Hooman Soleymani majd

Successful use of uterine artery embolisation to treat placenta increta in the first trimester

A 39-year-old Asian woman was admitted to hospital with persistent, heavy vaginal bleeding following an uncomplicated first trimester surgical termination of pregnancy (STOP). Her heavy bleeding continued after the STOP and she had recurrent hospital admissions which included two procedures to evacuate presumed retained products of conception. She eventually had a MRI scan performed which suggested placental tissue in the fundal region, extended into the uterine wall. The findings were consistent with placenta increta and the patient had a bilateral uterine artery embolisation (UAE), following which her symptoms rapidly subsided. We describe the first successfully managed case of persistent vaginal bleeding secondary to abnormal placentation. It would seem to substantiate the efficacy of UAE as a therapeutic modality for the conservative management of invasive placentation in the first trimester of pregnancy.

Pyometra presenting in conjunction with bowel cancer in a post-menopausal women: a case report

This case describes a 71 year old, post-menopausal woman who developed vaginal discharge. This complaint ultimately led to the discovery of bowel cancer in conjunction with a large sterile pyometra.The pyometra was not due to genital malignancy. The most likely conclusion is that the pyometra may have arisen as an inflammatory response to the adjacent bowel pathology. This case report highlights the need for clinicians to consider non-gynaecological cancer as a possible cause for otherwise unexplained pyometra.

Migration of levonorgestrel IUS in a patient with complex medical problems: what should be done?

Patients with complex medical problems should be counselled about the need for highly effective contraception. As failure resulting in pregnancy, could cause significant morbidity and mortality. The LNG–IUS has gained great popularity and generally has a low side effect profile; however, perforation of the uterus and migration of the device is a potentially serious complication known to be associated with its use. The current accepted management is removal of the device from the abdominal cavity in order to prevent further morbidity. However this is not always a simple matter in patients who have complex medical problems and who are deemed unfit for surgery. Each time the patient comes for renewal of the contraceptive method, clinicians need to reassess the risks and benefits. This is particularly relevant in patients who have complex medical problems where special attention needs to be given, not only to immediate risks but also to long-term ones. Careful individualised counselling and consideration are paramount and perhaps it would have been prudent to discuss vasectomy with this patient and her husband (as the first line of contraception), as this may have avoided the ensuing complications arising from the chosen method.

Factors Impacting the Success of Outpatient Hysteroscopy in the Rapid Access Clinic

Objective: Outpatient hysteroscopy (OPH) is increasingly used as the first line investigation for perimenopausal and postmenopausal women with abnormal uterine bleeding. With high success and good pathology detection rates it has the advantage of allowing investigation and management of patients within a one-stop clinic set-up, resulting in high patient acceptability. Failure rates are low, however the main limitation is patient intolerance secondary to pain. Difficulties are thought to be for encountered in nulliparous or postmenopausal women though the evidence is sparse. The aim of this study was to assess which patient factors have an impact on the success of OPH. Design: Prospective observational study Material and methods: The study was carried out from September 2012 to March 2013 in the outpatient hysteroscopy clinic at John Radcliffe Hospital, Oxford. All 96 patients in this series had their OPH performed by the same operator, using only a complete vaginoscopic approach. We used binary logistic regression to analyse which factors had an effect. Results: No significant correlation was found between age and menopausal status. Our study suggested that parity by itself is not predictive but it did find a statistically significant link between previous mode vaginal mode of delivery and successful OPH (p-value=0.001). Conclusions: This paper enhances our understanding of relevant patient factors, which will be useful in facilitating more patient specific counselling. It should also ideally encourage further studies into strategies to improve the success rate of this invaluable diagnostic and therapeutic modality.

A postmenopausal women presenting with atypical symptoms and cervical cancer: a case report

BackgroundGlobally cervical cancer kills millions of women every year. There is a wealth of evidence suggesting that cervical screening is one of the best defences against the development of cervical cancer. Lives could be saved if medical practitioners make a point of routinely enquiring about the date and result of the patients last cervical smear test and if they repeatedly emphasize the importance of attendance for cervical smear tests, especially in post-menopausal women.Case presentationA 66 year old caucasian woman presented with symptoms of a lower respiratory tract infection, weight loss, anorexia and night sweats. There was no history of post menopausal bleeding. She was admitted for intravenous antibiotics. A few days later she developed vomiting, abdominal pain and a brown vaginal discharge.She then had a CT scan which showed a pyometra extending to the umbilicus, with an intrauterine contraceptive device noted inside. After re-taking the history, it emerged that a Lippes loop was inserted 25 years previously. The patient was not given relevant information at the time and then unfortunately was lost to follow up.The pyometra was drained and the coil removed. However, at operation cervical cancer was suspected and biopsies taken. The patients sepsis improved after pyometra drainage but histology subsequently confirmed stage 1B squamous cell cervical carcinoma. She was referred for a radical hysterectomy.ConclusionEvery consultation is an opportunity for health education and promotion. Patients need to be encouraged to utilize cervical screening programmes. It is also important to remember that cervical cancer can present with non-specific symptoms, thus the onus is on all doctors to take a good history and perform a thorough examination. Failing to do so may delay making the right diagnosis, with associated morbidity and mortality.

Comparison of survival outcome of patients with primary peritoneal and fallopian tube carcinoma treated with neoadjuvant chemotherapy versus primary debulking surgery.

Abstract This study examines the overall survival of primary peritoneal cancer (PPC), in those patients who had primary debulking surgery (PDS) followed by six cycles of chemotherapy versus those who had neoadjuvant chemotherapy (NACT). This was a prospective observational study performed at Oxford Gynaecological Cancer Centre, over a 5-year period. Eighty-seven patients were clinically suspected of having PPC. Histology confirmed that 64 of these were PPC, with the balance being tubal in origin. PDS was performed in 31 cases. Although NACT was planned in 56 patients, 4 patients didn’t receive NACT and therefore excluded from the survival analysis. The overall median survival was 34 months. However, the 5-year survival was 12%. Survival in the PDS group was 46 months versus 24 months in the NACT (p = .011). The conclusion drawn from this study is that patients affected by PPC, selected for PDS have a greater survival advantage than those who had NACT.

Endoscopy in Gynecologic Oncology

Endoscopic surgery offers the advantages of quicker recovery, shorter hospital stay and a lower risk of complications such as infections, blood loss, wound infection, ileus and incisional hernias. The feasibility of endoscopy in gynecological cancer has been shown in numerous papers demonstrating equivalence in terms of radicality. Evidence for oncological outcome in terms of survival has been slower to arrive, but there is significant evidence being reported now in all three of the major gynecological cancers.

Differentiating pelvic actinomycosis from advanced ovarian cancer: a report of two cases, management reflections and literature review

Pelvic actinomycosis comprises a rare, subacute to chronic bacterial infection characterised by suppurative and granulomatous inflammation. Diagnosis is difficult as it may simulate pelvic malignancies. Laboratory and radiological findings are non-specific. We reported on 2 cases of pelvic actinomycosis mimicking ovarian malignancy with different management approaches that lead to opposite outcomes. We reviewed the literature on pelvic actinomycosis imitating ovarian cancer with a focus on its surgical management. Despite agreement on the duration of antibiotic therapy following surgical management, consensus regarding surgical approach was rather equivocal. We concluded that pelvic actinomycosis should be strongly suspected in women with presumed ovarian cancer of atypical presentation and a history of intrauterine devices (IUD).

Misleading menorrhagia in a peri-menopausal woman with underlying bowel cancer: a case report

A peri-menopausal woman presented with symptoms and signs suggestive of fibroids. She was fit and healthy with no significant past medical history. She consented to having a hysterectomy but her surgery was performed prior to any diagnostic imaging being done.At surgery there was an unexpected finding of disseminated carcinoma, diffusely infiltrating the uterus, fallopian tubes and ovaries. There was an omental cake that was biopsied. Frozen section showed signet ring cells, suggesting bowel carcinoma. Further intra-operative examination revealed a caecal tumour. After surgery she was investigated further and eventually referred for palliation, due to her advanced disease.