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Bean E, Knez J, Setty T, Tetteh A, Casagrandi D, Naftalin J, Jurkovic D. Natural history of endometriosis in pregnancy: ultrasound study of morphology of deep endometriosis and ovarian endometrioma. Ultrasound Obstet Gynecol 2023; 62:585-593. [PMID: 37448233 DOI: 10.1002/uog.26310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/02/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE To assess the morphological appearance of deep endometriosis and ovarian endometrioma in pregnancy using pelvic ultrasound examination. METHODS This was a prospective observational cohort study conducted over 3 years at University College London Hospital, which is a tertiary level referral unit for early pregnancy complications and an accredited endometriosis center. All women who participated provided written consent and were invited for surveillance ultrasound examination at the time of their routine scans in pregnancy. All scans were performed by a single operator to eliminate interobserver variability. The change in size of ovarian endometrioma and nodules was reported as change in their mean diameter. Ovarian endometrioma with irregular thick inner walls, hyperechoic papillary projections and/or high vascularity and hyperechoic nodules with moderate to high vascularity were reported as decidualized. RESULTS Sixty-five women with a live, normally sited pregnancy and concomitant ultrasound features of deep and/or ovarian endometriosis were included in the study. The median age of the study population was 34 (range, 23-44) years, and the median gestational age at presentation was 7 + 6 (range, 3 + 6 to 18 + 0) weeks. From the cohort, 47/65 (72%) were nulliparous, 48/65 (74%) had a previous diagnosis of endometriosis and 19/65 (29%) conceived via in-vitro fertilization. There were 10/65 (15% (95% CI, 7-24%)) women with ovarian endometrioma alone, 28/65 (43% (95% CI, 31-55%)) with endometriotic nodules alone and the remaining 27/65 (42% (95% CI, 30-54%)) had both. Of the women with ovarian endometrioma who underwent follow-up, 29/34 (85% (95% CI, 73-97%)) experienced cyst regression, 2/34 (6% (95% CI, 0-14%)) experienced cyst growth, and in 3/34 (9% (95% CI, 0.0-18%)) women, cyst size was unchanged. In 10/34 (29% (95% CI, 14-45%)), there was complete resolution of all cysts. Of the women with nodules who underwent follow-up, 43/51 (84% (95% CI, 74-94%)) experienced nodule regression, 2/51 (4% (95% CI, 0-9%)) experienced nodule growth and, in 6/51 (12% (95% CI, 3-21%)) women, nodule size was unchanged. In 4/51 (8% (95% CI, 0-15%)) women, there was complete resolution of all nodules. In 5/37 (14% (95% CI, 3-25%)) women who attended postnatal follow-up, complete resolution of all endometriotic lesions occurred during pregnancy. In 10/34 (29% (95% CI, 14-45%)) women with ovarian endometrioma and 27/51 (53% (95% CI, 39-67%)) women with nodules, a pattern of growth was observed in the first and second trimesters, followed by regression later in pregnancy. Features of decidualization were observed in 17/34 (50% (95% CI, 33-67%)) women with ovarian endometrioma, most commonly in the first trimester, and in 25/51 (49% (95% CI, 35-63%)) women with nodules, most commonly in the second trimester. CONCLUSIONS For the majority of women, despite features of decidualization being common in the first and second trimesters, ovarian endometrioma and deep nodules regress during pregnancy. Morphological changes of endometriosis in pregnancy are difficult to differentiate from characteristics of malignant lesions. Better understanding of the appearance of endometriosis in pregnancy is vital to minimize intervention and help counsel women regarding their condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Bean
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - J Knez
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
- University Medical Center Maribor, Clinic for Gynecology, Maribor, Slovenia
| | - T Setty
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - A Tetteh
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - D Casagrandi
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - J Naftalin
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - D Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
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Chaggar P, Tellum T, Thanatsis N, De Braud LV, Setty T, Jurkovic D. Prevalence of deep and ovarian endometriosis in women attending a general gynecology clinic: prospective cohort study. Ultrasound Obstet Gynecol 2023; 61:632-641. [PMID: 36776112 DOI: 10.1002/uog.26175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/28/2022] [Accepted: 01/23/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVES To assess using transvaginal ultrasound the prevalence of deep and ovarian endometriosis in premenopausal women attending a general gynecology clinic. We also investigated whether the presence of endometriosis was associated with various demographic factors and other pelvic abnormalities. METHODS This was a prospective observational cohort study carried out between February 2019 and October 2020. Consecutive premenopausal women who attended our general gynecology clinic underwent pelvic ultrasound examination, performed by a single experienced operator. Pregnant women and those with a history of hysterectomy or oophorectomy were excluded. The primary outcome was the prevalence of deep and/or ovarian endometriosis. Secondary outcomes were the anatomical distribution of endometriotic lesions and the association of endometriosis with demographic characteristics and various pelvic abnormalities, which were analyzed using logistic regression and multivariable analysis. RESULTS A total of 1026 women were included in the final study sample, of whom 194 (18.9% (95% CI, 16.6-21.4%)) had sonographic evidence of deep and/or ovarian endometriosis. Of the 194 women diagnosed with endometriosis, 106 (54.6% (95% CI, 47.4-61.8%)) were diagnosed with endometriotic nodules only, 26 (13.4% (95% CI, 9.0-19.0%)) with ovarian endometriomas only, and 62 (32.0% (95% CI, 25.5-39.0%)) women had evidence of both. There was a total of 348 endometriotic nodules in 168 women, located most frequently in the retrocervical area (166/348; 47.7% (95% CI, 42.4-53.1%)), uterosacral ligaments (96/348; 27.6% (95% CI, 23.0-32.6%)) and bowel (40/348; 11.5% (95% CI, 8.3-15.3%)). Multivariable analysis found significant positive associations between endometriosis and both adenomyosis (odds ratio (OR), 1.72 (95% CI, 1.10-2.69); P = 0.02) and pelvic adhesions (OR, 25.7 (95% CI, 16.7-39.3); P < 0.001), whilst higher parity (OR, 0.44 (95% CI, 0.24-0.81); P = 0.03) and history of Cesarean section (OR, 0.18 (95% CI, 0.06-0.52); P = 0.002) were associated with a lower occurrence of endometriosis. A total of 75/1026 women (7.3% (95% CI, 5.8-9.1%)) underwent laparoscopy within 6 months of pelvic ultrasound examination. There was very good agreement between ultrasound and surgical findings, with a kappa value of 0.84 (95% CI, 0.69-0.99). CONCLUSIONS Deep and/or ovarian endometriosis was present in nearly one in five women attending a general gynecology clinic. There were significant positive associations with adenomyosis and pelvic adhesions and negative associations with higher parity and previous Cesarean section. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- P Chaggar
- Institute for Women's Health, University College Hospital, London, UK
| | - T Tellum
- Institute for Women's Health, University College Hospital, London, UK
- Department of Gynaecology, Oslo University Hospital, Oslo, Norway
| | - N Thanatsis
- Institute for Women's Health, University College Hospital, London, UK
| | - L V De Braud
- Institute for Women's Health, University College Hospital, London, UK
| | - T Setty
- Institute for Women's Health, University College Hospital, London, UK
| | - D Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
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Ahmed I, Majeed A, Fernando R, Hyare H, Columb M, Setty T. Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study. Eur J Anaesthesiol 2021; 38:777-784. [PMID: 33470687 DOI: 10.1097/eja.0000000000001445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Currently, performing an epidural blood patch (EBP) for postdural puncture headache (PDPH) remains a subjective clinical decision. An evidence-based protocol may be of value in identifying women at high risk of developing a severe PDPH. OBJECTIVE To investigate a potential correlation between the extent of CSF spread in the epidural space, as noted on Magnetic Resonance Imaging (MRI), and the likelihood of development of severe PDPH in obstetric patients. DESIGN A prospective double-blind quasi-observational study. SETTING Eight tertiary obstetric units, from NHS hospitals. PATIENTS Parturients with accidental dural puncture (ADP) underwent T1 and T2-weighted MRI scans of the brain and lumbar spine within 48 h after delivery. All women were followed up, daily, for 1 week. MAIN OUTCOME MEASURES For each woman, a PDPH severity score was calculated using a four-point Verbal Reporting Scale (none = 0, mild = 1, moderate = 2, severe = 3), with additional points awarded for visual, auditory and emetic symptoms. MRIs were reported by a neuroradiologist, blind to the patient details, using a predefined MRI score. RESULTS Twenty-two parturients were recruited; 86% (n=19) developed PDPH and 10 of these (53%) required an EBP. The median (range) time for the onset of PDPH was 24 (4 to 126) hours. The median (range) cumulative PDPH severity score was 10 (0 to 21), whereas, the median (range) MRI score was 2.5 (0 to 12). Spearman (rs) analysis identified a significant positive correlation (rs = 0.46; P = 0.024) between cumulative PDPH severity and MRI scores. Of all the radiological features identified in an MRI (lumbar dural shift, caudal brain displacement, epidural or intrathecal blood), the presence of intrathecal blood was most strongly correlated with PDPH severity (P = 0.043). CONCLUSION Following an ADP, the extent of CSF spread in the epidural space correlates with the severity of subsequent PDPH. CLINICAL TRIAL NUMBER AND REGISTRY URL ISRCTN14959004, https://www.isrctn.com/.
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Affiliation(s)
- Iftikhar Ahmed
- From the Department of Anaesthesia, King Faisal Specialist Hospital & Research Centre, Kingdom of Saudi Arabia (IA, AM), Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar (RF), Department of Anaesthesia, University College Hospital, London (HH, TS) and Department of Anaesthesia, University Hospital of South Manchester, Wythenshawe, UK (MC)
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Al-Sulttan S, Bampoe S, Howle R, Setty T, Columb M, Patel A, Fernando R, Husain T, Sultan P. A prospective, up-down sequential allocation study investigating the effectiveness of vital capacity breaths using high-flow nasal oxygenation versus a tight-fitting face mask to pre-oxygenate term pregnant women. Int J Obstet Anesth 2020; 45:28-33. [PMID: 33129656 DOI: 10.1016/j.ijoa.2020.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/03/2020] [Accepted: 08/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The role of high flow nasal oxygenation (HFNO) for pre-oxygenation before obstetric general anaesthesia remains unclear. This study aimed to determine the number of vital capacity breaths using HFNO required to pre-oxygenate 90% of parturients to an end-tidal oxygen concentration fraction (FETO2) of ≥0.90 (termed EN90). METHODS Using up-down, sequential allocation trial design, volunteer term parturients undergoing caesarean delivery were investigated with HFNO with their mouth closed, followed by mouth open, and if FETO2 ≥0.90 was not achieved after a maximum of 20 vital capacity breaths, pre-oxygenation was attempted with a face mask. The primary outcome was the number of vital capacity breaths required using HFNO (mouth open and closed) to achieve EN90. Secondary outcomes included assessment of EN90 using mouth open versus mouth closed and face mask pre-oxygenation, maternal satisfaction and evaluation of fetal cardiotocography. RESULTS Twenty women at term were recruited. Successful pre-oxygenation occurred in 4 (20%), 3 (15%) and 14 (70%) women with HFNO mouth closed, HFNO mouth open, and via face mask respectively. At up to 20 vital capacity breaths, face mask pre-oxygenation was more successful at achieving EN90 compared with both HFNO with a closed (P=0.006) or open (P=0.001) mouth. Closed mouth HFNO did not outperform open mouth pre-oxygenation. CONCLUSION Face mask pre-oxygenation is more effective at achieving EN90 compared with to HFNO within a clinically acceptable number of vital capacity breaths. Further studies are needed to determine the role of HFNO in optimising the time before desaturation and for apnoeic oxygenation in term parturients.
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Affiliation(s)
- S Al-Sulttan
- Department of Anaesthesia, University College London NHS Trust, London, UK
| | - S Bampoe
- Department of Anaesthesia, University College London NHS Trust, London, UK; University College London, UK.
| | - R Howle
- Department of Anaesthesia, University College London NHS Trust, London, UK
| | - T Setty
- Anaesthesia, Queens Medical Centre, Nottingham, UK
| | - M Columb
- Anaesthesia & Intensive Care Medicine, University of Manchester Hospitals NHS Foundation Trust, Wythenshawe Hospital, UK
| | - A Patel
- University College London, UK
| | - R Fernando
- The Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - T Husain
- Anaesthesia, Ashford & St Peters NHS Foundation Trust, UK
| | - P Sultan
- Stanford University School of Medicine, CA, USA
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Ciechanowicz S, Setty T, Robson E, Sathasivam C, Chazapis M, Dick J, Carvalho B, Sultan P. Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery. Br J Anaesth 2019; 122:69-78. [DOI: 10.1016/j.bja.2018.06.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 05/18/2018] [Accepted: 06/25/2018] [Indexed: 12/29/2022] Open
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Pushpanathan E, Setty T, Carvalho B, Sultan P. A Systematic Review of Postoperative Pain Outcome Measurements Utilised in Regional Anesthesia Randomized Controlled Trials. Anesthesiol Res Pract 2018; 2018:9050239. [PMID: 30151005 PMCID: PMC6087609 DOI: 10.1155/2018/9050239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/24/2018] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Regional anesthesia is a rapidly growing subspecialty. There are few published meta-analyses exploring pain outcome measures utilised in regional anesthesia randomized controlled trials (RCTs), which may be due to heterogeneity in outcomes assessed. This systematic review explores postoperative pain outcomes utilised in regional anesthesia RCTs. METHODS A literature search was performed using three databases (Medline, Embase, and CINAHL). Regional anesthesia RCTs with postoperative pain as a primary outcome were included if written in English and published in one of the top 20 impact factor journals between 2005 and 2017. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS From the 31 included articles, 15 different outcome measures in total were used to assess postoperative pain. The most commonly (16/31) used outcome measures were verbal numerical grading of pain out of 10, total opioid consumption, and visual analogue scale 10 cm (VAS). The need for analgesia was used as an outcome measure where studies did not use a pain rating score. Ten studies reported pain scores on activity and 27/31 studies utilised ≥2 pain outcomes. Time of measurement of pain score also varied with a total of 51 different time points used in total. CONCLUSION Analysis of the articles demonstrated heterogeneity and inconsistency in choice of pain outcome and time of measurement within regional anesthesia studies. Identification of these pain outcomes utilised can help to create a definitive list of core outcomes, which may guide future researchers when designing such studies.
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Affiliation(s)
- E. Pushpanathan
- Department of Anaesthesia, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - T. Setty
- Department of Anaesthesia, University College Hospitals London NHS Foundation Trust, London, UK
| | - B. Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - P. Sultan
- Department of Anaesthesia, University College Hospitals London NHS Foundation Trust, University College London, London, UK
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