Background: Whilst validated quality-of-recovery (QoR) tools exist for general surgery, there is no specific obstetric equivalent. We aimed to develop and evaluate a modified QoR score after elective Caesarean delivery. Methods: Twenty-two obstetric specific items were selected following review and modification of the QoR-40 survey by 16 experts and interviews with 50 stakeholders. Item selection was based on relevance to Caesarean delivery and endorsement by >66% of stakeholders. Items were tested on women pre-delivery, at 24 h, and 25 h post-delivery. An 11item obstetric-specific QoR score (ObsQoR-11) was created based on correlation with a numerical rating scale (NRS) of global health status (r>0.20) at all time points. Reliability, responsiveness, acceptability, and feasibility were tested. Results: One hundred and fifty-two women responded to the 22-item questionnaire pre-delivery (complete in 146), 100 at 24 h, and 10 at 25 h. The ObsQoR-11 correlated with the global health status NRS (r¼0.53; 95% confidence interval: 0.43e0.62; P<0.0001) and discriminated good vs poor recovery (NRS score 70 vs <70 mm) at 24 h. There was a negative correlation between the ObsQoR-11 score at 24 h and hospital length of stay (r¼e0.39; P¼0.003). ObsQoR-11 was reliable (internal consistency: 0.85; split-half 0.76; testeretest intra-class correlation coefficient r i >0.6 in 82% of items) and responsive (Cohen effect size: 1.36; standardised response mean: 0.85). A longer 22-item ObsQoR had high (97%) completion rates and short (median: 2 min) completion times. Conclusions: The ObsQoR-11 provides a valid, reliable, and responsive global assessment of recovery after elective Caesarean delivery.

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/ probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m -2 ); low BMI (<18.5 kg.m -2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.

Introduction Regional anesthesia is a rapidly growing subspecialty. There are few published meta-analyses exploring pain outcome measures utilised in regional anesthesia randomized controlled trials (RCTs), which may be due to heterogeneity in outcomes assessed. This systematic review explores postoperative pain outcomes utilised in regional anesthesia RCTs. Methods A literature search was performed using three databases (Medline, Embase, and CINAHL). Regional anesthesia RCTs with postoperative pain as a primary outcome were included if written in English and published in one of the top 20 impact factor journals between 2005 and 2017. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. Results From the 31 included articles, 15 different outcome measures in total were used to assess postoperative pain. The most commonly (16/31) used outcome measures were verbal numerical grading of pain out of 10, total opioid consumption, and visual analogue scale 10 cm (VAS). The need for analgesia was used as an outcome measure where studies did not use a pain rating score. Ten studies reported pain scores on activity and 27/31 studies utilised ≥2 pain outcomes. Time of measurement of pain score also varied with a total of 51 different time points used in total. Conclusion Analysis of the articles demonstrated heterogeneity and inconsistency in choice of pain outcome and time of measurement within regional anesthesia studies. Identification of these pain outcomes utilised can help to create a definitive list of core outcomes, which may guide future researchers when designing such studies.

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What are the novel findings of this work?This is the first large prospective study to investigate using a non-invasive approach the prevalence of endometriosis in women with a wide range of complaints attending a gynecological outpatient clinic. What are the clinical implications of this work?We found that deep pelvic endometriosis was much more prevalent than thought previously. It is therefore important that effective non-invasive diagnostic tests are offered routinely to women during their initial outpatient visit to facilitate timely diagnosis and effective treatment of this often-debilitating disease.

Study question What is the impact of pregnancy on the morphological features and behaviour of ovarian endometrioma and deep endometriotic nodules? Summary answer For the majority of women, despite features of decidualization being common in the first and second trimesters, endometrioma and deep nodules will regress during pregnancy. What is known already Deep endometriosis and endometrioma subtypes are thought to affect approximately 5% of women in pregnancy, with about 50% being unaware of their condition. Pregnancy has a major effect on the size and morphological features of endometrioma, with published studies reporting a tendency for cyst regression. Decidualization, a hormonally induced pregnancy-related phenomenon, effects endometriomas and may raise suspicion of an ovarian malignancy. The behaviour of deep endometriosis in pregnancy is poorly understood and there is limited available literature on the subject. Study design, size, duration This was a prospective observational cohort study conducted over three years at a single centre. We included 65 women with a viable eutopic pregnancy and concomitant ultrasound features of deep and/or ovarian endometriosis. The study was conducted at University College London Hospital, which is a tertiary level referral unit for early pregnancy complications and an accredited Endometriosis Centre. Participants/materials, setting, methods All women who participated provided written consent and were invited for surveillance ultrasound examinations at the time of their routine scans in pregnancy. All scans were performed by a single operator to minimise interobserver error. The change in size of endometrioma and nodules were reported as change in their mean diameter. Endometrioma with irregular thick inner walls, hyperechoic papillary projections and/or high vascularity and hyperechoic nodules with moderate to high vascularity were reported as decidualized. Main results and the role of chance Sixty five women were included in the study. Their median age was 34 years (23-44), and the gestation at presentation was 7 + 6 weeks (3 + 6 to 18 + 0). 47/65(72%) were nulliparous, 48/65(74%) had a background of endometriosis and 19/65(29%) conceived following IVF. There were 10/65(15%, 95%CI 7-24) women with endometrioma alone, 28/65(43%, 95%CI 31-55) with nodules alone and the remaining 27/65(42%, 95%CI 30-54) had both. 29/34(85%, 95%CI 73-97) women with endometrioma experienced cyst regression, 2/34(6%, 95%CI 0-14) experienced cyst growth and in 10/34(29%, 95%CI 14-45) there was complete resolution of all cysts. 43/51(84%, 95%CI 74-94) women with nodules experienced nodule regression, 2/51(4%, 95%CI 0-9) experienced nodule growth and in 4/51(8%, 95%CI 0-15) there was complete resolution of all nodules. 5/37(14%, 95%CI 3-25) women who attended postnatal follow-up, experienced complete resolution of all endometriotic lesions during pregnancy . In 10/34(29%, 95%CI 14-45) women with endometrioma and 27/51(53%, 95%CI 39-67) with nodules, a pattern of growth was observed in the first and second trimesters, which preceded regression in later pregnancy. Features of decidualization were observed in 17/34(50%, 95%CI 33-67) women with endometrioma, most commonly in the 1st trimester, and 25/51(49%, 95%CI 35-63) women with nodules, most commonly observed in the 2nd trimester. Limitations, reasons for caution The lack of extended follow-up fails to establish the long-term impact of pregnancy, lactation and postnatal contraception on the behaviour of endometriosis. This study relies on ultrasound alone for the detection of moderate/severe disease with no correlation with laparoscopy. Wider implications of the findings Sonographic changes of endometriosis in pregnancy are difficult to differentiate from characteristics of malignant lesions. Better understanding of the appearance of endometriosis in pregnancy is vital to reduce unnecessary surgical procedures, associated morbidity to mothers and babies and will help clinicians to counsel women regarding the significance of their condition. Trial registration number The study was registered on Research Registry (Unique identifying number: researchregistry4569).

ObjectiveTo assess the morphological appearance of deep endometriosis and ovarian endometrioma in pregnancy using pelvic ultrasound examinationMethodsThis was a prospective observational cohort study conducted over three years at a single centre. We included 65 women with a live normally‐sited pregnancy and concomitant ultrasound feature of deep and/or ovarian endometriosis. The study was conducted at University College London Hospital, which is a tertiary level referral unit for early pregnancy complications and an accredited Endometriosis Centre. All women who participated provided written consent and were invited for surveillance ultrasound examinations at the time of their routine scans in pregnancy. All scans were performed by a single operator to minimise interobserver error. The change in size of endometrioma and nodules were reported as change in their mean diameter. Endometrioma with irregular thick inner walls, hyperechoic papillary projections and/or high vascularity and hyperechoic nodules with moderate to high vascularity were reported as decidualized.ResultsSixty five women were included in the study. Their median age was 34 years (23‐44), and the gestation at presentation was 7+6 weeks (3+6 to 18+0). 47/65 (72%) were nulliparous, 48/65 (74%) had a background of endometriosis and 19/65 (29%) conceived following IVF. There were 10/65 (15%, 95% CI 7‐24) women with endometrioma alone, 28/65 (43%, 95% CI 31‐55) with nodules alone and the remaining 27/65 (42%, 95% CI 30‐54) had both.29/34 (85%, 95% CI 73‐97) women with endometrioma experienced cyst regression, 2/34 (6%, 95% CI 0 – 14) experienced cyst growth and in 10/34 (29%, 95% CI 14‐45) there was complete resolution of all cysts. 43/51 (84%, 95% CI 74‐94) women with nodules experienced nodule regression, 2/51 (4%, 95% CI 0 – 9) experienced nodule growth and in 4/51 (8%, 95% CI 0‐15) there was complete resolution of all nodules. 5/37 (14%, 95% CI 3 – 25) women who attended postnatal follow‐up, experienced complete resolution of all endometriotic lesions during pregnancy. In 10/34 (29%, 95% CI 14‐45) women with endometrioma and 27/51 (53%, 95% CI 39‐67) with nodules, a pattern of growth was observed in the first and second trimesters, which preceded regression later in pregnancy.Features of decidualization were observed in 17/34 (50%, 95% CI 33 – 67) women with endometrioma, most commonly observed in the 1st trimester, and 25/51 (49%, 95% CI 35 – 63) women with nodules, most commonly observed in the 2nd trimester.ConclusionsFor the majority of women, despite features of decidualization being common in the first and second trimesters, endometrioma and deep nodules will regress during pregnancy. Morphological changes of endometriosis in pregnancy are difficult to differentiate from characteristics of malignant lesions. Better understanding of the appearance of endometriosis in pregnancy is vital to minimise intervention and help counsel women regarding the significance of their condition.This article is protected by copyright. All rights reserved.

The aim of this study was to compare the accuracy of seven classical machine learning (ML) models trained with ultrasound (US) soft markers to raise suspicion of forniceal endometriotic involvement. Methods: Input data to the models was retrieved from a database of 194 patients submitted to surgery for the suspicion of presence of deep endometriosis. The following models have been tested: k-nearest neighbours' algorithm (k-NN), Naive Bayes, Neural Networks (NNET-neuralnet), support vector machine (SVM), decision tree, random forest, and logistic regression. The data driven strategy has been to split randomly the complete dataset in two different datasets. The training dataset and the test dataset with a 67% and 33% of the original cases respectively. All models were trained on the training dataset and the predictions have been evaluated using the test dataset. The best model was chosen based on the best AUC demonstrated on the test dataset. The information used in all the models were: age; presence of US signs of uterine adenomyosis; presence of an endometrioma; adhesions of the ovary to the uterus; presence of ''kissing ovaries''; absence of sliding sign. All models have been trained using CARET package in R with ten repeated 10-fold cross-validation. Sensitivity, and specificity, were calculated using a Youden index threshold. Results: 28 women had a surgical diagnosis of forniceal endometriosis. In term of diagnostic accuracy, the best model was the Neural Net (AUC, 0.73; sensitivity, 0.78; specificity 0.70) but without significant difference with the others. Conclusions: The accuracy of ultrasound soft markers in raising suspicion of forniceal endometriosis using artificial intelligence (AI) models showed similar results to the logistic model.This study was partly supported by Fondazione di Sardegna grant F74I19001010007.