Philip W. Reginald

Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion.

Objective— To determine whether bilateral oophorectomy combined with hysterectomy is an effective treatment for chronic pelvic pain due to congestion. Design—Prospective non‐randomized single centre study.

Outpatient pipelle endometrial biopsy in the investigation of postmenopausal bleeding

Dilatation of the cervix and curettage of the endometrial cavity is commonly undertaken in women with postmenopausal bleeding to exclude endometrial carcinoma. Outpatient endometrial sampling using the pipelle endometrial biopsy device provides adequate tissue for histopathological diagnosis (Stovall 1991) and the procedure is acceptable to patients (Eddowes 1990). The purpose of this prospective trial was to compare the reliability of the pipelle endometrial biopsy device with dilatation and curettage in women with postmenopausal bleeding.

Persistent unilocular ovarian cysts in a general population of postmenopausal women: is there a place for expectant management?

OBJECTIVE At present it is not well known whether some persistent unilocular ovarian cysts can develop into malignancy. The aim of this observational study was to define the management of postmenopausal women with persistent unilocular ovarian cysts less than 50 mm in diameter and with normal serum CA 125 levels. METHODS Retrospective data were obtained from 226 post-menopausal women (mean age 56.2 years, range 45–87) with unilocular ovarian cysts who were followed up for a 5-year period. Women were referred because of postmenopausal symptoms, abdominal discomfort, and postmenopausal bleeding. All women underwent pelvic examination, transvaginal ultrasonography, and serum CA 125 measurement. Tumor-associated antigen CA 125 and ovarian cyst diameter were assessed routinely. Surgery was offered according to clinical indications and womens wishes. RESULTS Ovarian cyst diameter and serum CA 125 levels did not change in 172 of 226 women (76.1%). Conversely, the remaining 54 women had an increase in cyst diameter, and six of those (11.1%) also had raised serum CA 125 levels. All women with suspicious ovarian pathology (n = 54) and 84 without ovarian pathology underwent surgical management. International Federation of Gynecology and Obstetrics stage IB well-differentiated serous cystoadenocarcinomas were diagnosed in two of 54 women (3.7%). Serum CA 125 levels were elevated in both cases. CONCLUSION These findings suggest that the majority of unilocular ovarian cysts with diameter less than 50 mm are benign and remain unchanged. These lesions can be managed expectantly when there is no increase in the ovarian cyst diameter and the serum CA 125 concentration is normal.

Recurrent uterine inversion: a novel treatment approach using SOS Bakri balloon

A 29-year-old primigravida presented in spontaneous labour, at 37 + 6 weeks gestation. She had an uneventful antenatal course, with a normal anomaly scan at 20 weeks, which showed a fundal placenta. Her labour progressed quickly and advanced to the second stage just three and a half hours after the onset of the active phase. Twenty minutes later, a combination of ineffectual pushing and the development of atypical variable decelerations prompted the decision for an operative vaginal delivery. A healthy male baby weighing 3 kg was delivered by NevilleBarnes forceps, after the administration of a pudendal block. Syntometrine (Alliance, Chippenham, UK) was given intramuscularly and the placenta was delivered by controlled cord traction, 10 minutes after delivery of the baby. A brisk postpartum haemorrhage followed. The emergency bell was pulled immediately and senior labour ward staff arrived to provide assistance. Facial mask oxygen was given and two large bore intravenous cannula’s were inserted. Her blood pressure was 144/86, but she had a tachycardia of 138 bpm. Intravenous colloid was commenced, bloods were taken and four units of blood were cross matched. An indwelling urinary catheter was inserted and the postpartum haemorrhage managed with the administration of forty units of Syntocinon (Alliance) in 500 ml of saline, 500 mcg of ergometrine maleate and the administration of 800 mcg of rectal misoprostol. While attempting to perform bimanual compression of the uterus, an unexpected finding of second degree uterine inversion was diagnosed. The leading edge of the uterus was felt two inches above the hymenal ring. An attempt was made to replace the inversion as soon as it was diagnosed, but this was not possible because of inadequate analgesia. The patient was transferred to theatre and a spinal anaesthetic was performed rapidly. As soon as this was effective, an attempt to reposition the uterine inversion was made. About 1500 ml of saline was run through a silastic ventouse cup, to effect replacement of the inverted uterus. This manoeuvre was partially successful; however, full reduction was finally achieved by manual replacement. Thereafter, the episiotomy repair was completed and she was thoroughly examined to ensure that no other injuries were sustained. At that point, the estimated blood loss was about 2000 ml. The obstetric consultant confirmed the successful replacement of the uterus, which was now well contracted and the fundus was easily palpable at the level of the umbilicus. Intravenous antibiotics were commenced and the patient transferred to the high dependency unit on labour ward for close observation. The syntocinon infusion continued and she was given three units of blood postoperatively. The patient’s abdomen was soft, non tender and undistended. The uterus was well contracted and the lochia was moderate. However, 2 hours later, the patient became haemodynamically unstable, with a blood pressure of 79/50 mmHg and pulse of 124 bpm. The uterine fundus was found to be lowered. This prompted a vaginal examination, at which time more than a litre of blood and clots were removed from the upper vagina. Examination confirmed that the uterus had re-inverted with the uterine fundus felt within the uterine cavity. The cavity could not be completely explored because of significant discomfort and as manual reduction was not possible, a laparotomy was performed under general anaesthesia. The uterine inversion was confirmed. The fundus had inverted with both cornuae drawn adjacent to each other. There was no bleeding into the abdomen and no evidence of uterine perforation. The uterine fundus was then replaced bimanually under direct vision in a controlled manner. The uterus was hypotonic and two ampoules of

Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

Objective  To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP).

Benign pulmonary metastasizing leiomyomatosis in pregnancy: a rare complication after cesarean section

Benign metastasizing leiomyoma (BML) was first reported by Steiner in 1939 (1) as a rare tumor of benign histologic appearance, well-differentiated smooth muscle cells and dense connective tissue in the lung. Association with typical uterine leiomyomas has clearly been shown (2,3). Very recently, it has been confirmed that BML correlates positively with a history of previous hysterectomy for uterine leiomyoma (4). Because both benign uterine and pulmonary tumors have been found to depend on the estrogen and progesterone status, their growth is mainly retained to be hormone dependent (5). Therefore, hormone-level changes such as pregnancy and menopause might have important effects on the general course of the disease. We report a case of BML in a woman with a history of multiple uterine fibroids whose pregnancy was complicated by recurrent chest infections, pre-eclampsia and intrauterine growth retardation (IUGR).

Epithelioid cotyledonoid dissecting leiomyoma: a case report and review of the literature

A 63-year-old mother of two, presented with blood-stained vaginal discharge and right sided lower abdominal pain. A MRI examination confirmed a right parametrial mass, abutting the lateral margin of the uterus and the patient had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histological examination diagnosed a cotyledonoid leiomyoma, but with a new epithelioid variant. Cotyledonoid leiomyom’s usually have a large, fungating appearance and demonstrate apparent widespread infiltrative growth and extension into the pelvic cavity, broad ligament and retroperitoneal space which may raise significant concern about the possibility of a malignant neoplasm. As these tumours are rare and infrequently encountered, it is imperative that clinicians be aware of this entity as they may pose a significant diagnostic and management challenge when encountered. Awareness of this newly described epithelioid cell variant of cotyledonoid dissecting leiomyoma is necessary for an accurate diagnosis and to facilitate appropriate management decisions at the time of surgery. This new variant further emphasizes the need for meticulous histopathological assessment which should be undertaken to circumvent misdiagnosis. This has direct clinical relevance to all operating gynaecologists and may have implications for litigation because patients may be inappropriately and inadvertently over-treated for an essentially benign condition.

Medical management of chronic pelvic pain: the evidence

Abstract Chronic pelvic pain (CPP) forms a significant number of referrals both in primary care and to gynaecology clinics. Much has been written and reported on the subject, however, it remains a poorly understood and managed condition. CPP is defined as recurrent or constant pain in the lower abdominal region that has lasted at least 6 months. A specialist in the field encompassed within a multidisciplinary setting should ideally manage CPP. The causes of CPP can be not only of a gynaecological nature, but also span other branches of medicine including urology, gastroenterology, rheumatology, genitourinary medicine and psychiatry. Investigations are often unrewarding in eliciting a cause for particular symptomatology, which highlights the difficulty in treating these patients. Most studies have been directed towards the major gynaecological causes of CPP including pelvic venous congestion, endometriosis, and pelvic inflammatory disease (PID). However, these have been limited and evaluated treatments are confined to small sample sizes. This review aims to provide evidence-based medical management of the main causes of CPP.

Splenic rupture in utero following a road traffic accident. Case report

The patient, a 27-year-old married nurse, gravida 3, para 1, arrived in the accident and emergency department in the 36th week of pregnancy, having been involved in a road traffic accident 30 min earlier. She was the driver of a car that had run into the back of another, at about 35 mph. She was not wearing a seat-belt and was flung forward onto the steering wheel, taking most of the impact on her abdomen. She was complaining of upper abdominal discomfort but was otherwise well. She had felt fetal movement since the accident. Maternal observations were satisfactory, blood pressure 145/85 mmHg and pulse rate 90 beatdmin. The fetal heart rate was ausculated at 120 bcatdmin. The maternal abdomen was soft, and the uterus neither tender nor irritable. There was no evidence of any other maternal injury. She was transferred to the labour ward for cardiotography (CTG) and further reassurance. The initial CTG recording showed a reactive fetal heart with a baseline rate of 160 bcatdmin. The maternal pulse was 110 beatdmin at the time. An ultrasound scan showed a single, living fetus, presenting by the vertex. There was no obvious retro-placental hacmatoma. Because the patient continued to have abdominal discomfort and had palpable uterine contractions, she was kept on the labour ward for further observation. A clotting screen was normal. Ninety minutes after admission, a deceleration

A simplified method of laparoscopic presacral neurectomy for the treatment of central pelvic pain due to endometriosis

Sir, We were interested to read the recent paper by Nezhat & Nezhat (1992) concerning the use of laparoscopic presacral neurectomy. Undoubtedly these authors havc demonstrated that this procedure can bc performcd safely through the laparoscope. We do not however believe that their paper justifies the addition of this operation to the laparoscopist’s repertoire. Before doing so, the operation needs to be shown not just to be acceptably safe, but to be effective. In their study, only 52 of 85 women were followed up for 12 months or more. Assessment of improvement in pain and dysmenorrhoea were by ‘office visits, telephone interviews and a questionnaire’ only, with no apparent formalised assessment with structured qucstionnaire, visual analogue scoring or other objective means. There were no controls. All subjects had endometriosis, which was treated by laser excision and vaporisationthis alone might have been expected to account for some subjective or objective improvement of symptoms. Vercellini et al. (1991) have recently pointed out that there is no study to demonstrate that presacral neurectomy is effective, either alone or in addition to other forms of treatment in the treatment of pelvic pain due to endometriosis. Until a properly conducted controlled study with appropriate follow up and objective assessment of pain, demonstrates that presacral neurectomy, by whatever route, is an effective form of treatment, we believe there is no justification for its wider use. Malcolm GrBths Dept of Obstetrics & Gynaecology Royal Berkshire Hospital Reading RGl SAN Philip W. Reginald Dept of Obstetrics & Gynaecology Wexham Park Hospital Slough SL2 4HL