Transvaginal Ultrasound Scan Research Articles

Which factors are associated with trainees' confidence in performing obstetric and gynecological ultrasound examinations?

To explore the association between clinical training characteristics and trainees' level of confidence in performing ultrasound scans independently. A cross-sectional e-survey was distributed to members of the national societies of junior obstetricians/gynecologists in Denmark, Sweden and Norway (n = 973). Multiple linear regression models were used to explore the effect that amount of time spent in specialized ultrasound units and clinical experience had on trainees' confidence in performing ultrasonography independently. Exploratory factor analysis was used to identify factors that contributed to trainees' confidence in performing ultrasonography. Trainees' ultrasound confidence was finally compared with their expected levels of performance. Of the 682 respondents (response rate 70.1%), 621 met the inclusion criteria. Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently (P < 0.001). Trainees required more than 24 months of clinical experience and 12-24 days of training in specialized ultrasound units in order to feel confident about performing transvaginal and transabdominal ultrasound scans independently. Three factors were related to ultrasound confidence: technical aspects, image perception and integration of scan into patient care. There were significant differences between trainees' level of confidence and their expected levels of performance (P < 0.001). Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently. Discrepancies between trainees' confidence and their expected levels of performance raised concerns about the adequacy of current ultrasound training programs.

The Value of Vaginal Packing in Pelvic Floor Surgery

The objective of this study was to evaluate the effect of vaginal packing following pelvic floor surgery with regard to post-operative pain, bleeding and infection. This was a double-blind randomised study of women undergoing vaginal hysterectomy and/or pelvic floor repair at a tertiary urogynaecology unit. The primary outcome of day 1 post-operative pain was assessed using the short-form McGill Pain score. Secondary outcomes were haematological and infective morbidity, evaluated using changes in full blood count, and cultures of midstream urine and high vaginal swabs. A transvaginal ultrasound scan to exclude pelvic haematoma was performed at 6 weeks in all women who underwent vaginal hysterectomy with or without a pelvic floor repair. In total, 190 women were recruited: mean age 58.3 years (27–91 years), mean body mass index 27.4 kg/m2 and median parity 3. Women were randomised into the ‘pack’ (n = 86) and ‘no pack’ (n = 87) arms with no demographic differences between the groups. No statistically significant differences in the post-operative pain scores or secondary outcome measures were demonstrated. Incidence of haematoma formation (14.8 % no pack, 7.3 % pack, p = 0.204) was not statistically significant. There were three clinically significant complications in the no pack group and none in the pack group. This is the first study to examine pain in association with post-operative vaginal packing. There is no evidence to suggest that packing increases pain scores or post-operative morbidity. A trend towards increased haematoma and significant complications was seen in the no pack group. As vaginal packing does no harm and may be of some benefit it may be argued that packing should be recommended as routine clinical practice.

Does ovarian suspension following laparoscopic surgery for endometriosis reduce postoperative adhesions? An RCT

Is temporary ovarian suspension following laparoscopic surgery for severe pelvic endometriosis an effective method for reducing the prevalence of postoperative ovarian adhesions? Temporary ovarian suspension for 36-48 h following laparoscopic treatment of severe endometriosis does not result in a significant reduction of postoperative ovarian adhesions. Pelvic adhesions often develop following laparoscopic surgery for severe pelvic endometriosis. Adhesions can cause chronic pelvic pain and fertility problems compromising the success of treatment. Small observational studies suggested that temporary postoperative ovarian suspension to the abdominal wall may significantly reduce the prevalence of postoperative ovarian adhesions. This was a prospective within group comparison double-blind RCT. We recruited premenopausal women with severe pelvic endometriosis who required extensive laparoscopic surgery with preservation of the uterus and ovaries. Severity of the disease and eligibility for inclusion were determined at surgery. A total of 55 women were randomized to unilateral ovarian suspension for 36-48 h, 52 of which were included in the final analysis. Both ovaries were routinely suspended to the anterior abdominal wall during surgery. At the end of the operation, each woman was randomized to having only one ovary suspended postoperatively. The suture suspending the contralateral ovary was cut and a new transabdominal suture was inserted to act as a placebo. Both sutures were removed 36-48 h after surgery prior to discharge. Three months after surgery, all women attended for a detailed transvaginal ultrasound scan to assess ovarian mobility. Both the women and the ultrasound operators were blinded as to the side of postoperative ovarian suspension. The primary outcome was the prevalence of ovarian adhesions as described on ultrasound examination. Secondary outcomes were the severity of adhesions and the presence and intensity of postoperative pain. All 55 participants had severe pelvic endometriosis confirmed at laparoscopy. As each participant had only one of their ovaries suspended at the end of surgery, they acted as their own control. The median interval between ovarian suspension and postoperative scan was 99 days (interquartile range 68-114). There was no significant difference (P = 0.23) in the prevalence of postoperative ovarian adhesions between the suspended (20/52) and unsuspended (27/52) side (38.5 versus 51.9%) [odds ratio 0.56 (95% confidence interval 0.22-1.35)]. Ovaries were suspended postoperatively for 36-48 h. Longer suspension could result in lower prevalence of postoperative adhesions. The value of temporary ovarian suspension in women having surgery for mild-to-moderate endometriosis should be investigated further. The potential benefits of other adhesion prevention strategies, such as surgical barrier agents, in women undergoing surgical treatment for severe pelvic endometriosis should also be explored. E.S. received honoraria from Ethicon for provision of training to healthcare professionals and consultancy fees from Bayer. W.H. was supported by the research fund provided by the Gynaecology Ultrasound Centre, London UK. A.C. is on the advisory board for surgical innovations for which he receives an annual honorarium. A.C. also received support for courses and education from Storz and Johnson and Johnson and support for clinical nursing from Covidien and Lotus. The other authors declared no competing interests. Current Controlled Trials ISRCTN24242218.

Anti-Mullerian as predictor of reproductive outcome in infertile women: follow up.

ObjectiveThe aim of the present study was to investigate and to compare the relations of anti-Mullerian with the prognostic parameters and the outcome of assisted reproductive treatment.MethodsProspective longitudinal study. A total of one hundred and twelve infertile women. Inclusion criteria: i) both ovaries present, ii) no current or past diseases affecting ovaries or gonadotropin or sex steroid secretion, clearance, or excretion, iii) no current hormone therapy, iv) adequate visualization of ovaries at transvaginal ultrasound scans, and v) total number of small antral follicles (3-12 mm in diameter) between 1 and 32 follicles. On cycle day 3, woman underwent blood sampling for serum FSH and AMH measurement and a transvaginal ovarian ultrasound scan for follicle measurement. Ongoing pregnancy was evaluated as biochemical pregnancy and observation of gestational sac(s).ResultsMean age of 36.13 ± 4.65 years old, BMI 21.59 ± 2.78 kg/m2, and length of infertility of 2.88 ± 2.36 years. Their ovaries had an average of 13.74 ± 6.0 antral follicles and AMH was 2.49 ± 1.98 ng / mL. A significant relationship of AMH with age (r =-0.37 P <.01), with FSH (r =-0.22, P <.01), with AFC (r = 0.74, P <.00001), with smoking (P <.009), with SOP (P <.00001), with the total dose of the drug during stimulation ovarian (r =-0.36, P <.0004), with abortion (P <.05) and with the ongoing pregnancy (P <.05).ConclusionAMH is a marker of quantitative and qualitative aspects of the ovarian reserve.

Correlation between Perifollicular Vascularity and Outcome in Stimulated Intrauterine Insemination Treatment Cycles: A Study Using Two-Dimensional Transvaginal Power Doppler Ultrasound

Objective: The aim of this study is to assess any potential relationship between perifollicular vascularity and occurrence of pregnancy in cases of stimulated IUI cycles using the subjective grading system by 2D transvaginal power Doppler ultrasonography. Design: A prospective cross sectional cohort study. Method: This is a prospective cross-sectional cohort study of 90 stimulated IUI treatment cycles. Selected women were prescribed clomiphene citrate combined with highly purified urinary follicle stimulating hormone. All patients underwent serial transvaginal ultrasound scans starting from day 6 to 7 of the cycle. Perifollicular Doppler blood flows were assessed in dominant follicles ≥18 mm. The patients then were categorized into 3 groups (high vascularity group {G3 & G4}, low vascularity group {G1 & G2} and mixed grades group). Other parameters measured included number of follicles ≥ 18 mm in both ovaries, endometrial thickness and estradiol (E2) level . Human chorionic gonadotropin (hCG) injection 10,000 IU IM was given to the patient when the dominant follicle reached 18 mm in diameter. At that time, the endometrium was evaluated as regards endometrial thickness. IUI was carried out using prepared/“washed” semen (husband). All patients received luteal support in the form of progesterone from day of IUI for 14 days. Serum Β-hCG was estimated 2 weeks after insemination. Results: In this study, from all 90 cases only 8 cases got pregnant with pregnancy rate of 8.88% (6 cases got pregnant in high grade vascularity group; 2 cases in mixed grades group and no cases got pregnant in low grade group). There was statistically significant difference among the 3 groups as regarding the pregnancy rate (P value = 0.02). There is statistically significant difference in perifollicular resistance index (RI) and pulsatility index (PI) between pregnant and non pregnant cases (P value = 0.016 and 0.047 respectively). In this study, there is no statistically significant difference between pregnant and non pregnant cases as regarding endometrial thickness and E2 level at the day of hCG administration (P value = 0.39 and 0.76 respectively). Conclusion: Perifollicular blood-flow assessment by 2D transvaginal power Doppler is a good predictive for the outcome of stimulated IUI cycles.

Acute Abdomen in Interstitial Ectopic Pregnancy, An Emergency Laparoscopic Treatment

The present case report demonstrates a laparoscopic approach to treat interstitial cornual pregnancy in emergency. Interstitial ectopic pregnancy develops in the uterine portion of the fallopian tube which accounts for 2–4% of all ectopic pregnancies and has the potential to cause life-threatening hemorrhage at rupture. The mortality rate for a woman diagnosed with such a pregnancy is 2–2.5%. Diagnosis of interstitial pregnancy is made by ultrasound. In this case a 32 year-old woman, Gravida 0 Parity 0 Living 0 Ectopic 1, presented to the emergency obstetrical room complaining acute abdominal pain. There was a history of 10 weeks of pregnancy but no pelvic ultrasound scan was performed before the access. A transvaginal ultrasound scan immediately performed demonstrated a gestational sac with viable fetus in the right interstitial region. Moreover there was an ultrasound evidence of hemoperitoneum. She was transferred to the operating room and an emergency laparoscopy surgery was performed. The postoperative course was uneventful and the patient was discharged two days after the surgery. Interstitial pregnancies present a difficult management problem with no absolute standard of care in literature. Laparoscopic technique is under study with favorable results. For our personal point of view a treatment via laparoscopy could be performed both in elective and in emergency cases.

The value of vaginal packing in pelvic floor surgery: a randomised double-blind study

The objective of this study was to evaluate the effect of vaginal packing following pelvic floor surgery with regard to post-operative pain, bleeding and infection. This was a double-blind randomised study of women undergoing vaginal hysterectomy and/or pelvic floor repair at a tertiary urogynaecology unit. The primary outcome of day 1 post-operative pain was assessed using the short-form McGill Pain score. Secondary outcomes were haematological and infective morbidity, evaluated using changes in full blood count, and cultures of midstream urine and high vaginal swabs. A transvaginal ultrasound scan to exclude pelvic haematoma was performed at 6 weeks in all women who underwent vaginal hysterectomy with or without a pelvic floor repair. In total, 190 women were recruited: mean age 58.3 years (27-91 years), mean body mass index 27.4 kg/m(2) and median parity 3. Women were randomised into the 'pack' (n = 86) and 'no pack' (n = 87) arms with no demographic differences between the groups. No statistically significant differences in the post-operative pain scores or secondary outcome measures were demonstrated. Incidence of haematoma formation (14.8 % no pack, 7.3 % pack, p = 0.204) was not statistically significant. There were three clinically significant complications in the no pack group and none in the pack group. This is the first study to examine pain in association with post-operative vaginal packing. There is no evidence to suggest that packing increases pain scores or post-operative morbidity. A trend towards increased haematoma and significant complications was seen in the no pack group. As vaginal packing does no harm and may be of some benefit it may be argued that packing should be recommended as routine clinical practice.

Gestational Sac Aspiration of Heterotopic Ectopic Pregnancy in a Cesarean Section Scar

Abstract Background: This article describes a case of heterotopic pregnancy that included a normal twin intrauterine pregnancy and one cesarean section (CS) scar pregnancy diagnosed at 6 weeks of gestation. Ultrasound-guided aspiration of the ectopic gestational sac was performed, and the concurrent twin intrauterine pregnancy (IUP) was preserved successfully. The patient was a 50-year-old woman with secondary infertility. Case: The patient underwent in vitro fertilization and embryo transfer using a donor-egg program to achieve pregnancy with her current partner. At 6-weeks' gestation, she underwent a transvaginal ultrasound scan (US) examination showing a viable twin IUP with a third gestational sac with viable embryo located low within the anterior wall of the uterus. The appearance was consistent with a cesarean scar ectopic pregnancy. This was confirmed on a subsequent US 1 week later. She desired to continue the intrauterine pregnancy. US-guided aspiration of the cesarean scar ectopic pregnancy was ...

Laparoscopic Surgery for Ovarian Pregnancy using Diathermy Hook with Conservation of Ovary: A Case Report and Literature Review.

A 31-year-old woman presented with a 7-week history of irregular vaginal bleeding without abdominal pain. She had been using the intrauterine contraceptive device (IUD) for the last 3 years. A pregnancy test was positive and subsequent serum beta human chorionic gonadotropin (β-HCG) was 4992 mIU/mL. A transvaginal ultrasound scan demonstrated an empty uterus with an associated adnexal mass but no free fluid. A right primary ovarian ectopic pregnancy was diagnosed a laparoscopy. This was managed laparoscopically using monopolar diathermy hook with conservation of the ovary and minimal blood loss. Ovarian pregnancy is rare, especially in women without the classical risk factors for tubal pregnancy, and efforts should be made to exclude ectopic pregnancy in the absence of abdominal pain in a woman of reproductive age presenting with prolonged and irregular vaginal bleeding. Methods to conserve the ovary are also encouraged in cases of ovarian pregnancy.

Ultrasound mapping of pelvic endometriosis: does the location and number of lesions affect the diagnostic accuracy? a multicentre diagnostic accuracy study

BackgroundEndometriosis is a common condition which causes pain and reduced fertility. Treatment can be difficult, especially for severe disease, and an accurate preoperative assessment would greatly help in the managment of these patients. The objective of this study is to assess the accuracy of pre-operative transvaginal ultrasound scanning (TVS) in identifying the specific features of pelvic endometriosis and pelvic adhesions in comparison with laparoscopy.MethodsConsecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. They all underwent a systematic transvaginal ultrasound examination in order to identify discrete endometriotic lesions and pelvic adhesions. The accuracy of ultrasound diagnosis was determined by comparing pre-operative ultrasound to laparoscopy findings.Results198 women who underwent preoperative TVS and laparoscopy were included in the final analysis. At laparoscopy 126/198 (63.6%) women had evidence of pelvic endometriosis. 28/126 (22.8%) of them had endometriosis in a single location whilst the remaining 98/126 (77.2%) had endometriosis in two or more locations. Positive likelihood ratios (LR+) for the ultrasound diagnosis of ovarian endometriomas, moderate or severe ovarian adhesions, pouch of Douglas adhesions, and bladder deeply infiltrating endometriosis (DIE), recto-sigmoid colon DIE, rectovaginal DIE, uterovesical fold DIE and uterosacral ligament DIE were >10, whilst for pelvic side wall DIE and any ovarian adhesions the + LH was 8.421 and 9.81 respectively.The negative likelihood ratio (LR-) was: <0.1 for bladder DIE; 0.1-0.2 for ovarian endometriomas, moderate or severe ovarian adhesions, and pouch of Douglas adhesions; 0.5-1 for rectovaginal, uterovesical fold, pelvic side wall and uterosacral ligament DIE. The accuracy of TVS for the diagnosis of both total number of endometriotic lesions and DIE lesions significantly improved with increasing total number of lesions.ConclusionsOur study has shown that the TVS diagnosis of endometriotic lesion is very specific and false positive results are rare. Negative findings are less reliable and women with significant symptoms may still benefit from further investigation even if TVS findings are normal. The accuracy of ultrasound diagnosis is significantly affected by the location and number of endometriotic lesions.

Sensitivity of Myoma Imaging Using Laparoscopic Ultrasound Compared With Magnetic Resonance Imaging and Transvaginal Ultrasound

Study ObjectiveTo determine the efficacy of laparoscopic ultrasound (LUS) as compared with contrast-enhanced magnetic resonance imaging (CE-MRI) and transvaginal ultrasound (TVUS) in detection of uterine myomas. DesignRetrospective study of imaging methods used in a trial of LUS-guided radiofrequency volumetric thermal ablation in women with symptomatic myomas (Canadian Task Force classification II-2). SettingEleven medical university or private outpatient surgery clinics in the United States (nine sites) and Latin America (two sites). PatientsOne hundred thirty-five women with symptomatic myomas and objectively confirmed moderate to severe heavy menstrual bleeding. InterventionsLUS-guided radiofrequency volumetric thermal ablation of myomas. Measurements and Main ResultsPreoperative TVUS scans and CE-MRIs were read at each site, and all CE-MRIs were read by a central reader. LUS-guided scans were obtained intraoperatively by each surgeon by mapping the uterus just before radiofrequency volumetric thermal ablation. The imaging methods and their yields in terms of number of myomas found per subject were as follows: TVUS, 403 myomas (mean [SD] 3 [1.8]; range, 1–8); site CE-MRI, 562 myomas (4.2 [3.8]; range, 1–18); central reader, 619 myomas (4.6 [3.7]; range, 0–20); and LUS, 818 myomas (6.1 [4.9]; range, 1–29) (p < .001). LUS was superior to TVUS, CE-MRI, and the central reader for detection of small (≤1 cm3) myomas. Most imaged myomas were intramural: 197 (50.9%) by TVUS, 298 (55.5%) by site CE-MRI, 290 (48.7%) by the central reader, and 386 (48.5%) by LUS. ConclusionCompared with CE-MRI and TVUS, LUS demonstrates the most myomas, regardless of size or type.

Preoperative Detection of Sentinel Lymph Nodes in Endometrial Cancer Using SPECT/CT

We report the use of SPECT/CT in sentinel lymph node biopsy in endometrial cancer. The patient was a 54-year-old woman with the diagnosis of endometrial adnenocarcinoma, grade 2. Preoperative MRI and transvaginal ultrasound scans revealed tumor infiltrating more than 50% of the myometrium. The patient was qualified for total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic/paraaortic lymphadenectomy. Before the surgery, 2 cervical injections of the (99m)Tc-labeled nanocolloid (0.5 mCi) were administered and the SPECT/CT was performed using a standard dual-head gamma camera and a 6-slice spiral CT component.

Vasa Previa

To review experience with diagnosis, clinical associations, and outcomes of vasa previa in a single institution. This was a retrospective review of all identified vasa previa cases from January 1 1990, to June 30, 2010. Sixty cases of vasa previa were identified (53 singletons, seven twins); 56 cases were diagnosed before delivery. An abnormal cord insertion or abnormal placental location was present in 55 cases. Missed diagnoses were attributed to technical and observer factors. Preterm bleeding was encountered in 25 (42%) case group participants. Seven case group participants required an emergent delivery, with significant neonatal morbidity and mortality. Twin pregnancies had a significantly earlier median age at delivery of 32 weeks of gestation compared with 35 weeks of gestations in singletons (P=.01). The seven twin pregnancies had a 28.6% emergent preterm delivery rate, whereas singletons had a 4.1% rate (P=.07). In 14 case group participants, the membranous fetal vessel was located in the lower uterus and not directly over the cervix. The vessel location was not related to the risk of emergent delivery. Transvaginal ultrasound scans of at-risk patients can identify most cases of vasa previa. Preterm bleeding does not usually require immediate delivery. The rate of emergent preterm delivery was low in singleton pregnancies. Twins were delivered, on average, 3 weeks earlier than singletons. III.

Nipple-areola-complex sparing mastectomy: five years of experience in a single centre

This study aimed at assessing the outcomes of nipple-areola-complex-sparing mastectomy (NSM) of breast cancer in a single-centre and single-surgeon series after 5 years of experience. From June 2007 to January 2012, 58 female patients with breast cancer were admitted for NSM at our unit and 55 of these underwent NSM. All patients underwent a preoperative clinical and instrumental evaluation. The clinical evaluation consisted of physical examination by taking measurements of the prosthesis and through anamnesis. The instrumental evaluation used were mammography, chest X-ray, abdominal and breast ultrasound, blood test and, if necessary, magnetic resonance imaging. Specific inclusion criteria have been met in recruiting patients: clinically negative axillas, tumours < 3 cm in any of the quadrants, tumours more than 1 cm away from the NAC. The patients underwent a surgical and oncological follow-up. The surgical follow-up consisted in treating wounds, managing drainages and tissue expanders and then planning the replacement surgeries. The oncological follow-up consisted of periodical medical (such as blood tests including cancer markers) and radiological evaluations (such as mammography, chest X-ray, abdominal and transvaginal ultrasound scan and/or thorax-abdomen computed tomography) to assess the disease progression, and, if necessary the patients underwent chemotherapy or hormonal therapy. Out of 58 recruited patients undergoing NSM, only 3 patients (5.1 %) had an occult tumour in the NAC at intraoperative extemporaneous histological examination and required the NAC removal. The other 55 patients (94.9 %) did not have neoplastic involvement of NAC and at an average follow-up period of 21.7 months (range 3-55 months) only 4 (7.2 %) had disease progression. Nipple-Sparing Mastectomy is a highly specialized and oncologically sure procedure to be performed only in reference centres on selected patients.

Gestagen versus oral contraceptive pills to induce withdrawal bleeding before induction of ovulation by clomiphene citrate in polycystic ovary syndrome

Abstract Objective To compare between gestagen versus oral contraceptive pills to induce withdrawal bleeding before induction of ovulation by clomiphene citrate in polycystic ovary syndrome. Design Randomized controlled trial. Setting Integrated Fertility Center and Agial Fertility Center. Sample Fifty PCO female patients. Methods The patients were subdivided in 2 groups according to computer generated randomized program: Group I: Twenty five PCO female patients treated by cidolut nor 5 mg tablets (two tablets every day for 5 days). Group II: Twenty five PCO female patients treated by cilest tablets (one tablet every day for 21 days). All patients were observed until withdrawal bleeding followed by ovulation induction by clomiphene citrate from the second day of menses (100 mg per day for 5 days). The patients were then followed up by: - transvaginal ultrasound follicular scanning in days 10, 12, and 14 of withdrawal bleeding until ovulation was detected with additional evaluation of the endometrial thickness and pattern - serum progesterone was measured 7 days after the expected day of ovulation - pregnancy test 15 days after ovulation to detect pregnancy and 2 weeks later by U/S to detect fetal pulsation. Main outcome measures Endometrial thickness, number of mature follicles and serum progesterone level on day o f ovulation, and clinical pregnancy rate. Results There was no significant difference between the two groups regarding pregnancy rate. Conclusions A few studies show an apparent use of oral contraceptive pills in the improvement of ovulation induction by clomiphene citrate. Despite this, from the available data a causal relationship is not confirmed, so large prospective studies using larger sample size, and longer duration of treatment are needed. Meanwhile, close clinical surveillance of patients being treated with oral contraceptive pills is required.

Ectopic pregnancy: a review

Ectopic pregnancy (EP) presents a major health problem for women of child-bearing age. EP refers to the pregnancy occurring outside the uterine cavity that constitutes 1.2-1.4% of all reported pregnancies. All identified risk factors are maternal: pelvic inflammatory disease, Chlamydia trachomatis infection, smoking, tubal surgery, induced conception cycle, and endometriosis. These developments have provided the atmosphere for trials using methotrexate as a non-surgical treatment for EP. The diagnosis measure of EP is serum human chorionic gonadotropin, urinary hCGRP/i-hCG, progesterone measurement, transvaginal ultrasound scan, computed tomography, vascular endothelial growth factor, CK, disintegrin and metalloprotease-12 and hysterosalpingography. The treatment option of EP involves surgical treatment by laparotomy or laparoscopy, medical treatment is usually systemic or through local route, or by expectant treatment. It was concluded that review data reflect a decrease in surgical treatment and not an actual decline in EP occurrence so that further new avenues are needed to explore early detection of the EP.

Transvaginal Ultrasound Simulation and its Effect on Trainee Confidence Levels: A Replacement for Initial Clinical Training?

Introduction The ScanTrainer transvaginal ultrasound simulator has been developed to facilitate initial training of transvaginal ultrasound skills without patient contact. Due to the intimate nature of the examination and in some cases, limited training opportunities, the need for simulation-based education in ultrasound has gained momentum. Currently, research into the effectiveness of the ScanTrainer is limited. Methods A mixed method study was conducted in a single institution between October 2011 and January 2012. Participants were recruited using convenience sampling and allocated to the control (clinical training) or experimental (simulation training) group following a pre-test. After 10 hours of their allocated transvaginal ultrasound training method a post-test assessment was conducted and the results statistically analysed. Participants then experienced the alternative method of training and completed questionnaires. The results were used to inform semi-structured interviews for each group. Interview transcripts were interpreted using theme analysis. Results A small number of doctors completed the study, nine (82%) out of the 11 recruited. The majority of participants (89%) felt that practice on the ScanTrainer can increase confidence prior to attempting a real transvaginal ultrasound scan. Average scores showed that the simulation training group outperformed the clinical training group on overall score and each of the five post-test components. No statistically significant differences were demonstrated for overall score ( U = 13, P = 0.556) or the five components ( P = 0.190–1). Conclusions Transvaginal ultrasound training on the ScanTrainer has the potential to replace initial clinical training; however, further larger trials are required to evaluate. Clinically significant outcomes exist if the ScanTrainer training is proven to be more effective than initial clinical training. The ScanTrainer prepares a trainee and builds confidence to progress to clinical scanning, which has the potential to improve the patient experience.

Laparoscopic Cornuostomy for a Large Interstitial Ectopic Pregnancy

A 30-year-old woman with a known incomplete uterine septum was referred to our unit for persistent elevation of β-human chorionic gonadotropin levels. Twelve weeks earlier, she was assumed to have had a complete miscarriage at 7 weeks of gestation. A transvaginal ultrasound scan suggested a large right interstitial ectopic pregnancy, and the diagnosis was confirmed by laparoscopy (Fig. 1). Laparoscopic cornuostomy after myometrial injection with diluted vasopressin was performed. This was followed by the total removal of the gestational sac (Fig. 2) and laparoscopic repair of the cornuostomy incision in 2 layers.

Abstract 150: Ovarian visualization in transvaginal ultrasound scans and risk of ovarian cancer.

Abstract Background. Ovarian cancer is typically diagnosed at an advanced stage, resulting in poor survival. Detection of ovarian cancer at an early curable stage could reduce mortality; however, annual screening with transvaginal ultrasound (TVU) and CA-125 serum levels using predetermined cutpoints did not lower mortality in the Prostate, Lung, Colorectal and Ovarian (PLCO) trial. In this trial, approximately 40% of TVU scans resulted in non-visualization of the ovaries. Currently, TVU studies consider non-visualization of the ovaries as having normal ovaries, even though this may confer risk information. Accordingly, we assessed risk of ovarian cancer among women with non-visualization of the ovaries by TVU in the PLCO trial. Methods. Study participants were women from the ovarian screening arm of the PLCO trial. Briefly, women aged 55-74 years were recruited at ten US clinical centers between 1993 and 2001. Those with a previous diagnosis of ovarian cancer were excluded from enrollment. Subjects with at least one ovary underwent a TVU at baseline and annually for 3 additional years and were followed-up for up to 13 years. Individuals were excluded from the current analysis if they did not complete the baseline questionnaire or did not have at least one adequate screening (i.e., visualization of the iliac vessels). Ovaries were considered not visualized if they were not seen after a search of at least 5 minutes. Associations between participant characteristics and ovarian visualization were estimated using logistic regression models adjusted for age and calendar year. Hazard ratios (HR) and 95% confidence intervals (CI) were computed to estimate the risk of ovarian cancer with TVU visualization using Cox proportional hazard models. Age was the time metric and models were adjusted for calendar year, body mass index (BMI), race, parity and oral contraceptive (OC) use. Results. Our analysis included 29,329 women, with 98.6% of them having two or more TVUs. Two hundred and five women were diagnosed with invasive ovarian cancer during follow-up. Lack of visualization of the ovaries by TVU was associated with older age, non-White race, greater BMI, ever use of OC and ever having children. However, ovarian visualization was not associated with risk of ovarian cancer (HR=1.17; 95% CI: 0.86-1.59). Moreover, women with visualized ovaries but negative TVUs were not at elevated ovarian cancer risk compared to women with non-visualized ovaries (HR=1.06; 95% CI: 0.77-1.45). Conclusions. Women with non-visualization of the ovaries by TVU and those with visualization and a negative result do not have a different risk of ovarian cancer, suggesting that data for these women may be combined. Ongoing analysis will examine serial measurements of ovarian volume by TVU and ovarian cancer risk. Citation Format: Clara Bodelon, Amanda Black, Ruth M. Pfeiffer, Mark E. Sherman. Ovarian visualization in transvaginal ultrasound scans and risk of ovarian cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 150. doi:10.1158/1538-7445.AM2013-150

Abstract 4641: IL-16 in association with VEGFR-2 detect early tumor associated changes in the ovary.

Abstract Background: Ovarian cancer (OVCA) is a lethal malignancy of women with high rate of death among gynecological cancers. Due to the lack of an effective early detection test, OVCA in most cases are detected at late stage. Interleukin (IL)-16 is a cytokine involved in multiple immunopathobiological processes including inflammatory responses and production of proangiogenic cytokines. IL-16 is expressed by malignant epithelium and secreted in serum. Ovarian malignant transformation is followed by neovascularization and vascular endothelial growth factor receptor-2 (VEGFR-2) is a marker of tumor associated neovascularization (TAN). Thus, IL-16 and VEGFR-2 represent markers of OVCA at early stage may constitute an early detection test for OVCA. Objectives: The goal of this study was to determine whether IL-16 expression is associated with ovarian malignant transformation and to examine association between serum IL-16 levels and VEGFR-2 expression by TAN vessels during ovarian tumor development. Materials and methods: Normal (n =15) White Leghorn laying hens (3-4 years old) or hens with ovarian tumors (n=32) were selected by contrast enhanced transvaginal ultrasound scanning. Following serum collection, hens were euthanized, tissues were processed for routine histology, immunohistochemistry (IHC), protein and gene expression studies. Ovarian tumors were confirmed by gross morphology and microscopy. Expression of IL-16 by ovarian malignant epithelium and VEGFR-2 by ovarian TAN vessels were determined by IHC, immunoblotting and quantitative PCR. Serum IL-16 levels were determined by immunoassay. Correlation between serum IL-16 levels and frequencies of VEGFR-2 expressing microvessels were examined. Results: The intensity of IL-16 expression by normal ovarian epithelium was very weak (n=15). In contrast, the staining intensity of IL-16 by malignant epithelium increased significantly (p&amp;lt;0.001) in hens with early stage OVCA (n=15) and late stage OVCA (n=17). Compared with normal hens, serum levels of IL-16 were significantly higher in hens with early (n=15) and late stages (n=17) of OVCA (P&amp;lt; 0.0001). The expression of IL-16 protein and mRNA were stronger in malignant ovaries than normal ovaries. The population of VEGFR-2 expressing microvessels increased significantly (p&amp;lt;0.001) in hens with early stage OVCA than normal hens (p&amp;lt;0.001) and increased further in late stage OVCA. The increase in serum IL-16 was positively correlated with the population of VEGFR-2 expressing TAN vessels. Conclusion: IL-16 expression by ovarian malignant epithelium and its serum levels are associated with ovarian malignant transformation and correlated with VEGFR-2 expression. Thus IL-16 may be a useful serum marker and in combination with VEGFR-2 may detect OVCA at early stage. These findings will facilitate clinical studies to establish a non-invasive early OVCA detection test. Support: DOD Award # W81XWH-12-1-0460. Citation Format: Aparna Yellapa, Pincas Bitterman, Jacques S. Abramowicz, Janice M. Bahr, Sanjib Basu, Sameer Sharma, Animesh Barua. IL-16 in association with VEGFR-2 detect early tumor associated changes in the ovary. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4641. doi:10.1158/1538-7445.AM2013-4641