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 INTEREST(S) The authors have no conflict of interest. No funding was obtained for this work.
What is the time required for complete physical resolution of tubal ectopic pregnancies diagnosed on ultrasound imaging in women undergoing successful expectant management? DesignA 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 Downloaded for Anonymous User (n/a) at University College London Hospitals NHS Foundation 2020. For personal use only. No other uses without permissio 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. Results112/177 (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). ConclusionsPhysical 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.
Objectives To assess the inter‐rater agreement and reliability of using subjective pattern recognition for diagnosing endometrial cancer (EC) on ultrasound in women with postmenopausal bleeding (PMB). Methods This was a prospective cross‐sectional study conducted at a gynecological rapid‐access clinic, between October 2016 and December 2017, in which consecutive women with PMB and endometrial thickness of ≥ 4.5 mm on transvaginal ultrasound examination were included. Women on hormone replacement therapy or tamoxifen and those with a history of primary gynecological malignancy were excluded. Two raters independently performed ultrasound examinations, blinded to each other's findings, and classified women as having uniformly thickened endometrium, benign endometrial polyp or EC, using subjective pattern recognition. Inter‐rater reliability of ultrasound diagnosis was assessed using Cohen's kappa (κ) statistic. 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 (interquartile range (IQR), 57–69) years and a median endometrial thickness of 11.0 (IQR, 6.2–20.3) mm. Final histological analysis confirmed 16 (40%) women with EC, 16 (40%) with benign endometrial polyp, four (10%) with atrophic endometrium, three (8%) with proliferative endometrium and one (3%) with endometrial hyperplasia. Inter‐rater agreement for the ultrasound diagnoses of uniformly thickened endometrium, benign endometrial polyp and EC was 14/16 (87.5%), 22/30 (73.3%) and 28/34 (82.4%), respectively; inter‐rater reliability was good (κ = 0.69; 95% CI, 0.49–0.88). When the ultrasound diagnoses were grouped as either cancer or no cancer, inter‐rater agreement was 85% and inter‐rater reliability was good (κ = 0.78; 95% CI, 0.61–0.95). Rater A correctly identified 14/16 cases of EC and Rater B identified 15/16. EC was 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 90%, respectively. Conclusions Our results show good inter‐rater reliability of subjective pattern recognition in diagnosing uniformly thickened endometrium, benign endometrial polyp and EC on ultrasound in women with PMB. Our findings should facilitate wider use of subjective pattern recognition in routine clinical practice. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
What are the novel findings of this work? This is the largest study to show that the finding on ultrasound of an amniotic sac without a live embryo (amniotic sac sign) is a reliable sign of early pregnancy failure. What are the clinical implications of this work? Incorporating the amniotic sac sign into current diagnostic algorithms could reduce by more than 10% the need for follow-up scans in cases of diagnostic uncertainty in early pregnancy.
Aim: In the current review study, we present recent data regarding the importance of intertwin estimated fetal weight (EFW) and crown rump length (CRL) discordance for the prediction of adverse perinatal outcome both in monochorionic and in dichorionic diamniotic gestations. Results: Twins with significant weight disparity are associated with higher rates of perinatal morbidity and mortality, regardless of gestational age at delivery. However, there is no agreement regarding as to the cut off value above which the perinatal outcome is unfavorably affected and the threshold range from 10 to 30%. On the other hand, CRL discrepancy has proved to be a weak predictor of adverse outcomes, such as fetal or neonatal death in fetuses without chromosomal and structural abnormalities. In clinical practice, decisions about obstetric surveillance of discordant twin gestations, frequency of fetal sonographic monitoring and time of delivery are usually based on amniotic fluid volume and Doppler assessments on a weekly basis. Conclusion: Significant EFW discordance leads to adverse perinatal outcome, although the cut-off value has not yet been estimated. CRL discrepancy is not correlated well with adverse perinatal outcome. However, increased monitoring of women with EFW and CRL discrepancy is suggested.
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