise. A total of 1403/6012 (23.3%) women were asked to attend for follow-up ultrasound scans to resolve diagnostic uncertainties. 268/656 (40.9%) women with PUL required follow up scans, so the majority of follow up scans needed to reach a conclusive diagnosis were in women with pregnancies of uncertain viability (1135/1403 (80.1%)). By using the presence of amniotic sac without a live embryo to diagnose miscarriage at the initial visit the number of follow-up scans for pregnancies of uncertain viability would be reduced by 14.4% which accounted for 11% of all follow up scans during the study period. CONCLUSIONS: Our study showed that the finding of an amniotic sac without a live embryo on ultrasound ('amniotic sac sign') is a reliable marker of early pregnancy failure and could reduce the number of follow-up scans by 11% in cases of diagnostic uncertainty. This article is protected by copyright. All rights reserved