Emma Readman

Vaginal birth after Caesarean section: an Australian multicentre study

Retrospective analysis of medical records and individual case review was undertaken at 11 major obstetric hospitals for a 5 year period from July 1992 to June 1997 to investigate rates of vaginal birth after Caesarean section (VBAC), the occurrences of uterine rupture, and the outcomes for mother and infant following rupture.

Pain Relief and Outpatient Hysteroscopy: A Literature Review

Our early experience in setting up an ambulatory hysteroscopy service provoked a review of the literature, due to an unacceptably high failure rate. A literature review has been undertaken to establish the accepted success rates and reasons for failure, and to assess evidence for various analgesic protocols through randomized controlled trials. The data suggest the procedure is acceptable to most patients, with a completion success rate over 90%, and the use of analgesia may enhance the success rate. Analgesic protocols studied were nonsteroidal anti-inflammatory drugs, intracervical block, paracervical block, transcervical block, and topical analgesia. Failures are due predominantly to pain, stenosis, and poor view.

Outpatient hysteroscopy: Factors influencing post‐procedure acceptability in patients attending a tertiary referral centre

Background:  Ambulatory hysteroscopy is a safe, reliable and cost‐effective alternative to hysteroscopy under a general anaesthetic for the diagnosis of abnormal uterine bleeding.

Endosalpingiosis, an unrecognized condition: report and literature review

This study involves an audit of cases of endosalpingiosis diagnosed at a major teaching hospital and a review of the literature. The retrospective audit of endosalpingiosis was carried out from 1997 to 2000 at the Mercy Hospital for Women, Melbourne, Australia. Information was collected regarding the demographics, presentation and management for women with this diagnosis. During the period of review, endosalpingiosis was diagnosed in 45 patients. Pain was the most frequent presentation and laparoscopy with excision of “endometriosis” was the most frequent operation. Interestingly, of 64 peritoneal biopsies taken for suspected endometriosis, 20 were endosalpingiosis, 21 endometriosis, 7 both endometriosis and endosalpingiosis and 16 fibrosis, hyperplasia or normal. Endosalpingiosis is a relatively unknown condition. Its diagnosis may be missed since it often coexists with endometriosis or mimics endometriosis, and the majority of surgeons ablate lesions without obtaining a histological diagnosis. It is important to consider the diagnosis of endosalpingiosis since it may be associated with chronic pelvic pain. There are a few cases of endosalpingiosis in peritoneal washings that have been incorrectly interpreted as well-differentiated adencarcinoma and have been found in association with ovarian and cervical neoplasms.

Intraperitoneal Ropivacaine and a Gas Drain: Effects on Postoperative Pain in Laparoscopic Surgery

STUDY OBJECTIVE To assess the benefits of the combination of a gas drain and the instillation of local anesthetic on the incidence of pain after operative gynecologic laparoscopy. DESIGN Randomized control trial (Canadian Task Force classification I). SETTING Tertiary referral center. PATIENTS One hundred twenty-eight patients undergoing operative gynecologic laparoscopy procedures lasting less than 105 minutes. INTERVENTIONS Postoperatively, one group received a blocked drain and saline placed intraperitoneally; a second group was given a blocked drain and ropivacaine; a third group received a patent drain and saline; and a fourth was given a patent drain and ropivacaine. MEASUREMENTS AND MAIN RESULTS Visual analogue pain scores (VAS) were measured at 1, 2, 4, and 12 hours and day 1 to day 7. Also measured was opioid consumption at 4 hours, nausea, and activity scores. We found a statistically significant improvement in pain scores at 2 and 4 hours in the group allocated to receive a patent drain and ropivacaine. CONCLUSION We recommend the use of a gas drain and ropivacaine to reduce postoperative pain.

Are endometrial nerve fibres unique to endometriosis? A prospective case–control study of endometrial biopsy as a diagnostic test for endometriosis in women with pelvic pain

STUDY QUESTION Can the presence of endometrial nerve fibres be used as a diagnostic test for endometriosis in women with pelvic pain? SUMMARY ANSWER Endometrial fine nerve fibres were seen in the endometrium of women both with and without endometriosis, making their detection a poor diagnostic tool for endometriosis. WHAT IS KNOWN ALREADY Laparoscopy and biopsy are currently the gold standard for making a diagnosis of endometriosis. It has been reported that small density nerve fibres in the functional layer of the endometrium are unique to women with endometriosis and hence nerve fibre detection could function as a less invasive diagnostic test of endometriosis. However, it may be that other painful conditions of the pelvis are also associated with these nerve fibres. We therefore focused this prospective study on women with pelvic pain to examine the efficacy of endometrial nerve fibre detection as a diagnostic test for endometriosis. STUDY DESIGN, SIZE, DURATION This prospective case-control study conducted between July 2009 and July 2013 included 44 women with pelvic pain undergoing laparoscopic examination for the diagnosis of endometriosis. Immunohistochemical nerve fibre detection in endometrial curettings and biopsies using anti-protein gene product 9.5 was compared with surgical diagnosis. PARTICIPANTS/MATERIALS, SETTINGS, METHODS Paired endometrial biopsies and curettings were taken from patients with (n = 22, study group) and without (n = 22, control group) endometriosis. Tissue was analysed by immunohistochemistry and nerve fibres were counted whenever they were present in the functional layer of the endometrium. MAIN RESULTS AND THE ROLE OF CHANCE Fine nerve fibres were present in the eutopic endometrium of patients both with and without endometriosis. The presence of nerve fibres in curettings was not effective for either diagnosing or excluding endometriosis; sensitivity and specificity were 31.8 and 45.5% respectively, positive predictive value was 36.8% and negative predictive value was 40.0%. Few endometrial biopsy specimens were found to have nerve fibres present; sensitivity and specificity for endometrial biopsy were 13.6 and 68.2% respectively, positive predictive value was 30.0% and negative predictive value was 44.1%. LIMITATIONS, REASONS FOR CAUTION This was a relatively small sample size and studies like this are subject to the heterogeneous nature of the patient population and tissue samples, despite our best efforts to regulate these parameters. WIDER IMPLICATIONS OF THE FINDINGS Our results demonstrate that fine nerve fibres are present in women with and without endometriosis. Future work should focus on the function of endometrial nerves and whether these nerves are involved with the subfertility or pain that endometriosis sufferers experience. Our study does not support the detection of endometrial nerve fibres as a non-invasive diagnostic test of endometriosis in women with pelvic pain.

Is outpatient hysteroscopy the new gold standard? Results from an 11 year prospective observational study

In Australia, gynaecologists continue to investigate women with abnormal bleeding and suspected intrauterine pathology with inpatient hysteroscopy despite some evidence in the literature that that there is no difference in safety and outcome when compared to an outpatient procedure.

The effect of patient body mass index on surgical difficulty in gynaecological laparoscopy

Over the past three decades, rates of overweight and obesity internationally have risen to epidemic proportions. There are currently no published prospective studies examining the effect of obesity on gynaecologic laparoscopy for benign indications within a population with obesity rates comparable to Australian women.

Clinical approach to vulvovaginal cysts and abscesses, a review

Vulvovaginal cysts are a common problem for women, causing significant pain, discomfort and impact on quality of life. For clinicians, classifying and differentiating these cysts from each other and selecting appropriate management can be challenging, yet there is no integrated classification system and little literature that broadly summarises a clinical approach. We aimed to create a useful tool for clinicians by providing a detailed summary of various vulvovaginal cysts and abscesses with a clear novel classification system and hierarchy for diagnosis and management, to aid clinicians in this process.

Pain mapping, awake laparoscopy and chronic pelvic pain

Chronic pelvic pain is a difficult clinical problem responsible for one in 10 outpatient gynaecological referrals. Laparoscopy remains the gold standard as a diagnostic tool for this problem, as previously reported. Treatable pathology occurs in 83% of patients and in only 29% of controls. A clinical challenge occurs when there is no identifiable pathology, or if the pain is not ameliorated by some form of treatment. Microlaparoscopy and pain mapping are tools that might provide the solution for selected patients in this situation. The use of small calibre instruments (<5 mm) combined with local anaesthetic allows the technique of conscious pain mapping to be carried out. This was first described by Palter and Olive in 1996 and involves a systematic inspection and palpation of the pelvis including the uterine fundus, bladder peritoneum, Pouch of Douglas, ovaries, tubes, round ligaments, pelvic side walls, and small and large bowel. Although this procedure requires a high degree of patient cooperation, it should be considered in patients in whom no cause of pain can be detected.