Is routine adnexal scanning for postmenopausal bleeding of value? Observational study of 2101 women.

Our objective is to assess the merits of adnexal scanning during the investigation of women with postmenopausal bleeding (PMB) in terms of adnexal cancer diagnosis. This observational study was designed utilising an institutional PMB database in a teaching hospital, analysing a sample of 2101 consecutive women with PMB seen between 16th February 2012 and 12th August 2014 looking at the prevalence of cancer in adnexal masses identified on Trans-vaginal ultrasound scanning (TVS) in these PMB women. This study suggests that routine adnexal scanning in women with PMB may provide no benefit. It could be exposing women to unnecessary surgery or surveillance with the associated risks and cost implications. Most of the women who underwent surgery presented with palpable masses. Those with negative clinical examination had either benign masses which may have remained inconsequential or non-suspicious scan findings. A well-designed randomised controlled trial is needed to confirm the findings. Impact statement Trans-vaginal ultrasound scanning (TVS) is the standard first line investigation for women presenting with postmenopausal bleeding (PMB) primarily to assess the endometrial thickness. This has led to a widespread practice of opportunistic adnexal scanning, which generated a debate amongst gynaecologists about the value of such practice. This observational study, assessing the merits of routine adnexal scanning in these women in terms of adnexal cancer diagnosis, suggests that this practice may provide no benefit to women with isolated self-limiting PMB and unremarkable bimanual examination. It could be exposing women to unnecessary surgery or surveillance with the associated risks and cost implications when insignificant adnexal masses are identified on the scan. A well-designed randomised controlled trial is needed to elucidate if clinical examination in combination with endometrial scanning only is more effective and cost-effective than clinical examination followed by systematic pelvic scanning to detect cases of ovarian cancer in women with PMB.

Rare gynaecological emergency: massive intraperitoneal haemorrhage from spontaneous rupture of a superficial vessel on a large leiomyoma.

Uterine leiomyomas rarely present as gynaecological emergencies. We report a case of a 29-year-old nulliparous woman, with a negative pregnancy test, who presented with collapse and an admission haemoglobin count of 68 g/L. Urgent CT of the abdomen revealed a 14 × 19 × 10 cm uterine fibroid and intraperitoneal free fluid. Emergency laparotomy confirmed massive intraperitoneal haemorrhage from a large serosal vessel on top of a 19 cm subserosal fibroid. A myomectomy was performed, preserving this patient's fertility. Histopathology confirmed a benign leiomyoma with hydropic changes.

Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis.

OBJECTIVE: To estimate the accuracy of endometrial thickness measurement in the detection of endometrial cancer among women with postmenopausal bleeding with individual patient data using different meta-analytic strategies. DATA SOURCES: Original data sets of studies detected after reviewing the included studies of three previous reviews on this subject. An additional literature search of published articles using MEDLINE databases was preformed from January 2000 to December 2006 to identify articles reporting on endometrial carcinoma and sonographic endometrial thickness measurement in women with postmenopausal bleeding. METHODS OF STUDY SELECTION: We identified 90 studies reporting on endometrial thickness measurements and endometrial carcinoma in women with postmenopausal bleeding. TABULATION, INTEGRATION, AND RESULTS: We contacted 79 primary investigators to obtain the individual patient data of their reported studies, of which 13 could provide data. Data on 2,896 patients, of which 259 had carcinoma, were included. Several approaches were used in the analyses of the acquired data. First, we performed receiver operator characteristics (ROC) analysis per study, resulting in a summary area under the ROC curve (AUC) calculated as a weighted mean of AUCs from original studies. Second, individual patient data were pooled and analyzed with ROC analyses irrespective of study with standardization of distributional differences across studies using multiples of the median and by random effects logistic regression. Finally, we also used a two-stage procedure, calculating sensitivities and specificities for each study and using the bivariate random effects model to estimate summary estimates for diagnostic accuracy. This resulted in rather comparable ROC curves with AUCs varying between 0.82 and 0.84 and summary estimates for sensitivity and specificity located along these curves. These curves indicated a lower AUC than previously reported meta-analyses using conventional techniques. CONCLUSION: Previous meta-analyses on endometrial thickness measurement probably have overestimated its diagnostic accuracy in the detection of endometrial carcinoma. We advise the use of cutoff level of 3 mm for exclusion of endometrial carcinoma in women with postmenopausal bleeding.

Chuvash-type polycythemia in pregnancy managed by repeated venisections and heparin therapy: a case report.

BACKGROUND: Chuvash-type polycythemia is a rare blood disease associated with an increased tendency toward thrombosis and its resulting problems, which at times can be life threatening. The main goal of treatment is to prevent thrombosis and minimize the complications of therapy. CASE: A 20-year-old, Asian woman with her first pregnancy was admitted to the hospital at 16 weeks' gestation. Her initial blood work showed a hemoglobin level of 19 g/dL, hematocrit of 55% and erythropoietin level of 21.9 IU/L (laboratory reference range, 5-25). The results of a molecular analysis of the blood specimen confirmed the diagnosis of Chuvash-type polycythemia due to von Hippel-Lindau gene mutation. Weekly venisection until delivery was planned. Subsequently, the hemoglobin dropped to 15 g/dL and hematocrit to 44.6%. A 30-week scan demonstrated static growth below the third centile and oligohydramnios but normal Doppler findings. Prophylactic low-molecular-weight heparin was started. The next growth scan, at 32 weeks, showed an improvement in abdominal circumference. Three days later, fetal heart monitoring showed an abnormal pattern requiring an emergency cesarean section. CONCLUSION: Early institution of heparin is beneficial in the management of Chuvash-type polycythemia in pregnancy as the condition is thrombogenic.

Rectal tear during normal vaginal delivery with an intact anal sphincter: a case report.

BACKGROUND: A rectal tear with an intact anal sphincter is an unusual presentation. Failure to recognize or repair perineal and rectal lesions increases the chance of fistulas and incontinence. CASE: A 37-year-old woman, para 1, was admitted with spontaneous onset of labor at 36 weeks following an uncomplicated pregnancy. During the active second stage of labor, spurting of amniotic fluid through the anus was noted. Labor progressed normally, and the patient delivered a healthy infant of 2.5 kg. Immediate per rectal examination revealed a large rectal tear with an undamaged anal sphincter. The defect was repaired, and the patient recovered completely. CONCLUSION: Systematic examination of the perineum, vagina and rectum should be done to assess the severity of damage after all vaginal deliveries in order to recognize occult as well as visible damage. It should be treated promptly to reduce postpartum morbidity.

Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy.

Healthcare providers are facing increasing demands for improvement in quality of life for patients. Improvements in service provision for women are being ensured by the introduction of minimally invasive technologies into all spheres of gynaecologic practice. Ambulatory hysteroscopy (direct endoscopic visualization of the endometrial cavity) is an extremely exciting and rapidly advancing field of gynaecologic practice. It advanced dramatically during the 1990s, shifting the focus in healthcare away from inpatient diagnosis and treatment. Hysteroscopy is used extensively in the evaluation of common gynaecological problems that were previously evaluated with blind and inaccurate techniques (e.g. premenopausal menstrual disorders, infertility and postmenopausal bleeding). It allows direct visualization of the uterine cavity and the opportunity for targeted biopsy, safe removal of endometrial polyps, and treatment of submucous fibroids, septa and adhesions. Ambulatory hysteroscopy is safe, with a low incidence of serious complications; it has a small failure rate. There is a general consensus that hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous myomas, polyps, hyperplasia and cancer. Hysteroscopy in the ambulatory setting appears to have an accuracy and patient acceptability equivalent to inpatient hysteroscopy under general anaesthetic. The primary goal of this chapter is to provide a high-quality, evidence-based text on ambulatory diagnostic and operative hysteroscopy. The chapter includes in-depth analysis of the indications for outpatient hysteroscopy, its contraindications, the accuracy of diagnostic hysteroscopy, relevant risk management issues and, training and teaching.

The Birmingham Registry for Twin and Heritability Studies (BiRTHS).

In this article we present the protocol of the Birmingham Registry for Twin Heritability Studies (BiRTHS), which aims to establish a long-term prospective twin registry with twins identified from the antenatal period and subjected to detailed follow-up. We plan to investigate the concordance in anthropometrics and early childhood phenotypes between 66 monozygotic and 154 dizygotic twin pairs in the first 2 years of recruitment. In this project we plan to determine the relative contributions of heritability and environment to fetal growth, birth size, growth in infancy and development up to 2 years of age in an ethnically mixed population. Twins will be assessed with the Griffitth's Mental Development Scales, which will enable us to obtain detailed information on development. As maternal depression may have an effect on the twins' neurodevelopment, the Edinburgh Postnatal Depression Scale will be used at various stages during pregnancy and after delivery to assess maternal depressive symptoms. The increasing prevalence of obesity in both adults and children has raised concerns about the effect of maternal obesity in pregnancy on fetal growth. The prospective study design gives us the opportunity to obtain data on maternal nutrition (reflected by body mass index) and ante- and postnatal growth and development of twins.

Vulvar carcinoma presenting during pregnancy, associated with recurrent bone marrow hypoplasia: a case report and literature review.

BACKGROUND: Carcinoma of the vulva has predominantly been a disease of the elderly. Although occasionally it occurs in women under the age of 40 years, carcinoma of the vulva has been rarely diagnosed in pregnancy. Bone marrow hypoplasia can occur as a transient, pregnancy-related event; however, the recurrence of this pathology in future pregnancies is quite rare in the literature. CASE: A 29-year-old woman in her second pregnancy that was complicated by bone marrow hypoplasia had developed a squamous vulvar carcinoma. Each of these two conditions are quite rare in pregnancy, they may have occurred by chance, but there is a hypothetical possibility that bone marrow hypoplasia is an autoimmune disorder, with vulvar carcinoma occurring as a further complication in this immunoimpaired individual. CONCLUSION: This case also emphasizes the need to consider malignancy as a differential diagnosis in vulvar ulcers occurring in young women.

Evaluation of outpatient hysteroscopy and ultrasonography in the diagnosis of endometrial disease.

OBJECTIVE: To develop a multivariable approach to determine the added value of tests in routine practice where some diagnostic information is already available from clinical history. METHODS: Multivariable logistic regression models were built in a stepwise fashion, considering the clinical sequence used in the rapid access ambulatory diagnosis clinic (clinical history followed by transvaginal ultrasonography and hysteroscopy). The reference standard for confirmation of diagnosis was endometrial biopsy. The diagnostic accuracy of the models was determined by the area under the receiver operating characteristic curve. RESULTS: The area under the receiver operating characteristic curve for the model including historical features alone was 0.78. When hysteroscopy and ultrasonography were each added to the model, it increased to 0.81 (P =.008 for improvement) and 0.82 (P =.02 for improvement), respectively. CONCLUSION: The type of stepwise analysis we have developed is crucial in facilitating meaningful clinical interpretation about the value of diagnostic technology. Our finding that hysteroscopy or ultrasonography marginally but significantly increased the prediction of serious endometrial pathology above that predicted from patient history alone needs validation in an independent data set. The use of this approach is recommended when evaluating strategies for diagnosis.