Acceptability of early transvaginal or abdominal sonography in the first half of pregnancy

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Vaginal fluid index - The fifth amniotic pocket

OBJECTIVE

The forebag is a pocket of amniotic fluid preceding the fetal presenting part. Herein we describe the feasibility of transvaginal measurements of the forebag and assess its correlation with the standard amniotic fluid index (AFI).

METHODS

A prospective study was carried out between January 2019 and July 2020. Eligible cases were women with singletons, vertex presentation, and normal AFI at term. We assessed the implementation and acceptance of a novel process in the clinical practice setting. Feasibility was assessed by using transvaginal ultrasound to measure the three orthogonal planes of the forebag. The vaginal fluid index (VFI) was defined as the volume composite of the three orthogonal planes. Correlations of the forebag measurements with both AFI and maximal vertical pocket were then calculated.

RESULTS

In total, 292 out of 305 (95.7%) women were enrolled. All participants completed both transabdominal and transvaginal ultrasound, of which the vaginal pocket was demonstrated in 266 (91.1%) cases. We found significant correlations, in both nulliparas and multiparas, between the vaginal pocket measurements and the VFI to both the AFI and maximal vertical pocket measurements (R = 0.38, P < 0.001; R = 0.3, P < 0.001, respectively).

CONCLUSION

We introduced a new ultrasound variable, the VFI, with a high feasibility rate. This may provide invaluable information for future decision making around the time of delivery.

Does point-of-care ultrasonography cause discomfort in patients admitted with respiratory symptoms?

BACKGROUND

This study aimed to assess the patient-rated level of discomfort during point-of-care ultrasonography (POCUS) of the heart, lungs and deep veins in a population of patients admitted to an ED with respiratory symptoms and to what extent the patients would accept being assessed by the use of POCUS if they had to be examined for possible disease.

METHODS

A questionnaire-based observational study was conducted in an ED. Inclusion criteria were one or more of the following: respiratory rate > 20/min, oxygen saturation < 95 %, oxygen therapy initiated, dyspnoea, cough or chest pain. Patients were examined by the use of POCUS of the heart, lungs and deep veins. Patient-rated level of discomfort and acceptance were assessed using a standardised questionnaire.

RESULTS

The median duration of the sonographic examinations was 12 min (IQR 11-13, range 9-23). The median patient-rated level of discomfort for all three types of POCUS was 1 (IQR 1-1, range 1-8) on a scale from 1 to 10. All but one patient (99.6 % (95 % CI: 98.9-100 %)), would accept being examined by the use of POCUS as a part of routine ED diagnostics.

CONCLUSIONS

The patient-rated level of discomfort during POCUS of the heart, lungs and deep veins is very low and the vast majority of patients would accept being assessed by the use of POCUS if the patients once again had to be examined for possible disease.

Outcome of pregnancy with history-indicated cervical cerclage insertion in a low-resource setting

OBJECTIVE

History-indicated cervical cerclage insertion is required when factors in a woman's history could predispose to spontaneous miscarriage or preterm birth. This retrospective study determined the pregnancy outcome after insertion of history-indicated cervical cerclage for at least one previous mid-trimester spontaneous abortion over a 10-year period in a low-resource setting.

METHODS

This was a retrospective analysis of hospital data. Data was retrieved on biosocial and obstetrics parameters and analysed. The outcome measures were recurrence of spontaneous miscarriage, preterm delivery rate and fetal salvage rate. Descriptive frequencies were used to present results. The test of statistical significance was with Yates' coefficient correlation at 95% confidence interval.

RESULTS

Cervical cerclage rate was 7 per 1000 births. Diagnosis was clinical and cerclage was inserted at a mean gestational age of 15 ± 3.6 weeks. Hospital admission greater than five days after cerclage insertion had no statistically significant difference on preterm delivery (CI 95%; p value = 0.98). Repeat spontaneous miscarriage occurred less (5.6%) after cerclage insertion, fetal salvage rate was 75% and the preterm birth rate was 30%.

CONCLUSION

The limitations of the study notwithstanding, use of history-indicated cervical cerclage in pregnancy resulted in better fetal salvage rate and reduced recurrence of spontaneous miscarriage.

Transvaginal ultrasonography: a survey of the acceptability and its predictors among a native African women population

Objective

To determine the acceptability of transvaginal ultrasonography (TVU) and associated factors among Nigerian women.

Method

A cross-sectional survey was conducted among 3137 women who presented for transabdominal ultrasound scan between August and November 2010 in two referral hospitals in Nigeria. Data were obtained using a questionnaire. Descriptive and multivariate analysis was performed applying logistic regression analysis; predictors of willingness of participants regarding transvaginal ultrasound were identified using SPSS Statistics (SPSS Inc, Chicago, IL) version 17 software.

Results

The mean age of the women was 33.8 years (standard deviation = 7.9), with 88.8% currently married. About 84% were willing to have TVU, while 54.2% were indifferent about the gender of the sonologist. About 17.3% believed that the procedure is painful. Significant predictors of willingness to have TVU were previous sexual experience and douching, prior painful vaginal examination, and vaginal surgery.

Conclusion

The majority of Nigerian women expressed a willingness to have the TVU procedure without necessarily opting for any gender preference of the operator. Women should be adequately counseled on the operations of the procedure so as to be able to psychologically prepare for them.

SOGC Clinical Practice Guideline. Ultrasonographic cervical length assessment in predicting preterm birth in singleton pregnancies

OBJECTIVES

To review (1) the use of ultrasonographic-derived cervical length measurement in predicting preterm birth and (2) interventions associated with a short cervical length.

OUTCOMES

Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions.

EVIDENCE

Published literature was retrieved through searches of PubMed and The Cochrane Library up to December 2009, using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, incompetent cervix, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence and this guideline were reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the ultrasonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth.

SPONSORS

The Society of Obstetricians and Gynaecologists of Canada.

Reliability of three-dimensional sonographic measurements in early pregnancy using virtual reality

OBJECTIVE

To establish the reliability of three-dimensional (3D) ultrasound measurements in early pregnancy using a virtual reality system (the Barco I-Space).

METHODS

The study included 28 pregnancies with gestational ages ranging from 6 to 14 (median, 10) weeks. 3D volumes were acquired and offline measurements were made, where possible, of the yolk sac diameter, crown-rump length, biparietal diameter, head circumference and abdominal circumference, using specialized 3D imaging software (4D View). The datasets were then transferred to the Barco I-Space, a virtual reality system that allows the observer to perceive depth and interact with volume-rendered (ultrasound) data. The 3D rendered volumes were measured using a virtual pointer, controlled by a wireless joystick. For intraobserver variability, 3D and virtual reality volumes were measured twice by one operator. For interobserver variability, another operator performed the same measurements once. All measurements were repeated three times and their mean values were used for comparisons.

RESULTS

All intraclass correlation coefficients (ICCs) comparing 4D View measurements with I-Space measurements were > 0.97. Intra- and interobserver ICCs for the 4D View measurements were > 0.96 and for the I-Space ones were > 0.98, representing good agreement.

CONCLUSIONS

The application of virtual reality is a novel method of visualizing 3D ultrasound data and perception of the depth in the I-Space offers possibilities for measuring non-planar structures. We have demonstrated that early pregnancy measurements in the I-Space are reliable. New areas of embryonic and fetal biometry can now be explored using this technique, which we tentatively name 'virtual embryoscopy'.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.

[Ultrasonographic view and women's behaviour before first-trimester induced abortion]

Women's behaviour before induced abortion during an ultrasonographic exam was described. A psychosomatic analysis was carried out in the discussion to try to explain the different women's attitudes. Most women do not want to see ultrasonographic scan or keep photographs. One must of course respect women's choices as to their desire to see or not the ultrasound image of their foetus when pre-induced abortion ultrasound examination is performed. One should nonetheless be able to listen to their request, be it implicit.

Preconceptions versus experience of transvaginal ultrasonography in older women

OBJECTIVE

To determine whether women find that having a transvaginal ultrasound scan is better or worse than they had expected.

METHODS

Fifty-four consecutive women in an ovarian cancer screening trial filled in linked questionnaires before and after having a transvaginal ultrasound scan.

RESULTS

The women found that having a transvaginal scan was less painful (P = 0.003) and less embarrassing (P = 0.001) than they had expected. They found it less uncomfortable than expected in comparison to having mammography (P = 0.013) or a cervical smear (P = 0.004).

CONCLUSIONS

Women attending for a transvaginal scan can be reassured that it will not be as painful or embarrassing as they fear, and that it is not as uncomfortable as having mammography or a cervical smear.

Tolerability of transvaginal ultrasonography as an ovarian cancer screening test

OBJECTIVE

To evaluate the acceptability of transvaginal ultrasonography as a screening tool.

DESIGN

Prospective survey of women attending for screening within a randomised controlled trial.

SETTING

University Hospital in Teesside.

PARTICIPANTS AND METHODS

54 women completed a questionnaire immediately after their first transvaginal ultrasound scan.

RESULTS

52 of 54 (96%) questionnaires were suitable for full analysis. The women were unlikely to find the scan was painful, 47 vs three (p<0.001), or embarrassing 45 vs five (p<0.001). Women were more likely to find both a smear, 42 vs eight (p<0.001) and a mammogram, 47 vs two (p<0.001) was more uncomfortable than transvaginal ultrasonography.

CONCLUSIONS

Transvaginal ultrasonography is an acceptable tool for screening for ovarian cancer. It is better tolerated than other screening tools such as cervical smear and mammography.

Patient acceptance of transvaginal sonography in the early pregnancy unit setting

OBJECTIVE

To establish the acceptability of transvaginal scanning in patients attending an early pregnancy unit (EPU) due to problems in early pregnancy such as vaginal bleeding.

METHODS

An unselected group of pregnant women who were less than 8 weeks' gestation were invited to complete a questionnaire before the transvaginal scan regarding their views about the pregnancy and about the scan itself. They were asked to complete a second questionnaire after the scan had been performed. Information was collected about the presenting symptoms and the final diagnosis.

RESULTS

Of a total of 107 patients, the most common reason for attending the EPU was vaginal bleeding (51.4%). The primary concern for the majority of these women was their pregnancy, rather than the scan procedure itself. Their concerns about the scan were not altered by a previous history of miscarriages or by maternal age. After the scan, more than 77% of patients scored < or = 3 out of 10 with regard to discomfort, pain and embarrassment. Only 1.9% experienced marked discomfort, scoring > 8 out of 10. The scores were not altered by the patients' diagnoses. A total of 99% of patients said that they would agree to have a similar procedure in the future.

CONCLUSION

This questionnaire-based study confirms that patients attending with problems in early pregnancy find transvaginal sonography acceptable.

The gender of the examiner, the state of the pregnancy and women's perception of transvaginal sonography in the first trimester

OBJECTIVES

The objectives are to study the correlation between the women's perception of transvaginal sonography (TVS) and the gender of the examiner and the state of the pregnancy.

METHODS

The population studied was unselected women attending the early assessment unit at Sharoe Green Hospital with various complications of early pregnancy. All the women were in the first trimester. Only women who had TVS and who gave informed consent were included.

RESULTS

Four hundred and twenty five (425) women were recruited. A male doctor examined 215 (50.6%), while a female doctor examined the remaining 210 (49.4%). Two hundred and ninety eight (70.1%) of the pregnancies were viable and 127 (29.9%) were non-viable. About 98.1% of the women found TVS acceptable. There was no statistically significant difference in the women's perception of the procedure with regard to the gender of the examiner or the state of the pregnancy.

CONCLUSIONS

The majority of women (98.1%) perceived TVS favourably. The gender of the examiner and the state of the pregnancy have no influence on the women's perception of the procedure.