Anthony Griffiths

Rectovaginal endometriosis – a frequently missed diagnosis

Summary To assess the proportion of women found to have rectovaginal endometriosis who underwent a previous laparoscopy with negative findings, a 5-year retrospective observational study was carried out at the University Hospital of Wales, Cardiff UK, from 2001 to 2005. A total of 61 cases with potential symptoms of rectovaginal endometriosis who underwent laparoscopy were identified. Rectovaginal endometriosis was identified in 16 of these cases. Previous laparoscopy was carried out in 33 of these 61 cases. In the group of women found to have rectovaginal endometriosis, 14 cases of rectovaginal endometriosis were not identified by pre-referral laparoscopy. This study supports the anecdotal idea that rectovaginal endometriosis is an often missed diagnosis at the time of laparoscopy. Diagnostic laparoscopy by generalist gynaecologists frequently fails to diagnose rectovaginal endometriosis. The routine use of rectal probes at laparoscopy is recommended to increase diagnostic accuracy.

Fluid Within the Endometrial Cavity in an IVF Cycle—A Novel Approach to Its Management

Fluid within the endometrial cavity before embryo transfer in IVF cycles is associated with failure of implantation. The etiology of endometrial fluid is surrounded in controversy but it is associated with hydrosalpinges, polycystic ovarian disease, and subclinical uterine infections. The current treatment consists of postponing embryo transfer. This of course has biological and psychological disadvantages; a decreased implantation rate from frozen embryo transfer, and frustration and disappointment for the couple. Removing the fluid with an embryo transfer catheter immediately before embryo transfer may be a successful method of treatment.

Predicting the presence of rectovaginal endometriosis from the clinical history: A retrospective observational study

Summary Rectovaginal endometriosis is a severe variant of endometriosis. Common presenting symptoms for endometriosis include dysmenorrhoea, pelvic pain and dyspareunia. It is now recognised that there are other less traditional symptoms of endometriosis that are also relatively common. The aim of this study is to assess the relative strength of each of the potential symptoms of rectovaginal endometriosis and compare these with the laparoscopic and histological findings. In this retrospective, observational study the overall prevalence of rectovaginal endometriosis in the group was 31.4%. The presence of dyschesia gave a likelihood ratio of 1.27 (95% CI: 0.56 – 2.89) with a predictive prevalence of rectovaginal endometriosis of 37%. Apareunia and nausea or abdominal bloating were particularly strong markers for rectovaginal disease with a predictive prevalence of 87% and 89%, respectively. The classical symptoms often attributed to irritable bowel syndrome are also common in women with rectovaginal disease.

Transrectal ultrasound and the diagnosis of rectovaginal endometriosis: a prospective observational study

Background. Rectovaginal endometriosis is a severe form of pelvic endometriosis in which pharmacological treatment is relatively ineffective (Vercellini et al., Fertil Steril. 2005;84:1375–87). Laparoscopic surgical treatment is effective, but has the potential risks of bowel perforation and colostomy formation (Darai et al., Am J Obstet Gynecol. 2005;192:394–400). Transrectal ultrasound scanning can be applied as a preoperative tool to predict the presence of rectovaginal endometriosis and bowel wall involvement (Abrao et al., J Am Assoc Gynecol Laparosc. 2004;11:50–4). Methods. Thirty‐two women underwent transrectal ultrasound followed by therapeutic laparoscopy. Likelihood ratios and post‐test prevalences were calculated with Fagans normogram. This was then extrapolated with the aid of a mathematical model to a low‐risk population. Results. A positive likelihood ratio was found to be 10.89 (95% confidence ratio (CI): 1.62–73.15) and a negative likelihood ratio was found to be 0.24 (95% CI: 0.1–0.57). The pre‐test prevalence of rectovaginal endometriosis was 56%. The positive post‐test prevalence probability was 93%, and the negative post‐test prevalence probability was 23%. Conclusion. Preoperative transrectal ultrasound scanning for rectovaginal endometriosis is an extremely accurate predictive test, and strongly predicts the need for extensive laparoscopic dissection and potential bowel resection.

A survey of methods used to measure symphysis fundal height

Summary Symphysis fundal height (SFH) is currently used in the UK as a screening test to identify which pregnancies may require additional investigations including the use of ultrasound fetal biometry. The routine use of SFH has been subjected to extensive research assessing its sensitivity and also inter and intraobserver variation. This studys aim was to assess the current UK practice of SFH measurement and particularly looked at methods used in its measurement. A total of 250 healthcare professionals (doctors and midwives) were asked to complete a structured anonymous questionnaire of which 211 health professionals agreed to participate. The results revealed that SFH is used less frequently by the professionals with less than 10 years clinical experience compared to professionals with more than 10 years clinical experience. In addition there was significant variance in the methods used to measure SFH that would increase the interobserver error.

Desmoid tumours with familial adenomatous polyposis in pregnancy

(2003). Desmoid tumours with familial adenomatous polyposis in pregnancy. Journal of Obstetrics and Gynaecology: Vol. 23, No. 3, pp. 307-308.

Induction to delivery time interval in patients with and without preeclampsia: a retrospective analysis

Background.  Anecdotally, it is suggested that patients with preeclampsia have a shorter induction to delivery interval than patients without preeclampsia, despite there being no good objective evidence.

Perifollicular blood flow and pregnancy in superovulated intrauterine insemination (IUI) cycles: An observational comparison of recombinant follicle-stimulating hormone (FSH) and urinary gonadotropins

The group of patients who received urinary gonadotropins (n = 117) for follicular stimulation had a significantly higher incidence of high perifollicular blood flow compared with that of the group who received recombinant FSH (n = 114; 46.3% vs. 22.7%). The overall clinical pregnancy rate in patients stimulated with recombinant FSH was 10.91%, compared with 22.22% in the group stimulated with urinary gonadotropins.

Torsion of a rudimentary horn pregnancy—an unusual case presentation

Aplasia of the mullerian ducts during foetal life can result in the formation of a unicornuate uterus. This can be associated with varying degrees of a rudimentary horn. Of the female population, 5.5 % is thought to have a uterine abnormality, but only 0.1 % has this specific formation [1]. Unicornuate uteri with rudimentary horns are susceptible to many gynaecological and obstetric complications, such as infertility, endometriosis, urinary tract anomalies and premature delivery [2]. They can also, although seldom, undergo horn torsion [3]. Development of a pregnancy in a rudimentary horn is rare occurring in only 1/76,000–150,000 cases [4]. It is made possible when migration of the spermatozoa occurs through the abdominal cavity [5]. Pregnancy carries with it the risk of horn rupture, which can be fatal causing major haemorrhage. Rupture occurs in 80–90 % of cases at midtrimester [6]. When a pregnancy in a rudimentary horn is diagnosed, excision of the horn is often necessary to prevent this, often through a laparotomy and, only more recently, through laparoscopy [5]. Formation of a large uterine horn capable of sustaining a pregnancy is particularly uncommon. The neonatal survival in rudimentary horn pregnancies is only 2 % [6]. Here, we present a case of a patient who developed a pregnancy in a large rudimentary horn with the musculature capable of maintaining a viable pregnancy, but which had also undergone torsion, and who later required laparoscopic management for removal of products of conception. To the best of our knowledge, this is the first case report of the management of a torted rudimentary horn pregnancy in the literature.

Renal infarction in a postpartum woman with vascular type Ehlers–Danlos syndrome

Ehlers–Danlos syndromes (EDS) are a group of hereditary disorders of connective tissue, with a prevalence of between 1/5,000 and 1/25,000. The Villefranche classification identifies six clinical ty...