Abstracts
DOI: 10.1111/1471-0528.12827 www.bjog.org
Oral Presentations
FC.01 Audit on outpatient medical management of miscarriage
FC.02 Imaging in molar pregnancy – a multi-modal approach
Sinha, A; Muspratt, N; Goel, R; Chapman, W Habeeb, H
Chisholme, B; Treharne, A Bonduelle, M
Obstetrics & Gynaecology, Medway Maritime Hospital, UK Introduction Approximately 20% of pregnancies end in
miscarriage. NICE (2012) stated that vaginal misoprostol can be used for outpatient management of missed or incomplete miscarriage. No guidance is available on suitable ultrasound parameters. Methods Retrospective audit from June 2013 to January 2014 at Medway Maritime Hospital. Cases included all women who underwent outpatient medical management of miscarriage with 800 mcg misoprostol per vagina. Initial ultrasound findings were then compared with final outcomes following treatment. Primary outcome measure was the absence of retained products of conception on ultrasound scan, ie. a complete miscarriage. Results A total of 68 cases were identified. For women with missed miscarriages, gestational sac ranged 4.5–37.7 mm (mean 18.7 mm), and the crown-rump length (CRL) ranged 2–18.1 mm (mean 6.7 mm). For women with incomplete miscarriages, products of conception (POC) ranged 10–30 mm. After administration of misoprostol, all women were rescanned at an average of 10 days later (range 7–21 days). 79% (n = 54) women had complete miscarriages. 15% (n = 10) women required subsequent surgical management of miscarriage, and 6% (n = 4) required a second dose of misoprostol. Of the women requiring further management, 79% had an intact gestational < 12 mm and 57% had a gestational sac < 15 mm. 100% incomplete miscarriages were successfully managed with single dose misoprostol. Conclusion Misoprostol has a very high success rate for outpatient medical management of miscarriage, especially with regards to incomplete miscarriage. Its success rate appears to be reduced with larger, intact gestational sacs that are < 12 mm. This may lead to medical management only being offered to women with smaller gestational sacs and retained POC. However due to the small number of cases, more national data comparing ultrasound scan findings with success rates is required in order to come to a more formal conclusion.
Singleton Hospital, Swansea, South Wales, UK Background Gestational trophoblastic disease is often identified early (as partial or complete molar pregnancies), usually on the basis of suspicious ultrasound findings. This is often confirmed histologically. When referred for management, response rates are excellent with almost 100% cure rates. When the disease presents in the advanced stages (choriocarcinoma, placental site trophoblastic tumour) response rates are still excellent, but radiological imaging becomes critical in the diagnosis, investigation, management and follow-up of these cases. Case A 38-year-old lady was referred to the acute gynaecological take with symptoms of heavy menstrual bleeding. She had never been pregnant but was sexually active. Initially a urine pregnancy test was negative in accident and emergency but was weakly positive in the gynaecology department. A serum hCG was reported as > 200 000. A chest X-ray and abdominal CT were consistent with metastatic choriocarcinoma. MRI brain was negative. An ERPC was performed under ultrasound guidance and transferred for combination chemotherapy at Charing Cross Hospital. Histology from a pipelle biopsy was consistent with choriocarcinoma. Conclusion This lady made a good response but her treatment is still in progress. This case demonstrates how a wide range of imaging modalities can be used to complement each other in managing cases of choriocarcinoma. Radiological imaging can make a diagnosis when bedside tests conflict with clinical findings. Together they ensure detailed investigation, safe operative practice, are vital for FIGO staging and can provide reassurance at follow-up.
FC.03 BSGI trainees’ survey 2014 – results of a nationwide study of ultrasound training
Treharne, A Singleton Hospital, Swansea, South Wales, UK Introduction In January 2011, the BSGI launched a survey to
investigate the training needs, abilities, concerns and issues of trainees nationally. The results provided invaluable information that was returned to the deaneries for use in planning ultrasound and delivery and training. The survey was repeated in 2014 and the results are presented and contrasted with those obtained in 2011.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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Oral Presentations Methods The BSGI trainee representative carried out a national survey of USS training in Obstetrics and Gynaecology online across al deaneries in the UK. The anonymous, online survey was distributed via the RCOG trainees’ committee representatives and supported by the USS leads over a 3-month period. The survey was distributed and results collected using Survey Monkey. Results The survey commenced on January 10th 2014. It closes after a 3-month period. The results of this survey will be presented and contrasted with the 2011 results at the 2014 BSGI conference. The results of the previous survey were presented at the 2011 conference. The 2011 survey received 311 responses from 13 deaneries and the current edition aims to build on that success. Conclusions We hope that over the last 3 years there will have been an improvement in all the areas of ultrasound education surveyed and these include: Completion of basic modules; Teaching; Exposure; Assessment; Ability; Confidence; Support. The results are eagerly awaited.
FC.04 Validation of structured scoring sheet of recorded videos for assessing trainees’ competency in ultrasound
Alsalamah, A; Albalushi, D; Hood, K; Pugh, N Amso, N Cardiff University, School of Medicine, UK Background Objective structured assessment of technical skills (OSATS) has been used globally in evaluating trainees’ competence in the education of health professionals. Despite the objective of OSATS, scoring methods used by examiners have been a potential source of measurement error affecting the precision with which test scores are determined. A pilot phase was suggested for raters/examiners to rate the quality of assessment to minimise the disagreement between raters and allow more identification and clarification of areas of ambiguity. Objectives To evaluate the inter-rater reliability of objective checklist and subjective global rating (GRS) scores of two raters/ examiners, who reviewed recorded videos of ultrasound scanning performance in the ScanTrainer simulator (Medaphor,Cardiff, UK), in order to standardise scoring technique. Methods This is pilot study. 10 recorded videos were anonymised then evaluated and rated by two independent raters. Skill checklists and GRS were used for assessment. All video recordings were extracted from The ScanTrainer simulator. Results Results showed no differences in mean scores given by two raters for either the checklist or GRS ratings. Results indicated that the intra-rater reliability of test-retest was significant (0.99) for two raters in both checklist and GRS. For inter-rater reliability, the intra-class correlation coefficient (ICC) revealed that the consistency between two raters ratings was ‘excellent’ for both checklist and GRS scores (0.87 and 0.81) respectively. Conclusions Prior to conducting this study, the two raters had a joint training session to agree scoring practice by using sample
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videos. The rater/examiner training is necessary to standardise scoring method to improve the inter-rater agreement among raters prior to the assessment.
FC.05 Comparison of fetal growth in early pregnancy between spontaneous and IVF pregnancies: A prospective study
Spiliopoulos, D Economides, D Fetal Medicine Unit, Royal Free Hospital NHS Trust, London, UK Introduction The scope of this pilot study was to compare the fetal
growth between two groups of pregnant women: (a) those having spontaneous conception and (b) those with IVF pregnancies treated with progesterone supplementation in the first trimester. Methods Inclusion criteria included healthy women aged ≥18 years, singleton pregnancy of gestational age between 6 and 13 + 6 weeks, presence of live embryo on the ultrasound scan and IVF pregnancy on progesterone supplementation. Women were excluded if they were uncertain about their last menstrual period, if they were on medications or had medical conditions affecting fetal growth. Crown-rump length (CRL) fetal measurements of women booked for their dating scan in the Fetal Medicine Unit (FMU) were collected prospectively over a period of 4 months between October 2013 and February 2014, at Royal Free Hospital NHS Trust. A total of 120 pregnant women were included in the study. Results 100 women conceived spontaneously and 20 had undergone IVF treatment. Preliminary data showed that 10/20 (50%) of IVF cases had CRL measurements lying below the 50th centile and only 1/20 case (5%) was lying above the 50th centile. Instead, more than 95% of spontaneous conceptions had CRL measurements on the 50th centile. Independent samples t test was applied for comparing quantitative variables with normal distribution, and Mann–Whittney U test for comparison of quantitative variables without normal distribution. Conclusion Progesterone supplementation in early pregnancy could be associated with early growth restriction in IVF pregnancies. These pregnancies should be followed up in the second trimester with growth ultrasound scans. More data are needed to confirm these findings.
FC.06 Vesico-ovarian fistula as a result of tubo-ovarian abscess; a radiological and clinical diagnostic challenge
Khafizova, L1; Minas, V2 Alam, AM2 1
Department of Ophthalmology, University Hospital Aintree, UK; Department of Obstetrics and Gynaecology, Wirral University Teaching Hospital, UK 2
Background Tubo-ovarian abscess is a late complication of pelvic inflammatory disease. These usually occur in young women but can occur rarely in postmenopausal patients. Symptoms vary and can be atypical. Gynaecological, gastrointestinal and urinary
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
Oral Presentations
symptoms may present. Ultrasound is the main imaging tool used in the assessment of such patients. Magnetic resonance imaging and computed tomography are useful adjuncts especially for indeterminate adnexal masses. Case A 29-year-old woman with a 12-month history of left iliac fossa pain presented to the gynaecological outpatient department. She suffered with recurrent urinary tract infections and an episode of pyelonephritis. Ultrasound scan showed a normal renal tract and a left ovarian haemorrhagic cyst which was initially managed conservatively. Despite several courses of antimicrobial treatment she continued to complain of suprapubic pain, urgency and passing cloudy and offensive urine. To investigate her symptoms further a computed tomography scan of her abdomen and pelvis was performed and revealed normal urinary tract and possible tubo-ovarian abscesses. However, these findings still did not provide an explanation for her recurrent urinary tract infections. A cystoscopy was then performed which revealed a fistula at the bladder’s dome that was discharging pus like material into the bladder. A diagnosis of possible pelvic abscess erosion into the bladder with associated fistulation was made and the patient underwent laparotomy to drain the abscesses and repair her bladder. Conclusion In conclusion, imaging techniques are essential in the assessment of patients with possible pelvic inflammatory disease. Ultrasonography is a valuable initial investigation, but the findings can be non-specific. In these cases magnetic resonance imaging and computed tomography can provide additional information and differentiate an abscess from other types of pelvic masses. The rare presentation discussed here teaches us that cases of recurrent urinary tract infections require careful evaluation of both the pelvis and bladder.
FC.07 Management of cervical fibroid during the reproductive period background
Keriakos, R1 Maher, M2 1 Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Jessop Wing, Sheffield, UK; 2 School of Medicine, King’s College London, UK
Background This is a case report of a 29-year-old lady who presented with excessive vaginal discharge and sessile cervical fibroid arising from the vaginal portion of the cervix. Case She was not suitable for uterine artery embolisation as she has never previously been pregnant before. She was encouraged to get pregnant and to avoid surgical excision which can lead to hysterectomy. Shortly after, she became pregnant. She had many admissions during pregnancy due to bleeding from the fibroid,
and in one occasion she had blood transfusions. The fibroid increased in size to become larger than the head of the baby. An emergency caesarean section was performed at 37 weeks when she attended in labour before the date of her elective caesarean section. She was managed conservatively following delivery in the hope that the fibroid becomes smaller making surgery easier. The fibroid degenerated and reduced in size. Vaginal myomectomy was carried out. The patient is now pregnant for the second time and had a cervical suture at 20 weeks of gestation. Conclusion In this educational case report we discuss the different management options of cervical fibroids and review the literature of other similar cases and their outcome.
FC.08 A rare cause of recurrent haemothorax; thoracic endometriosis
Muthukumarasamy, S; Natas, S Jacques, A Guy’s and St Thomas’ Hospital NHS Trust, London, UK Background Endometriosis is defined as functioning endometrial tissue outside the uterus. It is usually seen within sites in the pelvis, such as the ovaries, uterosacral ligament and the cul-de sac peritoneum. Ocassionally deposits are seen within the thorax, known as Thoracic Endometrial Syndrome (TES), and patients can present with haemoptysis or haemothoraces. Case We present two cases of patients who presented to our institution, with recurrent pleural effusions, with a background of endometriosis. The first, a 37-year-old lady, presenting to our department with dyspnoea, and was found to have a large pleural effusion on chest radiograph. She went on to have chest drain insertion, which drained a black fluid. MR imaging of her pelvis, and chest confirmed, pelvic endometriosis and haemorrhagic component to the effusion. Due to symptomatic catamenial haemothoraces, the patient eventually went onto have pleurectomy under the thoracic surgeons, which confirmed endometrial pleural and diaphragmatic deposits. The second patient was a 39-year-old lady who also presented with recurrent right sided pleural effusions. MR imaging confirmed pelvic endometriosis and a nodule within the chest in keeping with an endometrial deposit. Conclusion Endometriosis can present with deposits in distant sites, including the thorax. Where premenopausal female patients presents with recurrent pleural effusions, although rare, the investigating clinician should consider the possibility of underlying endometriosis.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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Poster presentations
Case 2 A 32-year-old was admitted under surgical team with
Poster presentations PP.01 Ultrasound diagnosis extrauterine pregnancy
Nargund, A; Ramzan, I; Thomas, C; Lal, S Howells, R Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, Wales, UK Background The majority of ectopic pregnancies occur in the fallopian tube. Advanced ectopic pregnancy is rare, as tubal pregnancies generally will rupture before 11 weeks. Transvaginal ultrasound is considered the front-line diagnostic imaging method. Case A 31-year-old G2P1 attended a dating scan, which revealed an empty uterus and single live fetus outside the uterine cavity. Patient was referred to the Early Pregnancy Assessment Unit. On examination patient was asymptomatic with stable vital signs and soft, non- tender abdomen. Transabdominal sonography was repeated which confirmed an empty normal structured retroverted uterus, and normal right adnexae. A 13-week sized live fetus was imaged between uterus and left ovary with no abdominal free fluid. Impression was a left-sided broad ligament live ectopic pregnancy. Patient underwent a laparotomy. During laparotomy 5 x 6 x 7 cm size left ectopic pregnancy, extending into broad ligament was noted. Left salpingectomy and removal of whole ectopic pregnancy was performed. She was discharged on a day 3. Histology showed left tubal ectopic pregnancy. Conclusion The sensitivity of transvaginal sonography in the diagnosis of ectopic pregnancy is > 90%. Systematic approach helps to avoid misdiagnosis. The uterus and pelvis should be imaged in both longitudinal and transverse planes, whether a transabdominal or transvaginal probe is being used. Unruptured ectopic pregnancy in second trimester is rare. Management is surgical at this stage. Non-tubal ectopic pregnancy should be considered as a differential diagnosis before embarking on further management.
PP.02 Ultrasound diagnosis of adnexal torsion
Nargund, A; Joshi, N Tayaparan, A Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, Wales, UK Background Torsion of ovary, tube and both is responsible for 2.4–2.7% of gynaecological emergencies. We present two cases of adnexal torsion. Case 1 A 12-year-old girl had multiple admissions with right iliac fossa pain. An ultrasound examination revealed a simple anechoic cyst of 5 x 5.6 x 4.4 cm on the right ovary. CA125 was within normal limits. MRI confirmed the above findings. At laparoscopy, chronic right adnexal torsion with necrosis involving ovary with cyst and fallopian tube was identified. She underwent right salpingo-ophorectomy.
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sudden onset right iliac fossa pain, stabbing in nature radiating to the right inner thigh. Ultrasound examination showed a right ovarian cyst 3.1 cm. She was noted to have a slightly raised white cell count of 13.6 and neutrophilia of 11.6. Presumptive diagnosis of appendicitis was made. At laparoscopy, torsion of right fallopian tube with fimbrial cyst was identified with normal ovaries. Right salpingectomy was performed. Histology confirmed these findings. Both patients recovered well postoperatively. Conclusion The diagnosis of ovarian and adnexal torsion remains challenging. In all the cases of acute abdominal pain if an adnexal cyst is identified a Doppler flow should be under taken as this may be the only sonographic finding to identify early torsion which will lead to early intervention and potentially save the ovary and fallopian tube. In both the cases diagnosis was at the time of surgery. Prompt recognition is essential, as delay in diagnosis can lead to loss of ovary and impact on fertility. There is also potential risk of life-threatening thrombophlebitis or peritonitis.
PP.03 Audit of management and prognosis of isolated mild ventriculomegaly in Aneurin Bevan University Health Board (ABUHB) from 2003 to 2012
Sanak Sindagi, P1 Nair, M2 1 Department of Obstetrics and Gynaecology, Nevill Hall Hospital, Wales, UK; 2Department of Obstetrics and Gynaecology, Royal Gwent Hospital, Wales, UK
Introduction Isolated mild ventriculomegaly affects 0.15–0.7% of
pregnancies.1 The developmental prognosis for children seems to be better than that described for ventriculomegaly associated with other anomalies.2 But the risk of developmental delay is still unclear and presents a challenge to physicians for managing and counselling prospective parents. This audit evaluates the prenatal management and prognosis of isolated mild cerebral ventriculomegaly. This is the first study on ventriculomegaly in Wales Methods 63 cases of ventriculomegaly were reported from the health board to CARIS database with Hydrocephalus during 2003–2012. 35 were identified as isolated mild ventriculomegaly. 30 cases were reviewed, 5 notes could not be traced. Of the 30, 3 were lost to follow-up as they moved out of the area. Results 28 cases were diagnosed at second trimester anomaly scan, while one patient booked late at 28 weeks and in another the anomaly developed later in pregnancy. 100% women were screened for TORCH infection, all were negative for current infections. All women were offered amniocentesis, 9 (30%) of them accepted, all 30% were normal karyotype. All women had scans every 4 weeks. Two women underwent termination due to progression of ventriculomegaly. In 17 (63%) cases of ventriculomegaly resolved in third trimester, it is difficult to assess the prognosis of these babies as they did not have cranial ultrasound or neurodevelopmental assessment routinely.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
Poster presentations
Conclusion In our study all routine investigations including
TORCH and karyotype are normal. 63% of the cases of mild isolated ventriculomegaly resolved in utero. It has highlighted the lack of uniform policy in neonatal assessment. There are limitations including the retrospective model, small sample size and not having the neonatal follow-up. References:
1. Wax JR, Bookman L, Cartin A, Pinette MG, Blackstone J. Mild fetal cerebral ventriculomegaly: diagnosis, clinical associations and outcomes. Obstet Gynaecol Survey 2003; 58: 407–14. 2. Mercier A, Eurin D, Mercier PY, Verspyck, Marpeau L, Marret S. Isolated mild fetal cerebral ventriculomegaly: a retrospective analysis of 26 cases. Prenat Diagn 2001; 21: 589–95.
PP.04 Morphological changes in conservatively managed benign ovarian cyst characterised by simple ultrasonography rules in asymptomatic postmenopausal women: A retrospective cohort study based on the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) data
Yadav, SK; D’Angelo, A; Abdurazaq, B Amso, NN Department of Obstetrics & Gynaecology, Cardiff University School of Medicine, UK Introduction Postmenopausal simple ovarian cysts are often seen
by transvaginal sonography (TVS) and its frequent use in clinical settings. Nevertheless, due to inconstant sonographic appearance of ovarian cystic tumour, it is very challenging to make definite diagnosis by ultrasound. The aim of this study is to prospectively revise the validation of simple ultrasound rules to characterise the benignity or malignancy of conservatively managed adnexal masses in asymptomatic postmenopausal women using the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) database. Methods This is a retrospective cohort study in which ten ultrasonography simple rules from the International Ovarian Tumour Analysis (IOTA) were applied in a conservatively managed group in UKCTOCS. Asymptomatic postmenopausal women aged 50–74 years were recruited for this study through the 13 regional UKCTOCS trial NHS centres located in the UK. Results One thousand nine hundred volunteers’ ultrasound data were retrospectively collected from the UKCTCOS database. 845 volunteers had surgical management. Prevalence scan of 1055 data were retrieved for the analysis on volunteers who had conservative management.104 were excluded from the analysis due to missing information. Hence, simple based ultrasound rules were applied to 951 volunteers. After applying simple rules, 789 (83%) volunteers adnexal masses were classified as benign, 85 (9%) were malignant and 77 (8%) were inconclusive Conclusion Simple based ultrasound rules are very simple and easily reproducible to triage the women with adnexal masses.
However, most benign adnexal masses cannot be correctly classified by simple based rules. 9% of adnexal masses which classified as malignant indicates the high false positive results. Similarly, 8% of adnexal masses which classified as inconclusive suggest that further evaluation by expert examiner is required. Hence, simple based rules need to be further validated in order to avoid unnecessary risk of surgery, hospitalisation and socio-economic cost.
PP.05 Antenatal visualisation of cleft lip and palate in South Wales: Can offline 3D assessment and dataset analysis improve detection? A comparison of 2D and 3D examinations
Rogers, A University Hospital Llandough/Cardiff University, UK Background The primary aim of this study was to investigate fetal face and palate ultrasound imaging detection rates, to assess whether it is possible to improve diagnostic accuracy by using 3D techniques. This consequently may improve quality of care to obstetric patients by including 3D ultrasound performed by a sonographer, in the examination of the fetus at the 20-week anomaly scan visit. Methods A retrospective review of results from the Congenital Anomaly Register and Information Service (CARIS) was performed to assess antenatal oro-facial cleft detection rates between 1998 and 2010, for South Wales, UK. A prospective pilot study of 20 patients undergoing both 2D and 3D examinations was performed and offline reconstruction of the 3D data was compared to the 2D visualisation of the lips and palate. Results The retrospective results indicated that there were cases of undiagnosed oro-facial clefting occurring within South and mid-Wales. There was considerable improvement in detection rates after the introduction of Antenatal Screening Wales guidelines, although the impact on the detection of isolated cleft palate was negligible. In the prospective study, successful reconstruction of the fetal hard palate was completed in 100% of cases, with a variable increase in time. Visualisation of the structures in 2D was rated better than 3D, but the inter-rater reliability was better for 3D reconstruction. Conclusion Confidence in 2D fetal lip imaging is lower than expected and clefting of the lips is under diagnosed with present imaging protocols. Implementing 3D imaging into routine protocols would not be detrimental to service delivery in terms of time, but further assessment is needed of the benefit of 3D imaging locally.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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Poster presentations
PP.06 Preoperative assessment of deep pelvic endometriosis with MRI; a useful adjunct to the gynaecological surgeon
Muthukumarasamy, S; Nagraj, H; Westerland, O; Natas, S Jacques, A Guy’s and St Thomas’ Hospital NHS Trust, London, UK Background Deep pelvic endometriosis is a cause of severe pelvic pain, which can be difficult to assess clinically. Ultrasound often does not provide detailed assessment, in order to plan complete surgical excision of painful deposits. Laparoscopy can also be limited in the assessment of subperitoneal disease, or where there are deep pelvic adhesions obliterating the pelvic spaces.
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In these cases MRI can be invaluable to the gynaecologist in preoperative assessment and surgical planning, in particular, where bowel involvement may require more complex surgery. MRI findings were used to plan appropriate surgical approach, and the earlier involvement of other surgical specialties in more complex cases, if needed. Cases In this review we present the MR appearances of deep pelvic endometriosis with involvement of the uterosacrine ligament, torus uterinus, as well as visceral deposits involving the rectum and bladder. Conclusion MRI provides a useful adjunct to the gynaecologist in surgical planning, and the preoperative assessment of deep pelvic endometriosis.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
Video Presentation
Video presentation V.01 Ultrasound guided surgical management of hematocolpos, hemtaometria and hematosalpinx in a menstruating teenage girl
Speers, LJ1; Cook, S1; Neelankavil, J1 Amso, N2 1 Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, Wales, UK; 2Engagement, Learning and Teaching Institute for Translation, Innovation, Methodology and Engagement, Department of Obstetrics & Gynaecology, School of Medicine, Cardiff University, UK
Background A 13-year-old female presented to the paediatric admissions unit at her local hospital after repeated presentations to the general practitioner with lower abdominal pain for which no cause had been identified. Case On presentation a history of acute on chronic exacerbation of lower abdominal pain was described. Chronic pain originated from the time of menarche, which occurred a year prior to this presentation. The pain was cyclical and described as severe enough to cause regular absences from school. Clinical examination was grossly unremarkable except for a tender abdomen. There were no reported urinary symptoms, and bowel function suggested an element of constipation. Menstruation was regular with a 28-day
cycle. There was no significant past medical or surgical history. Investigation included ultrasound and magnetic resonance imaging (MRI). A diagnosis of hematosalpinx, hematometria, hematocolpos and a low longitudinal vaginal septum was made. Subsequent referral and review in our tertiary centre resulted in the patient commencing a combined oral contraceptive pill with continuous use to inhibit further menstrual loss and listing for urgent surgery. Examination under anaesthetic, revealed normal external genitalia. A single vaginal cavity was visualised and explored with vaginosocopy. A bulging septum 2 cm into the cavity, extending upward from anterior vaginal wall was discovered. Ultrasound guided septal incision was performed and drainage of collected menstrual fluid occurred. An obstructed right horn of a uterine didelphys with intravaginal septum had been alleviated. The postoperative period was uneventful and the patient was discharged later the same day. Outpatient review 2 months later revealed an improvement to abdominal pain and continued vaginal loss, suggesting the septal incision was still patent. Follow-up MRI is now planned. Conclusion Successful surgical management of an uncommon anatomic variance was achieved with the use of ultrasound guidance. At 2 months postprocedure this patient’s quality of life had significantly improved.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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DOI: 10.1111/1471-0528.12827 www.bjog.org
Oral Presentations
FC.01 Audit on outpatient medical management of miscarriage
FC.02 Imaging in molar pregnancy – a multi-modal approach
Sinha, A; Muspratt, N; Goel, R; Chapman, W Habeeb, H
Chisholme, B; Treharne, A Bonduelle, M
Obstetrics & Gynaecology, Medway Maritime Hospital, UK Introduction Approximately 20% of pregnancies end in
miscarriage. NICE (2012) stated that vaginal misoprostol can be used for outpatient management of missed or incomplete miscarriage. No guidance is available on suitable ultrasound parameters. Methods Retrospective audit from June 2013 to January 2014 at Medway Maritime Hospital. Cases included all women who underwent outpatient medical management of miscarriage with 800 mcg misoprostol per vagina. Initial ultrasound findings were then compared with final outcomes following treatment. Primary outcome measure was the absence of retained products of conception on ultrasound scan, ie. a complete miscarriage. Results A total of 68 cases were identified. For women with missed miscarriages, gestational sac ranged 4.5–37.7 mm (mean 18.7 mm), and the crown-rump length (CRL) ranged 2–18.1 mm (mean 6.7 mm). For women with incomplete miscarriages, products of conception (POC) ranged 10–30 mm. After administration of misoprostol, all women were rescanned at an average of 10 days later (range 7–21 days). 79% (n = 54) women had complete miscarriages. 15% (n = 10) women required subsequent surgical management of miscarriage, and 6% (n = 4) required a second dose of misoprostol. Of the women requiring further management, 79% had an intact gestational < 12 mm and 57% had a gestational sac < 15 mm. 100% incomplete miscarriages were successfully managed with single dose misoprostol. Conclusion Misoprostol has a very high success rate for outpatient medical management of miscarriage, especially with regards to incomplete miscarriage. Its success rate appears to be reduced with larger, intact gestational sacs that are < 12 mm. This may lead to medical management only being offered to women with smaller gestational sacs and retained POC. However due to the small number of cases, more national data comparing ultrasound scan findings with success rates is required in order to come to a more formal conclusion.
Singleton Hospital, Swansea, South Wales, UK Background Gestational trophoblastic disease is often identified early (as partial or complete molar pregnancies), usually on the basis of suspicious ultrasound findings. This is often confirmed histologically. When referred for management, response rates are excellent with almost 100% cure rates. When the disease presents in the advanced stages (choriocarcinoma, placental site trophoblastic tumour) response rates are still excellent, but radiological imaging becomes critical in the diagnosis, investigation, management and follow-up of these cases. Case A 38-year-old lady was referred to the acute gynaecological take with symptoms of heavy menstrual bleeding. She had never been pregnant but was sexually active. Initially a urine pregnancy test was negative in accident and emergency but was weakly positive in the gynaecology department. A serum hCG was reported as > 200 000. A chest X-ray and abdominal CT were consistent with metastatic choriocarcinoma. MRI brain was negative. An ERPC was performed under ultrasound guidance and transferred for combination chemotherapy at Charing Cross Hospital. Histology from a pipelle biopsy was consistent with choriocarcinoma. Conclusion This lady made a good response but her treatment is still in progress. This case demonstrates how a wide range of imaging modalities can be used to complement each other in managing cases of choriocarcinoma. Radiological imaging can make a diagnosis when bedside tests conflict with clinical findings. Together they ensure detailed investigation, safe operative practice, are vital for FIGO staging and can provide reassurance at follow-up.
FC.03 BSGI trainees’ survey 2014 – results of a nationwide study of ultrasound training
Treharne, A Singleton Hospital, Swansea, South Wales, UK Introduction In January 2011, the BSGI launched a survey to
investigate the training needs, abilities, concerns and issues of trainees nationally. The results provided invaluable information that was returned to the deaneries for use in planning ultrasound and delivery and training. The survey was repeated in 2014 and the results are presented and contrasted with those obtained in 2011.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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Oral Presentations Methods The BSGI trainee representative carried out a national survey of USS training in Obstetrics and Gynaecology online across al deaneries in the UK. The anonymous, online survey was distributed via the RCOG trainees’ committee representatives and supported by the USS leads over a 3-month period. The survey was distributed and results collected using Survey Monkey. Results The survey commenced on January 10th 2014. It closes after a 3-month period. The results of this survey will be presented and contrasted with the 2011 results at the 2014 BSGI conference. The results of the previous survey were presented at the 2011 conference. The 2011 survey received 311 responses from 13 deaneries and the current edition aims to build on that success. Conclusions We hope that over the last 3 years there will have been an improvement in all the areas of ultrasound education surveyed and these include: Completion of basic modules; Teaching; Exposure; Assessment; Ability; Confidence; Support. The results are eagerly awaited.
FC.04 Validation of structured scoring sheet of recorded videos for assessing trainees’ competency in ultrasound
Alsalamah, A; Albalushi, D; Hood, K; Pugh, N Amso, N Cardiff University, School of Medicine, UK Background Objective structured assessment of technical skills (OSATS) has been used globally in evaluating trainees’ competence in the education of health professionals. Despite the objective of OSATS, scoring methods used by examiners have been a potential source of measurement error affecting the precision with which test scores are determined. A pilot phase was suggested for raters/examiners to rate the quality of assessment to minimise the disagreement between raters and allow more identification and clarification of areas of ambiguity. Objectives To evaluate the inter-rater reliability of objective checklist and subjective global rating (GRS) scores of two raters/ examiners, who reviewed recorded videos of ultrasound scanning performance in the ScanTrainer simulator (Medaphor,Cardiff, UK), in order to standardise scoring technique. Methods This is pilot study. 10 recorded videos were anonymised then evaluated and rated by two independent raters. Skill checklists and GRS were used for assessment. All video recordings were extracted from The ScanTrainer simulator. Results Results showed no differences in mean scores given by two raters for either the checklist or GRS ratings. Results indicated that the intra-rater reliability of test-retest was significant (0.99) for two raters in both checklist and GRS. For inter-rater reliability, the intra-class correlation coefficient (ICC) revealed that the consistency between two raters ratings was ‘excellent’ for both checklist and GRS scores (0.87 and 0.81) respectively. Conclusions Prior to conducting this study, the two raters had a joint training session to agree scoring practice by using sample
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videos. The rater/examiner training is necessary to standardise scoring method to improve the inter-rater agreement among raters prior to the assessment.
FC.05 Comparison of fetal growth in early pregnancy between spontaneous and IVF pregnancies: A prospective study
Spiliopoulos, D Economides, D Fetal Medicine Unit, Royal Free Hospital NHS Trust, London, UK Introduction The scope of this pilot study was to compare the fetal
growth between two groups of pregnant women: (a) those having spontaneous conception and (b) those with IVF pregnancies treated with progesterone supplementation in the first trimester. Methods Inclusion criteria included healthy women aged ≥18 years, singleton pregnancy of gestational age between 6 and 13 + 6 weeks, presence of live embryo on the ultrasound scan and IVF pregnancy on progesterone supplementation. Women were excluded if they were uncertain about their last menstrual period, if they were on medications or had medical conditions affecting fetal growth. Crown-rump length (CRL) fetal measurements of women booked for their dating scan in the Fetal Medicine Unit (FMU) were collected prospectively over a period of 4 months between October 2013 and February 2014, at Royal Free Hospital NHS Trust. A total of 120 pregnant women were included in the study. Results 100 women conceived spontaneously and 20 had undergone IVF treatment. Preliminary data showed that 10/20 (50%) of IVF cases had CRL measurements lying below the 50th centile and only 1/20 case (5%) was lying above the 50th centile. Instead, more than 95% of spontaneous conceptions had CRL measurements on the 50th centile. Independent samples t test was applied for comparing quantitative variables with normal distribution, and Mann–Whittney U test for comparison of quantitative variables without normal distribution. Conclusion Progesterone supplementation in early pregnancy could be associated with early growth restriction in IVF pregnancies. These pregnancies should be followed up in the second trimester with growth ultrasound scans. More data are needed to confirm these findings.
FC.06 Vesico-ovarian fistula as a result of tubo-ovarian abscess; a radiological and clinical diagnostic challenge
Khafizova, L1; Minas, V2 Alam, AM2 1
Department of Ophthalmology, University Hospital Aintree, UK; Department of Obstetrics and Gynaecology, Wirral University Teaching Hospital, UK 2
Background Tubo-ovarian abscess is a late complication of pelvic inflammatory disease. These usually occur in young women but can occur rarely in postmenopausal patients. Symptoms vary and can be atypical. Gynaecological, gastrointestinal and urinary
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
Oral Presentations
symptoms may present. Ultrasound is the main imaging tool used in the assessment of such patients. Magnetic resonance imaging and computed tomography are useful adjuncts especially for indeterminate adnexal masses. Case A 29-year-old woman with a 12-month history of left iliac fossa pain presented to the gynaecological outpatient department. She suffered with recurrent urinary tract infections and an episode of pyelonephritis. Ultrasound scan showed a normal renal tract and a left ovarian haemorrhagic cyst which was initially managed conservatively. Despite several courses of antimicrobial treatment she continued to complain of suprapubic pain, urgency and passing cloudy and offensive urine. To investigate her symptoms further a computed tomography scan of her abdomen and pelvis was performed and revealed normal urinary tract and possible tubo-ovarian abscesses. However, these findings still did not provide an explanation for her recurrent urinary tract infections. A cystoscopy was then performed which revealed a fistula at the bladder’s dome that was discharging pus like material into the bladder. A diagnosis of possible pelvic abscess erosion into the bladder with associated fistulation was made and the patient underwent laparotomy to drain the abscesses and repair her bladder. Conclusion In conclusion, imaging techniques are essential in the assessment of patients with possible pelvic inflammatory disease. Ultrasonography is a valuable initial investigation, but the findings can be non-specific. In these cases magnetic resonance imaging and computed tomography can provide additional information and differentiate an abscess from other types of pelvic masses. The rare presentation discussed here teaches us that cases of recurrent urinary tract infections require careful evaluation of both the pelvis and bladder.
FC.07 Management of cervical fibroid during the reproductive period background
Keriakos, R1 Maher, M2 1 Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Jessop Wing, Sheffield, UK; 2 School of Medicine, King’s College London, UK
Background This is a case report of a 29-year-old lady who presented with excessive vaginal discharge and sessile cervical fibroid arising from the vaginal portion of the cervix. Case She was not suitable for uterine artery embolisation as she has never previously been pregnant before. She was encouraged to get pregnant and to avoid surgical excision which can lead to hysterectomy. Shortly after, she became pregnant. She had many admissions during pregnancy due to bleeding from the fibroid,
and in one occasion she had blood transfusions. The fibroid increased in size to become larger than the head of the baby. An emergency caesarean section was performed at 37 weeks when she attended in labour before the date of her elective caesarean section. She was managed conservatively following delivery in the hope that the fibroid becomes smaller making surgery easier. The fibroid degenerated and reduced in size. Vaginal myomectomy was carried out. The patient is now pregnant for the second time and had a cervical suture at 20 weeks of gestation. Conclusion In this educational case report we discuss the different management options of cervical fibroids and review the literature of other similar cases and their outcome.
FC.08 A rare cause of recurrent haemothorax; thoracic endometriosis
Muthukumarasamy, S; Natas, S Jacques, A Guy’s and St Thomas’ Hospital NHS Trust, London, UK Background Endometriosis is defined as functioning endometrial tissue outside the uterus. It is usually seen within sites in the pelvis, such as the ovaries, uterosacral ligament and the cul-de sac peritoneum. Ocassionally deposits are seen within the thorax, known as Thoracic Endometrial Syndrome (TES), and patients can present with haemoptysis or haemothoraces. Case We present two cases of patients who presented to our institution, with recurrent pleural effusions, with a background of endometriosis. The first, a 37-year-old lady, presenting to our department with dyspnoea, and was found to have a large pleural effusion on chest radiograph. She went on to have chest drain insertion, which drained a black fluid. MR imaging of her pelvis, and chest confirmed, pelvic endometriosis and haemorrhagic component to the effusion. Due to symptomatic catamenial haemothoraces, the patient eventually went onto have pleurectomy under the thoracic surgeons, which confirmed endometrial pleural and diaphragmatic deposits. The second patient was a 39-year-old lady who also presented with recurrent right sided pleural effusions. MR imaging confirmed pelvic endometriosis and a nodule within the chest in keeping with an endometrial deposit. Conclusion Endometriosis can present with deposits in distant sites, including the thorax. Where premenopausal female patients presents with recurrent pleural effusions, although rare, the investigating clinician should consider the possibility of underlying endometriosis.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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Poster presentations
Case 2 A 32-year-old was admitted under surgical team with
Poster presentations PP.01 Ultrasound diagnosis extrauterine pregnancy
Nargund, A; Ramzan, I; Thomas, C; Lal, S Howells, R Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, Wales, UK Background The majority of ectopic pregnancies occur in the fallopian tube. Advanced ectopic pregnancy is rare, as tubal pregnancies generally will rupture before 11 weeks. Transvaginal ultrasound is considered the front-line diagnostic imaging method. Case A 31-year-old G2P1 attended a dating scan, which revealed an empty uterus and single live fetus outside the uterine cavity. Patient was referred to the Early Pregnancy Assessment Unit. On examination patient was asymptomatic with stable vital signs and soft, non- tender abdomen. Transabdominal sonography was repeated which confirmed an empty normal structured retroverted uterus, and normal right adnexae. A 13-week sized live fetus was imaged between uterus and left ovary with no abdominal free fluid. Impression was a left-sided broad ligament live ectopic pregnancy. Patient underwent a laparotomy. During laparotomy 5 x 6 x 7 cm size left ectopic pregnancy, extending into broad ligament was noted. Left salpingectomy and removal of whole ectopic pregnancy was performed. She was discharged on a day 3. Histology showed left tubal ectopic pregnancy. Conclusion The sensitivity of transvaginal sonography in the diagnosis of ectopic pregnancy is > 90%. Systematic approach helps to avoid misdiagnosis. The uterus and pelvis should be imaged in both longitudinal and transverse planes, whether a transabdominal or transvaginal probe is being used. Unruptured ectopic pregnancy in second trimester is rare. Management is surgical at this stage. Non-tubal ectopic pregnancy should be considered as a differential diagnosis before embarking on further management.
PP.02 Ultrasound diagnosis of adnexal torsion
Nargund, A; Joshi, N Tayaparan, A Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, Wales, UK Background Torsion of ovary, tube and both is responsible for 2.4–2.7% of gynaecological emergencies. We present two cases of adnexal torsion. Case 1 A 12-year-old girl had multiple admissions with right iliac fossa pain. An ultrasound examination revealed a simple anechoic cyst of 5 x 5.6 x 4.4 cm on the right ovary. CA125 was within normal limits. MRI confirmed the above findings. At laparoscopy, chronic right adnexal torsion with necrosis involving ovary with cyst and fallopian tube was identified. She underwent right salpingo-ophorectomy.
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sudden onset right iliac fossa pain, stabbing in nature radiating to the right inner thigh. Ultrasound examination showed a right ovarian cyst 3.1 cm. She was noted to have a slightly raised white cell count of 13.6 and neutrophilia of 11.6. Presumptive diagnosis of appendicitis was made. At laparoscopy, torsion of right fallopian tube with fimbrial cyst was identified with normal ovaries. Right salpingectomy was performed. Histology confirmed these findings. Both patients recovered well postoperatively. Conclusion The diagnosis of ovarian and adnexal torsion remains challenging. In all the cases of acute abdominal pain if an adnexal cyst is identified a Doppler flow should be under taken as this may be the only sonographic finding to identify early torsion which will lead to early intervention and potentially save the ovary and fallopian tube. In both the cases diagnosis was at the time of surgery. Prompt recognition is essential, as delay in diagnosis can lead to loss of ovary and impact on fertility. There is also potential risk of life-threatening thrombophlebitis or peritonitis.
PP.03 Audit of management and prognosis of isolated mild ventriculomegaly in Aneurin Bevan University Health Board (ABUHB) from 2003 to 2012
Sanak Sindagi, P1 Nair, M2 1 Department of Obstetrics and Gynaecology, Nevill Hall Hospital, Wales, UK; 2Department of Obstetrics and Gynaecology, Royal Gwent Hospital, Wales, UK
Introduction Isolated mild ventriculomegaly affects 0.15–0.7% of
pregnancies.1 The developmental prognosis for children seems to be better than that described for ventriculomegaly associated with other anomalies.2 But the risk of developmental delay is still unclear and presents a challenge to physicians for managing and counselling prospective parents. This audit evaluates the prenatal management and prognosis of isolated mild cerebral ventriculomegaly. This is the first study on ventriculomegaly in Wales Methods 63 cases of ventriculomegaly were reported from the health board to CARIS database with Hydrocephalus during 2003–2012. 35 were identified as isolated mild ventriculomegaly. 30 cases were reviewed, 5 notes could not be traced. Of the 30, 3 were lost to follow-up as they moved out of the area. Results 28 cases were diagnosed at second trimester anomaly scan, while one patient booked late at 28 weeks and in another the anomaly developed later in pregnancy. 100% women were screened for TORCH infection, all were negative for current infections. All women were offered amniocentesis, 9 (30%) of them accepted, all 30% were normal karyotype. All women had scans every 4 weeks. Two women underwent termination due to progression of ventriculomegaly. In 17 (63%) cases of ventriculomegaly resolved in third trimester, it is difficult to assess the prognosis of these babies as they did not have cranial ultrasound or neurodevelopmental assessment routinely.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
Poster presentations
Conclusion In our study all routine investigations including
TORCH and karyotype are normal. 63% of the cases of mild isolated ventriculomegaly resolved in utero. It has highlighted the lack of uniform policy in neonatal assessment. There are limitations including the retrospective model, small sample size and not having the neonatal follow-up. References:
1. Wax JR, Bookman L, Cartin A, Pinette MG, Blackstone J. Mild fetal cerebral ventriculomegaly: diagnosis, clinical associations and outcomes. Obstet Gynaecol Survey 2003; 58: 407–14. 2. Mercier A, Eurin D, Mercier PY, Verspyck, Marpeau L, Marret S. Isolated mild fetal cerebral ventriculomegaly: a retrospective analysis of 26 cases. Prenat Diagn 2001; 21: 589–95.
PP.04 Morphological changes in conservatively managed benign ovarian cyst characterised by simple ultrasonography rules in asymptomatic postmenopausal women: A retrospective cohort study based on the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) data
Yadav, SK; D’Angelo, A; Abdurazaq, B Amso, NN Department of Obstetrics & Gynaecology, Cardiff University School of Medicine, UK Introduction Postmenopausal simple ovarian cysts are often seen
by transvaginal sonography (TVS) and its frequent use in clinical settings. Nevertheless, due to inconstant sonographic appearance of ovarian cystic tumour, it is very challenging to make definite diagnosis by ultrasound. The aim of this study is to prospectively revise the validation of simple ultrasound rules to characterise the benignity or malignancy of conservatively managed adnexal masses in asymptomatic postmenopausal women using the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) database. Methods This is a retrospective cohort study in which ten ultrasonography simple rules from the International Ovarian Tumour Analysis (IOTA) were applied in a conservatively managed group in UKCTOCS. Asymptomatic postmenopausal women aged 50–74 years were recruited for this study through the 13 regional UKCTOCS trial NHS centres located in the UK. Results One thousand nine hundred volunteers’ ultrasound data were retrospectively collected from the UKCTCOS database. 845 volunteers had surgical management. Prevalence scan of 1055 data were retrieved for the analysis on volunteers who had conservative management.104 were excluded from the analysis due to missing information. Hence, simple based ultrasound rules were applied to 951 volunteers. After applying simple rules, 789 (83%) volunteers adnexal masses were classified as benign, 85 (9%) were malignant and 77 (8%) were inconclusive Conclusion Simple based ultrasound rules are very simple and easily reproducible to triage the women with adnexal masses.
However, most benign adnexal masses cannot be correctly classified by simple based rules. 9% of adnexal masses which classified as malignant indicates the high false positive results. Similarly, 8% of adnexal masses which classified as inconclusive suggest that further evaluation by expert examiner is required. Hence, simple based rules need to be further validated in order to avoid unnecessary risk of surgery, hospitalisation and socio-economic cost.
PP.05 Antenatal visualisation of cleft lip and palate in South Wales: Can offline 3D assessment and dataset analysis improve detection? A comparison of 2D and 3D examinations
Rogers, A University Hospital Llandough/Cardiff University, UK Background The primary aim of this study was to investigate fetal face and palate ultrasound imaging detection rates, to assess whether it is possible to improve diagnostic accuracy by using 3D techniques. This consequently may improve quality of care to obstetric patients by including 3D ultrasound performed by a sonographer, in the examination of the fetus at the 20-week anomaly scan visit. Methods A retrospective review of results from the Congenital Anomaly Register and Information Service (CARIS) was performed to assess antenatal oro-facial cleft detection rates between 1998 and 2010, for South Wales, UK. A prospective pilot study of 20 patients undergoing both 2D and 3D examinations was performed and offline reconstruction of the 3D data was compared to the 2D visualisation of the lips and palate. Results The retrospective results indicated that there were cases of undiagnosed oro-facial clefting occurring within South and mid-Wales. There was considerable improvement in detection rates after the introduction of Antenatal Screening Wales guidelines, although the impact on the detection of isolated cleft palate was negligible. In the prospective study, successful reconstruction of the fetal hard palate was completed in 100% of cases, with a variable increase in time. Visualisation of the structures in 2D was rated better than 3D, but the inter-rater reliability was better for 3D reconstruction. Conclusion Confidence in 2D fetal lip imaging is lower than expected and clefting of the lips is under diagnosed with present imaging protocols. Implementing 3D imaging into routine protocols would not be detrimental to service delivery in terms of time, but further assessment is needed of the benefit of 3D imaging locally.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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Poster presentations
PP.06 Preoperative assessment of deep pelvic endometriosis with MRI; a useful adjunct to the gynaecological surgeon
Muthukumarasamy, S; Nagraj, H; Westerland, O; Natas, S Jacques, A Guy’s and St Thomas’ Hospital NHS Trust, London, UK Background Deep pelvic endometriosis is a cause of severe pelvic pain, which can be difficult to assess clinically. Ultrasound often does not provide detailed assessment, in order to plan complete surgical excision of painful deposits. Laparoscopy can also be limited in the assessment of subperitoneal disease, or where there are deep pelvic adhesions obliterating the pelvic spaces.
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In these cases MRI can be invaluable to the gynaecologist in preoperative assessment and surgical planning, in particular, where bowel involvement may require more complex surgery. MRI findings were used to plan appropriate surgical approach, and the earlier involvement of other surgical specialties in more complex cases, if needed. Cases In this review we present the MR appearances of deep pelvic endometriosis with involvement of the uterosacrine ligament, torus uterinus, as well as visceral deposits involving the rectum and bladder. Conclusion MRI provides a useful adjunct to the gynaecologist in surgical planning, and the preoperative assessment of deep pelvic endometriosis.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
Video Presentation
Video presentation V.01 Ultrasound guided surgical management of hematocolpos, hemtaometria and hematosalpinx in a menstruating teenage girl
Speers, LJ1; Cook, S1; Neelankavil, J1 Amso, N2 1 Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, Wales, UK; 2Engagement, Learning and Teaching Institute for Translation, Innovation, Methodology and Engagement, Department of Obstetrics & Gynaecology, School of Medicine, Cardiff University, UK
Background A 13-year-old female presented to the paediatric admissions unit at her local hospital after repeated presentations to the general practitioner with lower abdominal pain for which no cause had been identified. Case On presentation a history of acute on chronic exacerbation of lower abdominal pain was described. Chronic pain originated from the time of menarche, which occurred a year prior to this presentation. The pain was cyclical and described as severe enough to cause regular absences from school. Clinical examination was grossly unremarkable except for a tender abdomen. There were no reported urinary symptoms, and bowel function suggested an element of constipation. Menstruation was regular with a 28-day
cycle. There was no significant past medical or surgical history. Investigation included ultrasound and magnetic resonance imaging (MRI). A diagnosis of hematosalpinx, hematometria, hematocolpos and a low longitudinal vaginal septum was made. Subsequent referral and review in our tertiary centre resulted in the patient commencing a combined oral contraceptive pill with continuous use to inhibit further menstrual loss and listing for urgent surgery. Examination under anaesthetic, revealed normal external genitalia. A single vaginal cavity was visualised and explored with vaginosocopy. A bulging septum 2 cm into the cavity, extending upward from anterior vaginal wall was discovered. Ultrasound guided septal incision was performed and drainage of collected menstrual fluid occurred. An obstructed right horn of a uterine didelphys with intravaginal septum had been alleviated. The postoperative period was uneventful and the patient was discharged later the same day. Outpatient review 2 months later revealed an improvement to abdominal pain and continued vaginal loss, suggesting the septal incision was still patent. Follow-up MRI is now planned. Conclusion Successful surgical management of an uncommon anatomic variance was achieved with the use of ultrasound guidance. At 2 months postprocedure this patient’s quality of life had significantly improved.
ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG
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