Objective-To improve the interpretation of future studies in women who are initially diagnosed with a pregnancy of unknown location (PUL), we propose a consensus statement with definitions of population, target disease and final outcome.
90.9% of ectopic pregnancies in this study population can be accurately diagnosed using TVS prior to surgery. The diagnosis of an ectopic pregnancy should be based on the positive visualization of an adnexal mass using TVS. This should in turn result in a decrease in the number of false positive laparoscopies.
Preoperative real-time dynamic TVS evaluation using the sliding sign seems to establish with a high degree of certainty whether the POD is obliterated. Given the increased risk of deep infiltrating endometriosis in women with POD obliteration, the TVS sliding sign technique may also be useful in the identification of women who may be at a higher risk for bowel endometriosis.
Advances in preoperative diagnostic as well as surgical techniques for the treatment of endometriosis, especially deep endometriosis call for a classification system that includes all aspects of the disease such as peritoneal, ovarian endometriosis and deep endometriosis and secondary adhesions. The widely accepted r-ASRM classification has certain limitations due to 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 as well as 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 via a consensus process and will be described in detail-the #Enzian classification.
Objective To assess the accuracy of new transvaginal ultrasoundscan-based markers and to compare them to conventional ultrasound methods used in the detection of common pelvic pathology in women with chronic pelvic pain (CPP).Design A prospective observational study.
Setting Teaching hospital.Population A total of 120 consecutive women with CPP undergoing transvaginal ultrasonography before either diagnostic or operative laparoscopy.Methods Anatomical abnormalities, e.g. endometrioma or hydrosalpinx (hard markers), were documented. The woman was then assessed for the presence or absence of 'soft markers' (reduced ovarian mobility and site-specific pelvic tenderness).Main outcome measure Presence or absence of pelvic pathology noted during laparoscopy.Results Seventy women had pelvic pathology, of whom 51 had endometriosis alone, 7 both endometriosis and pelvic adhesions, 6 pelvic adhesions, 1 hydrosalpinx with endometriosis and 5 hydrosalpinx and pelvic adhesions. The likelihood ratio for the hard markers was infinity (specificity was 100%), for the soft makers 1.9 (95% CI 1.2-3.1) and for a 'normal' ultrasound 0.18 (0.09-0.34). The pre-test probability of pelvic disease in our population of women with CPP was 58%, and this probability of disease was raised to 100% with the presence of hard markers and to 73% with the presence of soft markers. The pre-test probability of 58% fell to 20% when ultrasound finding was found to be normal.
ConclusionThis new approach improves the detection and exclusion of significant pathology in women with CPP and may lead to a reduction in the number of unnecessary laparoscopies carried out on women with CPP.
In unselected women attending an EPU, pregnancy location can be diagnosed accurately in over 90% of all pregnancies and in 73.9% of ectopic pregnancies with a single TVS.
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