Evaluating the effectiveness of a web-based intervention to promote mental wellbeing in women and partners following miscarriage, using a modified patient preference trial design: an external pilot.

This article describes an external pilot study of a modified 'partially randomised patient preference' trial comparing a web-based intervention (designed to promote mental wellbeing) with standard care post-miscarriage. Assessment comprised an online administration of baseline measures with follow-up at 3 months following registration. Baseline data were obtained from 60 women (and seven partners) post-discharge from one of two Early Pregnancy Assessment Units. 'Intention to treat' versus a 'per protocol' sensitivity analysis showed the effects of introducing a 'preference' option post-randomisation, and highlights the benefits compared with a randomised controlled trial design to enable a robust evaluation of the website in promoting mental wellbeing after miscarriage.

The genetic causes of the sequential occurrence of multiple primary malignancies in a young woman--5 years on.

The finding of three primary gynaecological malignancies in a young woman attending our unit was documented in 2001. We provide an update on this report as new events have prompted further discussion on the role of clinical guidelines in cancer management. The discovery of a genetic predisposition demonstrates the need for multidisciplinary input and heightened awareness in similar cases while the importance of treating each patient as an individual is emphasized.

The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months.

OBJECTIVE: To identify the trajectories of anxiety and depression in women and in their partners over 13 months after miscarriage. DESIGN: A prospective study with follow up at 6 and 13 months after miscarriage. SETTING: Three Scottish Early Pregnancy Assessment Units. SAMPLE: Of the 1443 eligible individuals approached, 686 (48.3%) consented to participate (432 women; 254 men). Complete data were obtained from 273 women and 133 men at baseline, 6, and 13 months. METHODS: On completion of the management of the index miscarriage, eligible and consenting women and men underwent an initial assessment comprising a semi-structured interview and a standardised self-report questionnaire. The latter was readministered at the follow-up assessments. MAIN OUTCOME MEASURES: The hospital anxiety and depression scale (HADS), a reliable and valid measure of general psychopathology for use in nonpsychiatric samples. RESULTS: Compared with depression, anxiety was overall the greater clinical burden. Over the 13-month period, women reported higher levels of anxiety and depression than men. Over time, a significantly greater level of adjustment was reported by women particularly with regards to the resolution of anxiety symptoms. The effect of time on HADS scores in either gender was similar between subgroups of socio-demographic and clinical factors. CONCLUSIONS: These findings verify that early pregnancy loss represents a significant emotional burden for women, and to some extent for men, especially with regards to anxiety. For many, the detrimental effects of miscarriage are enduring and display a complex course of resolution. These findings are discussed in terms of their clinical implications for early identification and management.

Invasive adenocarcinoma of the vagina following surgery for adenocarcinoma in situ of the cervix--recurrence or implantation?

A 51-year-old woman underwent cervical conization for severe glandular abnormal cells. Histology noted adenocarcinoma in situ (AIS) with incomplete excision margins. Four months later, hysterectomy revealed no residual disease. Six months subsequently she developed invasive adenocarcinoma of the upper vagina. This report documents the unusual behavior of AIS and its management difficulties.

A reappraisal of the role of chlorambucil in patients with end stage ovarian cancer who have previously been treated with platinum regimens.

The role of chlorambucil in end stage platinum resistant epithelial ovarian cancer was evaluated in women with end stage ovarian cancer. They had received platinum based chemotherapy and all other intravenous chemotherapeutic options had been exhausted. Over a 15 year period, 30 patients were identified. The median age was 64.5 years (range 45-81). The median number of chlorambucil pulses was 4 (range 1-16). The median survival following the introduction of chlorambucil was 5.5 months (range 0.72-38.8). The 22 patients who survived for longer than three months were significantly younger than those who did not (p = 0.03). Apart from two patients who developed transient myelosupression there were no toxic side effects. Chlorambucil should be considered as a therapeutic option in end stage ovarian cancer. It is has minimal toxicity, and can be prescribed safely for long term use. In younger women, an increase in benefit may be anticipated.

Flap repair: an effective strategy for minimising sexual morbidity associated with the surgical management of vulval intra epithelial neoplasia.

OBJECTIVE: To assess the sexual function after local excision and flap repair for symptomatic vulval intraepithelial neoplasia (VIN). STUDY DESIGN: A retrospective analysis of five sexually active women who had persistent, symptomatic VIN diagnosed in a dedicated tertiary referral vulval clinic and treated with local excision and flap repair. Sexual function was assessed using a modified version of the Sabbatsberg Sexual Self-Rating Scoring (SRS) system. RESULTS: The mean age of the cohort was 32 years (range 30 to 51). Four patients had previously been unsuccessfully treated with local excision. Follow up ranged from 5 to 33 months. The SRS scores were 90, 90, 81, 72 and 25. Endogenous depression may explain this last score. There has been no recurrence of VIN. CONCLUSION: In sexually active women with symptomatic VIN III, a flap reconstruction should be considered in addition to local excision as the treatment of choice.

Flap repair: an effective strategy for minimising sexual morbidity associated with the surgical management of vulval intra epithelial neoplasia

Objective: To assess the sexual function after local excision and flap repair for symptomatic vulval intraepithelial neoplasia (Vin). Study Design: A retrospective analysis of five sexually active women who had persistent, symptomatic VIN diagnosed in a dedicated tertiary referral vulval clinic and treated with local excision and flap repair. Sexual function was assessed using a modified version of the Sabbatsberg Sexual Self-Rating Scoring (SRS) system. Results: The mean age of the cohort was 32 years (range 30 to 51). Four patients had previously been unsuccessfully treated with local excision. Follow up ranged from 5 to 33 months. The SRS scores were 90, 90, 81, 72 and 25. Endogenous depression may explain this last score. There has been no recurrence of VIN. Conclusion: In sexually active women with symptomatic VIN III, a flap reconstruction should be considered in addition to local excision as the treatment of choice (AU)

The prevalence of lupus anticoagulant and anticardiolipin antibodies in women with a history of first trimester miscarriages.

OBJECTIVE: To determine the prevalence of lupus anticoagulant and raised anticardiolipin antibodies in women with a history of two or more miscarriages in the first trimester of pregnancy. DESIGN: A prospective study of lupus anticoagulant and anticardiolipin antibody levels in unselected women with a history of two or more first trimester miscarriages. SETTING: The prepregnancy clinic and miscarriage antenatal clinic in a tertiary referral centre. SUBJECTS: Two hundred and forty-three women, of whom 113 (47%) had a past history of two miscarriages, and 130 (53%) had three or more miscarriages. MAIN OUTCOME MEASURES: Quantitative detection of lupus anticoagulant and anticardiolipin antibodies; number of miscarriages in women in the normal and the abnormal groups. RESULTS: Of the 243 women tested, 41 (16.8%) had an abnormality of lupus anticoagulant or anticardiolipin antibodies. This was significantly different from the normal population as previously reported. Sixteen women (6.6%) were positive for lupus anticoagulant, 20 (8.2%) had elevated anticardiolipin antibodies, and five (2%) had both abnormalities. The most frequently positive test for lupus anticoagulant was the dilute Russel viper venom time, and IgG was the most frequently elevated anticardiolipin antibody. Of the women with a history of only two miscarriages, 15% had an abnormality of lupus anticoagulant or anticardiolipin antibodies, compared with 18.5% of those with a history of three or more miscarriages. This did not reach statistical significance. There were 117 (48%) primary miscarriers and 126 (52%) secondary miscarriers. Of the primary miscarriers, 17% had an abnormality, compared to 18% of the secondary miscarriers. CONCLUSIONS: These findings provide further evidence of an association between lupus anticoagulant and anticardiolipin antibodies and early pregnancy loss. It is not known if these are the cause of miscarriage, markers for miscarriage, or if antiphospholipid antibodies develop as a result of a noncontinuing pregnancy. Further studies comparing various treatments are required before women with these antibodies can be optimally managed.

Providing for women following miscarriage.

It is apparent that an increased awareness amongst health care workers of the need for parents to grieve the loss of their baby, regardless of the gestation, is essential. It should also be noted that this time of coming to terms with the loss can be quite lengthy. This healing may be aided by support groups such as the Miscarriage Association, and also through pre-pregnancy counselling clinics. Support in the next pregnancy appears to improve the chance of a successful pregnancy outcome in women with a history of recurrent miscarriages. It is important that the current interest in bereavement counselling does not lead to every miscarriage being 'magnified into a catastrophe'. For some women the event will pass with little trauma. In seeking to improve the management of this distressing condition we must be careful to take into consideration the individual's requirements. In a recent publication by SANDS, guidelines for the management of patients who have experienced the loss of a baby are given. This book can be commended for all involved in the care of women at the time of pregnancy loss.