An analysis of the outcomes of cervical cone biopsies performed in a low resource setting.

Following skills transfer to this low resource setting, we carried out a descriptive analysis of the outcomes of all cone biopsies performed for women with cervical intra-epithelial neoplasia 3 (CIN 3). We also compared two methods of cone biopsy. All the women had follow-up smear tests at 6 and 18 months. There were no cases of CIN 3 at follow-up. 80% had normal smears at 18 months and 20% had CIN 1. Compared with knife cone biopsy, women who had an electric knife (hand-held diathermy blade) cone biopsy had a significantly smaller volume of mean blood loss (55.5mls ± 15.9 vs 153.3ml ± 40, p < 0.001). With appropriate skills transfer, women with CIN 3 in a low resource setting can be effectively treated with conisation procedures. The diathermy knife is preferred to cold knife because of its associated low blood loss.

A multi-centre audit on the use of vaginal prostaglandin for the induction of labour.

To induce labour, the National Institute for Health and Clinical Excellence (NICE) guideline recommend a maximum total dose of 6 mg of prostaglandin E(2) tablet or 4 mg of prostaglandin E(2) gel for women with an unfavourable cervix (3 mg gel for all other women). To determine clinicians' compliance with these recommendations, the data of 1,424 women, who were induced at 10 obstetric units in England, were reviewed. A higher-than-recommended total dose was administered in 11% of the sample. Women who received prostaglandin tablets had a 2.5-fold greater likelihood to receive higher-than-recommended maximum total dose (OR: 2.6, 95% CI: 1.8-3.7; p < 0.001) and nine-times more likely to receive double the recommended maximum total dose (OR: 8.7, 95% CI: 2.9-24.4; p < 0.001). In this audit, 1 in 9 women, who underwent induction of labour, received higher than the recommended maximum total dose of vaginal prostaglandin.

The incidence of uterine leiomyoma and other pelvic ultrasonographic findings in 2,034 consecutive women in a north London hospital.

New generation technologies provide alternative ways of assessing the female pelvis, and provide improved estimates of the incidence of uterine leiomyoma. To determine the incidence of uterine leiomyoma and other incidental findings, the request forms for pelvic ultrasound scan and the scan results of 2,034 consecutive women was reviewed. There were 586 women with scan-detected uterine leiomyoma giving an incidence of 29.9%, although only 3% of the women had clinically suspected leiomyoma. Pain was the leading indication for a pelvic ultrasound scan in women without a uterus, whereas in women with a uterus, bleeding was the leading indication. Other scan findings included ovarian cyst, 11.4% and polycystic ovaries, 7.5%. Uterine leiomyoma was four times more frequent in women over 40 years (odds ratio 4.1, 95% confidence interval, 3.3-5.0). These women were two times more likely to have multiple leiomyomas (OR 2.01, 95% CI, 1.4-2.8) and 30% more likely to have large leiomyomas (OR 1.3, 95% CI, 1.0-2.1).

Vernix caseosa peritonitis.

Vernix caseosa peritonitis (VCP) is a rare and serious complication of caesarean section. It is thought to occur as a result of spillage of amniotic fluid and or meconium into the maternal peritoneal cavity at caesarean section. It manifests as an acute abdomen days to weeks after a seemingly uncomplicated caesarean section. Only 18 cases have been reported in the literature and all but one are from the USA. The pathophysiology is incompletely understood. In the past, the management of VCP included a laparotomy and removal of suspected abdominal organs which were invariably found to be normal on histopathological examination. However, the characteristic intraoperative finding was a cheesy white exudate that coats the visceral organs. The organs themselves were not inflamed. Histological examination of biopsy specimen of the cheesy exudates is the only way to make a diagnosis of VCP. This would reveal anucleate squamous cells along with lanugo hair and foreign body giant cell reaction. From recent case reports, peritoneal lavage appears to be the mainstay of treatment of VCP. Increased awareness of this condition is crucial so that it is considered in the differential diagnosis of post-caesarean acute abdomen thereby avoiding the unnecessary removal of healthy intra-abdominal organs. This review article summarises the current state of knowledge on VCP.

Are we complying with NICE guidelines on the use of prostaglandin E2 for induction of labour? A survey of obstetric units in the UK.

To determine whether obstetric units in the UK comply with the recommendations by the National Institute for Clinical Excellence (NICE) on the maximum doses of intravaginal prostaglandin for induction of labour, a cross-sectional telephone survey of all obstetric units in the UK listed on Dr Foster's website was undertaken. The maximum doses recommended by NICE were exceeded by 86.4% (76/88) and 61.1% (55/90) of units that use intravaginal prostaglandin tablet and intravaginal prostaglandin gel, respectively. Units that use prostaglandin tablets were four times more likely to exceed the recommended maximum dose (OR = 4.03, 95% CI, 1.9 - 8.4), six times more likely to use 50% or more of the recommended maximum dose for nulliparous women (OR = 5.9, 95% CI, 3.1 - 11.0), and six times more likely to use 50% or more of the recommended maximum dose for multiparous women (OR = 6.5, 95% CI, 3.0 - 13.9). A majority of obstetric units in the UK exceed the maximum doses of intravaginal prostaglandin recommended by NICE for induction of labour.

Salvage autotransfusion versus homologous blood transfusion for ruptured ectopic pregnancy.

OBJECTIVE: To compare the clinical outcomes of simple salvage autotransfusion and homologous blood transfusion in the management of ruptured ectopic pregnancies. METHODS: Standard statistical analysis was done and relative risk (RR) and 95% confidence interval (CI) were calculated for 112 women randomized to salvage autotransfusion or donor blood transfusion following ruptured ectopic pregnancy. RESULTS: More women in the autologous group received more than 1000 mL of blood (RR, 6.41; 95% CI, 2.75-15.24) and had a hematocrit greater than 0.27 at discharge (RR, 3.62; 95% CI, 1.41-6.67). There were no significant differences in the incidence of postoperative fever (RR, 0.95; 95% CI, 0.43-2.01), postoperative wound infection (RR, 0.73; 95% CI, 0.17-3.19) or duration of hospital stay longer than 7 days (RR, 1.3; 95% CI, 0.44-4.31). CONCLUSION: In resource-poor countries, women with a ruptured ectopic pregnancy receive more blood with salvage autotransfusion.

Late pre-term (32 - 36 weeks) birth in a North London hospital.

Most of the complications of pre-term delivery arise in the 1 - 2% of births before 32 weeks' gestation. However, late pre-term birth (32 - 36 weeks' gestation) is still worrying for the mother and clinician. In a retrospective study that compared the management and outcome of 103 singleton pregnancies delivered between 32 and 36 weeks' of gestation with 103 age-matched controls that delivered at term, a short inter-pregnancy interval, early pregnancy bleeding, pre-labour spontaneous rupture of membranes, a history of pre-term delivery and Asian race or single marital status were found to be significant factors. The groups did not differ in parity, BMI, smoking status or history of miscarriages and terminations. Following a logistic regression analysis, the following emerged as risk factors for late pre-term delivery; a history of previous pre-term delivery (OR = 7.2; 95% CI 1.6 - 33.2), a short (<12 months) inter-pregnancy interval (OR = 4.1; 95% CI 2.2 - 7.5), early pregnancy bleeding (OR = 7.6; 95% CI 1.3 - 38.3) and pre-labour spontaneous rupture of membranes (OR = 13.3, 95% CI 3.1 - 55.2).

External cephalic version (ECV): experience in a sub-Saharan African hospital.

External cephalic version (ECV) is not a popular procedure in developing countries such as Nigeria. Over a 3-year period, we prospectively studied women who had ECV in a Nigerian University Teaching hospital. Comparative analysis was made between the successful ECV and the unsuccessful ECV groups. Following adequate counselling, Nigerian women were willing to accept an ECV for the singleton term breech. The ECV success rate was 67%. Favourable factors for success were multiparity (Relative Risk, RR 3.8; 95% confidence interval, CI 1.14 - 12.1), flexed breech (RR 2.4; 95% CI 1.02 - 5.7), unengaged breech (RR 4.8; 95% CI 1.3 - 17.2), normal liquor volume (RR 4.8; 95% CI 1.3 - 17.1) and a posterior placenta (RR 6.8; 95% CI 2.8 - 16). Once turned, 97% of the babies remained cephalic until delivery. The caesarean section rate in each group was higher than the unit rate of 12.7%. There was one fetal death from cord prolapse in the vaginal breech delivery group.

Recurrent stillbirths: a matched case-control study of unexplained stillbirths at term.

The aim of this study was to assess the recurrent risk of an unexplained stillbirth at term. A total of 75 women who delivered stillbirths were matched for maternal age and parity with 75 controls. After excluding explained stillbirths, matched cases and controls were compared for maternal age, length of gestation, birth weight and 'interval to next birth'. The main outcome measure was the frequency of recurrence of a stillbirth. Both groups were similar for maternal age and length of gestation. Birth weight was marginally different (odds ratio (OR) = 0.997, 95% confidence interval (CI) 0.996, 0.999) and 'interval to next birth' was longer (OR = 1.08, 95% CI 1.00, 1.17). There were no stillbirths in cases and controls at follow-up. We conclude that a woman who has had an unexplained stillbirth at term has no greater risk of recurrence than a matched control. However, the 'interval to next birth' was significantly longer.

Large babies and unplanned Caesarean delivery.

OBJECTIVE: The relationship between birth weight > or =4000 g and unplanned Caesarean delivery was examined. DESIGN: A retrospective cohort study. SETTING: A district general hospital. POPULATION: Two thousand three hundred and ninety-three women who delivered babies weighing > or =2500 g. METHODS: The mode of delivery of babies who weighed > or =4000 g was compared with those who weighed between 2500 and 4000 g. Comparative analysis of data was followed by regression analysis of explanatory variables. The effect of increasing birth weight on unplanned Caesarean delivery was determined. RESULTS: Women who had an unplanned Caesarean were delivered at an earlier gestation (OR = 0.89, 95% CI 0.81-0.97; P = 0.007), and were more likely to be primiparous (OR 5.4, 95% CI 4.1-7.1; P = 0.0001). Further, women who had an unplanned Caesarean were more likely to have babies weighing > or =4000 g (OR = 2.24, 95% CI 1.61-3.12; P = 0.003). The odds of having an unplanned Caesarean were increased 16.9-fold with a previous Caesarean (95% CI 9.24-30.8; P = 0.001). When a previous Caesarean was combined with a baby weighing > or =4000 g, the odds of having an unplanned Caesarean increased 37.8 times (95% CI 18.8-75.8), compared to a woman who previously had a normal vaginal birth and a baby weighing between 2500 and 4000 g. CONCLUSION: Birth weight > or =4000 g is associated with more than a two-fold increased risk of an unplanned Caesarean delivery. The risk increased further (37.8 x) when a previous Caesarean delivery was combined with a birth weight > or =4000 g.

Interstitial cystitis.

Interstitial cystitis (IC) is a debilitating chronic inflammatory disorder of the bladder. It affects predominantly middle-aged Caucasian women. The diagnosis, made from the combination of symptoms, cystoscopic findings and bladder biopsies, is often delayed in the gynaecology setting because of a low index of suspicion. The pathophysiology is incompletely understood, although mast cell activation, altered bladder epithelial permeability and sensory afferent nerve up-regulation are thought to play key roles. Recent theories include the role of an antiproliferative factor. A wide assortment of therapies is available and many more are under trial. Until the causes and pathogenesis of IC are unraveled, mainstream medical treatment will remain palliative and cystectomy with urinary diversion, the only potential cure. In addition to our long experience on managing this disorder, we present a comprehensive review of the current thoughts on the aetiology and management of IC.

Autotransfusion for ruptured ectopic pregnancy.

OBJECTIVES: Clinical outcomes following the exclusive use of autotransfusion in the management of ruptured ectopic pregnancy are reviewed. METHODS: A MEDLINE search (1966-2002) for relevant articles documenting the exclusive use of autotransfusion, and data collection and analysis was made. RESULTS: There were 21 studies, 16 from developing and five from developed countries, involving 632 cases of ruptured ectopic pregnancies. Hypovolemic shock with significant hemoperitoneum (>500 ml) was the most common complication. The procedure was performed completely manually in developing countries and with the help of a device in developed countries. The mean volume of autotransfused blood was over 1000 ml, with mean hemoglobin levels ranging from 6 to 12.5 g/dl. Mean posttransfusion hemoglobin levels were higher than pretransfusion levels. There was one death, thought to be due to pulmonary embolism, and nine major and minor complications. CONCLUSIONS: Autotransfusion is useful in the management of ruptured ectopic pregnancy.

Simultaneous intrauterine and ovarian pregnancy following treatment with clomiphene citrate.

Heterotopic pregnancy is increasingly being diagnosed since the advent of assisted reproductive technology involving the use of superovulatory drugs and/or in-vitro fertilization and the availability of high-resolution ultrasound scans. There are reports of Heterotopic tubal pregnancies following clomiphene use. Heterotopic ovarian pregnancies are however rare. Clomiphene citrate, which is widely used in the primary care setting to treat anovulatory infertility, is felt safe. We present a case of heterotopic ovarian pregnancy following treatment with clomiphene citrate. The diagnosis and management of heterotopic ovarian pregnancy are also discussed.

Interstitial cystitis coexisting with vulvar vestibulitis in a 4-year-old girl.

Interstitial cystitis (IC) is a disorder that is difficult to diagnose and is thought to be uncommon in children. We report the first case of IC coexisting with vulvar vestibulitis in a 4-year-old girl. She presented with urinary symptoms and pelvic and vulvar pain. Cystoscopic and histological investigation confirmed interstitial cystitis and vulvar vestibulitis. Gynecologists are often called upon to deal with symptoms referable to the genital tract. It is important to always include interstitial cystitis in the differential diagnosis of urinary symptoms associated with pelvic pain.

Risk factors for placenta praevia in southern Nigeria.

OBJECTIVE: To determine the risk factors for placenta praevia in Ile-Ife, southern Nigeria. DESIGN: A prospective case control study. SETTING: A tertiary center--Obafemi Awolowo University Teaching Hospital, Ile-Ife, southern Nigeria. SUBJECTS: One hundred and thirty six patients with confirmed placenta praevia constituted the cases. Controls consisted of one hundred and thirty six patients who delivered at term immediately after each indexed case and did not have placenta praevia. RESULTS: Cases and controls were similar in terms of twin deliveries (P = 0.72) and past history of uterine surgery (P = 0.47). After adjusting for confounders, factors associated with risk of placenta praevia were history of retained placenta [OR = 6.7(95% CI 1.2-36.6)], previous caesarean section [OR = 4.7, (95% CI 1.9-11.4)], previous abortion [OR = 2.9 (95% CI 1.1-5.1)], grand multiparity [OR = 2.1 (95% CI 1.6-7.1)] and age over 35 years [OR = 1.4 (95% CI 1.2-6.6)]. CONCLUSIONS: From our study, the risk factors for placenta praevia are a history of retained placenta, previous caesarean section, previous abortion, grand multiparity and maternal age over 35 years.

Primary postpartum haemorrhage.

Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. In the developing countries, it is responsible for the death of about 125 000 women each year. Death from postpartum haemorrhage is eminently preventable. It is essential that first-line staff are able to prevent, make early diagnosis and provide prompt management of primary PPH. This article focuses on the prevention and management of primary PPH and highlights recent developments. Relevant current literature using the MEDLINE search strategy was examined.