Canadian Association of Radiologists Obstetrics and Gynecology Diagnostic Imaging Referral Guideline

Abstract

French

The Canadian Association of Radiologists (CAR) Obstetrics and Gynecology Expert Panel consists of radiologists specializing in obstetrics and gynecology, obstetrics and gynecology physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 12 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 46 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 68 recommendation statements across the 12 scenarios related to the evaluation of obstetrics and gynecology clinical and diagnostic scenarios. This guideline presents the methods of development and the imaging recommendations for a variety of obstetrical and gynecological conditions including pregnancy assessment, recurrent first trimester pregnancy loss, post-partum indications, disorders of menstruation, localization of intra-uterine contraceptive device, infertility assessment, assessment of adnexal mass, pelvic pain of presumed gynecological origin, and pelvic floor evaluation.

Keywords

obstetrics gynecology diagnostic imaging referral guidelines adults recommendations

Introduction

Beginning in October 2021, an Expert Panel (EP) comprised of radiologists specializing in obstetrics and gynecology, obstetrics and gynecology physicians, a patient advisor, and an epidemiologist/guideline methodologist met to develop a new set of recommendations specific to referral pathways for obstetrics and gynecology. Through discussion (via virtual meetings), the EP developed a list of 12 clinical/diagnostic scenarios to be covered by this guideline. These recommendations are intended primarily for referring clinicians (e.g., family physicians, nurse practitioners); however, they may also be used by radiologists, other clinicians in allied specialties, patients, and patient representatives.

Our methods describing the guideline development process, including the rapid scoping review to identify the evidence base, have been published in CMAJ Open ¹ and an editorial to this series of guideline publications is available in CARJ.² The application of well-established scoping review and rapid review guidance (JBI,³ Cochrane Handbook,⁴ Cochrane Rapid Review Methods Group)⁵ and guideline methodology (i.e., Grading of Recommendations Assessment, Development, and Evaluation or GRADE)^6,7 were used to identify the evidence-base and to guide the Expert Panel in determining the strength and direction of the recommendations for each clinical scenario (Table 1). The quality of conduct and reporting of the included guidelines identified in the scoping review were evaluated with the AGREE-II checklist⁸, using a modified scoring system. In instances where guidelines were lacking, expert consensus was used to develop the recommendation. Contextualization to the Canadian health care system was discussed for each recommendation, with discussion around the factors found in the Evidence to Decision framework in GRADE for guidelines (e.g., balance of desirable and undesirable outcomes, values and preferences, resources implications).⁷

Table 1.

Recommendation text, symbol, and interpretation.

Recommendation	AGAINST	FOR
STRONG	Strong, against “we recommend against” (↓↓) ⁃ All or almost all informed people would not recommend/choose the course of action and only a small proportion would.	Strong, for “we recommend” (↑↑) ⁃ All or almost all informed people would recommend/choose the course of action and only a small proportion would not. ⁃ Request discussion if the intervention is not offered.
CONDITIONAL	Conditional, against “we suggest against” (↓) ⁃ Most informed people would not recommend/choose the course of action, but a substantial number would. ⁃ This may be conditional upon patient values and preferences, the resources available or the setting in which the intervention will be implemented.	Conditional, for “we suggest” (↑) ⁃ Most informed people would recommend/choose the course of action, but a substantial number would not. ⁃ This may be conditional upon patient values and preferences, the resources available or the setting in which the intervention will be implemented.

Note: Down arrows are red and Up arrows are green when available in colour.

Created using the guidance provided in Andrews and colleagues.⁶

A systematic search for guidelines (with an a priori defined inclusion criteria) was run in Medline and Embase on November 24, 2021. The search was limited to publications from 2016 onward (Supplementary file Appendix 1). Supplemental searching included the following national radiology and/or guideline groups: the American College of Radiology, the National Institute for Health and Care Excellence, the Society of Obstetricians and Gynaecologists of Canada, and the Royal College of Radiologists 8^th Edition (2017). Recommendations for each clinical scenario were formulated over six virtual meetings from February to April 2022. External review and feedback were obtained from radiologists, emergency medicine physicians, family physicians, obstetrics and gynaecology physicians, and a nurse practitioner. The full guideline can be found on the CAR website (www.car.ca).

Results

Systematic Scoping Review

A total of 4279 records were identified through the electronic database and nine additional records were added from the supplemental search. A total of 46 guidelines, plus seven companion papers, were included (Figure 1 PRISMA flow diagram). Potentially relevant guidelines published in languages other than English can be found in Supplementary file Appendix 2. A list of excluded records including justifications for exclusion is available upon request. Most guidelines were rated as moderate or high quality, using the modified AGREE-II checklist (Supplementary file Appendix 3). The number of guidelines included per clinical/diagnostic scenario ranged from zero to 16, with a median of five guidelines per clinical scenario.

Figure 1.

PRISMA flow diagram.

Recommendations

Additional details of the included guidelines, including which imaging modalities (e.g., computed tomography [CT], magnetic resonance imaging [MRI], radiograph [XR], saline infusion sonohysterogram [SIS], ultrasound [US]) that were discussed can be found in Supplementary file Appendix 4. Recommendations do not specify when contrast should or should not be used, as this may vary based on clinical presentation, regional practice preferences, preference of the referring clinician, radiologist and the patient, and resource availability.

A guideline is intended to guide and not be an absolute rule. Medical care is complex and should be based on evidence, a clinician’s expert judgment, the patient’s circumstances, values, preferences, and resource availability. Not all imaging modalities are available in all clinical environments, particularly in rural or remote areas of Canada. Decisions about patient transfer, use of alternative imaging or serial clinical examination and observation can be difficult. Therefore, the expected benefits of recommended imaging, risks of travel, patient preference, and other factors must be considered. The guideline recommendations are to assist the choice of imaging modality in situations where it is deemed clinically necessary to obtain imaging.

We reviewed relevant recommendations related to the 12 clinical/diagnostic scenarios previously published by radiology and specialty societies, including: the Canadian Association of Radiologists,⁹ the American College of Obstetricians and Gynecologists,^10,11 the American College of Radiology,^{12

-28} the American Society of Clinical Oncology,²⁹ the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group,^30,31 the European Society of Urogenital Radiology,³² the French College of Gynecologists and Obstetricians,³³ the International Society of Ultrasound in Obstetrics and Gynecology,³⁴ the International guideline on polycystic ovarian syndrome,^35

-38 the National Institute for Health and Care Excellence,^39

-47 the Society for Maternal-Fetal Medicine,⁴⁸ the Society of Abdominal Radiology,⁴⁹ the Society of Obstetricians and Gynaecologists of Canada,^50

-57 the Royal College of Obstetricians and Gynaecologists,^58
-60 and the 2017 Royal College of Radiologists.⁶¹

Recommendations are presented in three tables: Pregnancy assessment recommendations (Table 2), Post-partum, recurrent pregnancy loss, and infertility recommendations (Table 3), and Gynecology recommendations (Table 4).

Table 2.

Pregnancy assessment recommendations.

Clinical/Diagnostic Scenario and Recommendations
OG01. 1 ^ST TRIMESTER ASSESSMENT ^{9,10,12 -15,34,39 -41,50 -54,58,61}
1. In patients with suspected pregnancy, we recommend against US for pregnancy confirmation (↓↓). Confirmed intrauterine pregnancy 2. In patients in the 1^st trimester with confirmed intrauterine pregnancy, we recommend transabdominal US as the initial imaging modality for the following: pregnancy dating, to assess fetal number, chorionicity and amnionicity in multiple gestations, measurement of nuchal translucency (in single and multiple gestations), screening for select major anatomical abnormalities (such as anencephaly), and in patients with suspected complications of early pregnancy (↑↑). ↳2.1 If transabdominal US is indeterminate or suboptimal for these clinical indications, we recommend transvaginal US as an adjunct (↑↑). 3. In patients in the 1^st trimester with a viable or potentially viable intrauterine pregnancy, we suggest not using Doppler as an adjunct to US without a clear clinical indication (↓). Suspected pregnancy of unknown location (PUL) or ectopic pregnancy 4. In patients in the 1^st trimester with a positive pregnancy test and a suspected PUL or ectopic pregnancy, we recommend a combined transabdominal and transvaginal US approach as the initial imaging technique (↑↑). The uterus should be thoroughly scanned for the presence of a gestational sac, and in its absence, then the adnexa should be thoroughly scanned for the presence of a mass. ↳4.1 If results are initially inconclusive, we recommend close clinical and biochemical assessment with follow-up repeat US assessment (↑↑).
OG02. 2 ^ND TRIMESTER ASSESSMENT ^{9,10,15 -19,34,39,42,50,55,58 -61}
1. In patients in the 2^nd trimester of pregnancy, typically between 18-20 weeks, we recommend routine screening with transabdominal US, for evaluation of fetal anatomy, fetal growth, and general assessment of the placenta (↑↑). ↳1.1 Where indicated, in the evaluation of fetal growth and well-being, characterization of complex anatomy, and placental and cord assessment, we recommend Doppler as an adjunct (↑↑). ↳ 1.2 For complex fetal conditions, if US is indeterminate or if further investigation is required, we suggest MRI (↑). Timing of the MRI may be determined based on clinical indication. 2. In patients in the 2^nd trimester of pregnancy with suspected low location of the placenta or invasive placentation, we recommend a combined transabdominal and transvaginal US approach (↑↑). ↳2.1 We recommend Doppler as an adjunct (↑↑). ↳ 2.2 For suspected invasive placentation, if US is indeterminate or if further investigation is required, we suggest MRI (↑). 3. In patients in the 2^nd trimester with a history of pre-term birth, or with other risk factors for pre-term birth, and in patients with suspected preterm labour, we recommend transvaginal US for assessment of the cervix (↑↑). ↳3.1 If transvaginal US is declined or is not feasible, we recommend transperineal US as an alternative (↑↑). 4. In patients in the 2^nd trimester experiencing vaginal bleeding, we recommend a combined transabdominal and transvaginal US approach (↑↑). ↳4.1 We recommend Doppler as an adjunct (↑↑). 5. Following the routine anatomy scan, if risk factors are identified and/or fetal cardiac screening examination is abnormal, we suggest fetal echocardiography US (↑).
OG03. 3 ^RD TRIMESTER ASSESSMENT ^{9,11,15 -17,19 -21,34,48,55,59,61}
1. In patients in the third trimester who have not received a 1^st or 2^nd trimester diagnostic US, we recommend transabdominal US for general assessment of the pregnancy (↑↑). ↳1.1 We recommend Doppler and/or transvaginal US as adjuncts, as clinically indicated (↑↑). 2. In high-risk 3^rd trimester pregnancies, including multifetal pregnancy, we recommend transabdominal US surveillance to monitor fetal growth and well-being (↑↑). ↳2.1 We recommend Doppler and/or transvaginal US as adjuncts, as clinically indicated (↑↑). ↳ 2.2 For complex fetal conditions, if US is indeterminate or if further investigation is required, we suggest MRI (↑). Timing of the MRI may be determined based on clinical indication. 3. In patients diagnosed with low-lying placenta or placenta previa in the 2^nd trimester, we recommend a transvaginal US to reassess placental location by the mid-3^rd trimester (↑↑). ↳3.1 We recommend Doppler as an adjunct (↑↑). 4. In patients in the 3^rd trimester of pregnancy with suspected invasive placentation, we recommend a combined transabdominal and transvaginal US approach (↑↑). ↳4.1 We recommend Doppler as an adjunct (↑↑). ↳ 4.2 If further investigation is required, we suggest MRI (↑). 5. In patients in the 3^rd trimester of pregnancy experiencing vaginal bleeding, we recommend a combined transabdominal and transvaginal US approach (↑↑). ↳5.1 We recommend Doppler as an adjunct (↑↑).

MRI: magnetic resonance imaging; US: ultrasound.

Strength of Recommendation: ↑↑: Strong for; ↑: Conditional for; ↓: Conditional against; ↓↓: Strong against; EPc: Expert panel consensus.

Table 3.

Post-partum, recurrent pregnancy loss, and infertility clinical/diagnostic scenario recommendations.

Clinical/Diagnostic Scenario and Recommendations
OG04. POST-PARTUM (UP TO 6 WEEKS) ^9,22,33
Hemorrhage 1. In patients with early and/or late post-partum hemorrhage,* we recommend a combined transabdominal and transvaginal US approach as the initial imaging modality (↑↑).↳1.1 We recommend Doppler as an adjunct (↑↑). ↳1.2 If US is indeterminate or further investigation is required, we suggest MRI as the next imaging modality (↑). ↳1.3 If MRI is unavailable or contraindicated, we suggest close clinical observation with follow-up transabdominal and transvaginal US (EP consensus).2. In patients with early and/or late post-partum hemorrhage where there is clinical concern for intraabdominal bleeding, we suggest CT to confirm, localize, and assess for the presence of active bleeding (↑).* Early PPH: within 24 hours; Late PPH: >24 hours to 6 weeks Post-partum infection 3. In patients with suspected or confirmed post-partum infection, we recommend a combined transabdominal and transvaginal US approach as the initial imaging modality to exclude retained products of conception and assess for complications of infection (↑↑).↳3.1 If US is indeterminate or further investigation is required, we suggest CT or MRI as the next imaging modality depending on the clinical situation (↑). ↳3.2 If CT and MRI are unavailable or contraindicated, we suggest close clinical monitoring and follow-up US (EP consensus).
OG05. RECURRENT PREGNANCY LOSS (1^ST TRIMESTER) ^9,23,61
1. In patients with recurrent 1^st trimester pregnancy loss, we recommend a combined transabdominal and transvaginal US approach as the initial imaging technique (↑↑).↳1.1 We suggest Doppler as an adjunct (↑). ↳1.2 If US is negative, indeterminate, or if additional workup of complex abnormalities identified on US is required, we recommend MRI pelvis as the next imaging technique (↑↑).2. In patients with suspected Müllerian duct or intracavitary abnormalities based on initial assessment, we suggest MRI, 3D US, or SIS for further characterization (↑).
OG06. INFERTILITY ASSESSMENT ^{9,23,30,31,43,61}
1. In patients with infertility, we recommend transabdominal US and/or transvaginal US as the initial imaging technique (↑↑).↳1.1 We suggest Doppler as an adjunct (↑). ↳1.2 If initial assessment by US is indeterminate or if additional workup of the endometrium is required, we recommend 3D US, SIS, or MRI as the next imaging technique (↑↑).↳1.3 If US assessment of the adnexa is indeterminate or if additional workup of the adnexa is required, we recommend MRI as the next imaging technique (↑↑).2. In patients with infertility, for the assessment of tubal patency, we recommend SIS or HSG (↑↑).3. In the investigation of the male factor infertility, we recommend US as the initial imaging technique to assess for varicoceles (↑↑).

CT: Computed tomography; HSG: Hysterosalpingography; MRI: magnetic resonance imaging; SIS: Saline infusion sonohysterogram; US: ultrasound

Strength of Recommendation: ↑↑: Strong for; ↑: Conditional for; ↓: Conditional against; ↓↓: Strong against; EPc: Expert panel consensus

Table 4.

Gynecology clinical/diagnostic scenario recommendations.

Clinical/Diagnostic Scenario and Recommendations
OG07. EVALUATION OF ADNEXAL MASS ^{9,24,29,56,57,61}
1. In patients with suspected adnexal mass with no acute symptoms, we recommend a combined transabdominal and transvaginal US approach as the initial imaging technique (↑↑). ↳1.1 We recommend Doppler as an adjunct (↑↑). ↳1.2 If US is indeterminate or further investigation is required, we recommend MRI as the next imaging technique (↑↑).
OG08. EVALUATION OF ACUTE PELVIC PAIN OF PRESUMED GYNECOLOGIC ORIGIN ^{9,25,26,33,61}
1. In patients with acute pelvic pain of presumed gynecologic origin, we recommend a combined transabdominal and transvaginal US approach as the initial imaging technique (↑↑).↳1.1 We recommend Doppler as an adjunct (↑↑). ↳1.2 If US is indeterminate or further investigation is required and immediate management is not indicated, we recommend follow-up combined transabdominal and transvaginal US approach (↑↑). ↳1.3 If further investigation is required, we suggest CT (in beta-HCG negative patients) (↑). ↳1.4 In pregnant patients and for problem-solving, where indicated, we suggest pelvic MRI (↑).
OG09. EVALUATION OF CHRONIC PELVIC PAIN OF PRESUMED GYNECOLOGIC ORIGIN ^{9,27,32,44,49,61}
1. In patients with chronic pelvic pain of presumed gynecologic origin, we recommend a combined transabdominal and transvaginal US approach as the initial imaging technique (↑↑).↳1.1 We recommend Doppler as an adjunct (↑↑). ↳1.2 If further investigation is required, we suggest CT (in beta-HCG negative patients) (↑). ↳1.3 in pregnant patients and for problem-solving, where indicated, we suggest pelvic MRI (↑).
OG10. PELVIC FLOOR EVALUATION IN FEMALES
No recommendation. The role of imaging in evaluation of the pelvic floor is an evolving science and further research is required to guide recommendations in this field.
OG11. DISORDERS OF MENSTRUATION ^{9,28,35-38,45-47,61}
1. In patients with abnormal uterine bleeding, we recommend a combined transabdominal and transvaginal US approach as the initial imaging technique (↑↑).↳1.1 We suggest Doppler as an adjunct (↑). ↳1.2 If further investigation of the endometrium is required, we recommend SIS as the next imaging technique (↑↑). ↳1.3 If sonographic investigations are inconclusive or unavailable, we recommend MRI (↑↑).2. For patients diagnosed on clinical and biochemical grounds with polycystic ovarian syndrome, we do not recommend the routine use of US for evaluation of ovarian morphology (↓↓).↳2.1 If clinical and biochemical indices are equivocal, we recommend transvaginal US to assess ovarian morphology (↑↑).
OG12. LOCALIZATION OF INTRA-UTERINE CONTRACEPTIVE DEVICE ^9,61
1. In patients where localization of an intra-uterine contraceptive device (IUCD) is required, we recommend a combined transabdominal and transvaginal US approach as the initial imaging technique (↑↑).↳1.1 We suggest 3D US as an adjunct, where available (↑). ↳1.2 If IUCD is not seen in the uterus on US, we recommend XR of the abdomen and pelvis as the next imaging technique (↑↑).

CT: Computed tomography; MRI: magnetic resonance imaging; US: ultrasound.

Strength of Recommendation: ↑↑: Strong for; ↑: Conditional for; ↓: Conditional against; ↓↓: Strong against; EPc: Expert panel consensus.

There are clinical/diagnostic scenarios that may pertain to more than one CAR guideline section. For example, pelvic floor evaluation can be found in both the Obstetrics & Gynecology guideline and will be in the Urology, Adrenal, and Genitourinary guideline. As not all guidelines are available concurrently, it is possible these scenarios may be updated in subsequent guideline sections to include a newer evidence-base.

Supplemental Material

Supplemental Material - Canadian Association of Radiologists Obstetrics and Gynecology Diagnostic Imaging Referral Guideline

Supplemental Material for Canadian Association of Radiologists Obstetrics and Gynecology Diagnostic Imaging Referral Guideline by Candyce Hamel, Baharak Amir, Barb Avard, Karen Fung Kee Fung, Beth Furey, Juliette Garel, and Hournaz Ghandehar in Canadian Association of Radiologists Journal

Footnotes

Acknowledgments

We would like to thank: Becky Skidmore for creating the search strategies for the systematic scoping review, Leila Esmaeilisaraji for her role as a reviewer on the scoping review, and the following individuals on the Diagnostic Imaging Referral Guidelines Working Group and external stakeholders for providing feedback on the guideline (listed alphabetically): Samuel Campbell, Elisa Cohen, Noel Corser, Cathy MacLean, Ryan Margau (WG co-chair), Lucie Morin, Paul Pageau (WG co-chair), Erin Sarrazin, Charlotte Yong-Hing, Kaitlin Zaki-Metias.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canadian Medical Association

ORCID iD

Candyce Hamel

Supplemental Material

Supplemental material for this article is available online.

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