A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage.

OBJECTIVE: To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding. DESIGN: A randomised controlled trial. SETTING: Two university teaching hospitals. PARTICIPANTS: Four hundred women with abnormal uterine bleeding (postmenopausal bleeding, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular periods) above the age of 35 years, between June 1993 and January 1995. MAIN OUTCOME MEASURES: 1. Incidence of detection of abnormal pathology by vaginal ultrasound, outpatient hysteroscopy and endometrial biopsy compared with inpatient hysteroscopy and curettage; 2. Number of 'lesions' (e.g. fibroids, polyps, endometrial hyperplasia or malignancy) found by hysteroscopy that would have been missed by the combination of endometrial sampling and ultrasound; 3. Comparison of the quality of tissue obtained for histology by outpatient endometrial sampling and inpatient curettage; and 4. An evaluation of patient acceptability of outpatient and inpatient procedures. RESULTS: 1. A combination of transvaginal sonography, Pipelle endometrial biopsy and outpatient hysteroscopy has similar efficacy to inpatient hysteroscopy and curettage for the investigation of abnormal uterine bleeding; 2. Hysteroscopy will detect some fibroids and polyps missed by a combination of transvaginal ultrasound and Pipelle endometrial sampling; 3. The quality of histological samples obtained by outpatient Pipelle were comparable to those obtained by formal inpatient curettage; and 4. Outpatient procedures were well tolerated, with good patient acceptability. CONCLUSION: Transvaginal sonography and endometrial biopsy can safely be used as the initial investigations in the management of abnormal uterine bleeding. Hysteroscopy can be used as a second line investigation. Outpatient hysteroscopy with local anaesthesia is well tolerated although general anesthesia may occasionally be necessary.

Management of women referred to early pregnancy assessment unit: care and cost effectiveness.

OBJECTIVE: To assess the efficiency of an early pregnancy assessment unit in the care of women with bleeding or pain in early pregnancy. DESIGN: Analysis of women attending in the first year of the unit's operation and in the six months immediately before its introduction. SETTING: Early pregnancy assessment unit in a district general hospital serving a population of 310,000. PATIENTS: 1141 women referred with bleeding or pain in early pregnancy. MAIN OUTCOME MEASURES: Length of stay in hospital required for diagnosis and treatment. RESULTS: Before the unit was established the mean admission time was one and a half (range half to three) days for women who required no treatment and three (one and a half to five) days in women requiring evacuation of uterus. These times were reduced to two hours as an outpatient and one day respectively for most women after the unit was established. Between 318 and 505 women were estimated to have been saved from unnecessary admission, and 233 had their stay reduced; the associated saving was between pounds 95,000 and pounds 120,000 in one year. CONCLUSIONS: The early pregnancy assessment unit improved the quality of care and also produced considerable savings in financial and staff resources.

Colposcopic diagnosis and treatment of cervical dysplasia at a single clinic visit. Experience of low-voltage diathermy loop in 1000 patients.

In a study of 1000 women referred over 20 months with abnormal smears and in whom the entire transformation zone could be seen the aim was to test the feasibility of colposcopic assessment and treatment at one visit to the clinic. 897 women needed only one visit. This was achieved by using a modification of the large loop diathermy excision technique and by careful attention to the timing of the clinic visit. 103 required further visits, for the following reasons: incomplete excision on histology and/or subsequently abnormal smear (85), secondary haemorrhage (6), microinvasion or invasive carcinoma (9), biopsy specimens unusable (3). Further treatment was given in 4.1% of the cervical dysplasias. All patients treated in a single visit preferred this approach to the alternative of colposcopic assessment and biopsy followed, after histological examination, by local ablation by laser, excision by loop biopsy technique, or cone biopsy.

Recovery of the intrauterine contraceptive device from the sigmoid colon. Three case reports.

PIP: 3 cases of copper IUDs recovered during laparotomy from the sigmoid colon are presented. One woman was a 24-year old mother of 5 who had had 2 cesarean sections since the disappearance of her Cu-7 IUD in 1980. She had right upper quadrant abdominal pain for 1 year with gall bladder stones. The IUD was found lying 80% in the gut lumen. After colotomy she recovered. The 2nd woman was 31 years old, pregnant for the 4th time after failure of her IUD. She was experiencing a constant left iliac fossa ache. The IUD was shown to be extrauterine by ultrasound, could not be seen at laparoscopy, and was removed by colotomy. The 3rd woman was a 37-year old mother of 5, 19 weeks' pregnant, having a septic miscarriage on admission. She had labor induced, but the IUD was not expelled. Her pain worsened, and fever and tachycardia persisted. Emergency laparotomy revealed a perforated posterior uterine wall with the Cu-7 eroding the serosa of the sigmoid colon. It was removed but the defect was not repaired. She required a subtotal hysterectomy, and a second laparotomy with a temporary colostomy, and her recovery was complicated by pulmonary embolism and cardiac failure. These cases draw attention to the importance of proper management of patients with no visible IUD thread. Ultrasound, and if necessary x-rays and laparoscopy should precede laparotomy. Expulsion of an IUD is rarely unnoticed, nor should pregnancy with an IUD be assumed to be due to an expelled device.^ieng