Phillip Smith

A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage

Objective To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding.

Use of C‐reactive protein as a predictor of chorioamnionitis in preterm prelabour rupture of membranes: a systematic review

Background  Studies examining the use of C‐reactive protein (CRP) as a predictor of chorioamnionitis in preterm prelabour rupture of membranes (PPROM) report highly conflicting results. Despite this, CRP is commonly used for the early diagnosis of chorioamnionitis.

The effectiveness and complications of graft materials used in vaginal prolapse surgery.

Purpose of review In the last decade, there has been an increase in the use of graft materials in vaginal prolapse surgery. Most of the evidence available is based on case studies produced by the manufacturers, with few randomized controlled trials. In October 2008, the United States Food and Drug Administration issued a safety warning on the use of grafts in vaginal surgery. It has been suggested that there is a greater need to review the evidence on the effectiveness and complication of grafts. Recent findings This article explores the recent literature on the use of grafts in vaginal prolapse surgery. The use of grafts versus standard techniques for vaginal wall repair is examined, looking at subjective and objective cure as well as complications. Summary Despite the wide use of grafts in vaginal prolapse surgery, there is still a need for level 1 evidence to support their use, with long-term follow-up of 3 or 5 years. There is, however, good evidence to support the use of grafts in suburethral slings and abdominal sacrocolpopexy.

Diagnosis of liver infarction postpartum.

BACKGROUND: Patients with antiphospholipid syndrome (APS) have increased risks of developing thromboembolism, and the risk maybe amplified by the hypercoagulable state associated with pregnancy. CASE: A patient presented with severe chest pain, mild pyrexia associated with elevated serum transaminases, and marked neutrophilia after vaginal delivery. Liver infarction was diagnosed by spiral computer tomography and treated successfully with anticoagulation. CONCLUSION: Liver infarction is a possible diagnosis in a patient with antiphospholipid syndrome who presents with chest or abdominal pain in the postpartum period.

To pull or not to pull, that is the question-how should we define prolapse?

Eleven per cent of women will at some stage in their lives undergo an operation for uterovaginal prolapse or incontinence [1, 2]. With an ageing population, and the desire for women to remain active and free from symptoms of prolapse, it is probable that the demand for urogynaecological surgery will increase. Over the last decade, debate has occurred about the best surgical treatment for uterovaginal prolapse, comparing alternative operations. In this debate, there is an assumption that data collected in one unit, concerning the degree of prolapse present in the women undergoing surgery, are comparable to the data acquired in another unit. What has perhaps not been discussed enough is the standardised examination of the support to the vagina, cervix, and uterus, and an agreement reached as to what constitutes symptomatic prolapse. Recent editorials have been written about how to best define pelvic organ prolapse based on symptoms, and identifying a Pelvic Organ Prolapse Quantification (POPQ) examination point beyond which subjects can be said to have symptomatic prolapse. Except for recommending the POPQ system, there has been very little mention about how to standardise the examination of the patient, and thus arrive at the POPQ values [3–5]. A good scientific test yields reproducible results under standardised conditions that can be repeated by different investigators. Without agreement as to a standardised method of examination, and documentation, the comparison of alternative surgical techniques for treatment cannot be compared between studies at different institutions. In addition, definitions of what is normal and abnormal should be based on scientific data rather than opinion. Since the stages of the POPQ system were based on committee opinion, we must accept the fact that these definitions of prolapse, based on the measurements made, are not evidence-based. As an example, the POPQ grading scheme labels as “grade 1 prolapse” women whose support is clearly within normal limits. There is a great variation in the practice of urogynaecological examination throughout the world, and within each separate country. Although it is generally accepted that prolapse is more symptomatic when the patient is standing, in many countries it has been conventional to examine patients in the left lateral position, using a Sims speculum with the patient “straining down”. This often leads to an underestimation of the true nature and degree of uterovaginal descent, especially as patients with pelvic muscle weakness may limit straining in an effort to maintain continence, both of urine and flatus, to avoid embarrassment. Examination with the patient standing and straining down, or in a gynaecological examination chair, has been shown to more accurately display the true extent of prolapse [6, 7]. In some centres it is normal practice to attempt to demonstrate maximal uterovaginal descent by applying traction to the cervix and vaginal walls, either under anaesthesia in theatre prior to surgery, or even in outpatients/ the office [8]. This practice deserves careful consideration. Two recent publications have looked at the results of POPQ examination pre-operatively and intra-operatively, with the use of traction [9, 10]. In both studies, applying traction to the cervix or vaginal apex intra-operatively resulted in much greater descent then could be documented during the pre-operative office POPQ examination. In one study all the cervices could be brought to within 1 cm of the P. Smith (*) Department of Urogynaecology, Southmead Hospital, Bristol BS10 5NB, UK e-mail: pasmithgyn@blueyonder.co.uk

Does pre-operative traction on the cervix approximate intra-operative uterine prolapse? Comment.

Dear Editor, We read with interest the paper by Chao et al. [1], which demonstrates that the cervix (and uterus) can be pulled down almost to the same degree in the outpatient setting as under anaesthesia. The question is: What does this tell us? We suggest that it only tells us whether a vaginal hysterectomy (VH) would be possible, and indeed how easy that procedure might be. It does not tell us whether it should be performed, or whether it will improve the patient’s subsequent symptoms of prolapse. We have recently shown in our study [2] that cervical traction in theatre in women with anterior wall prolapse will pull all uteri down to POPQ stage II. None of these patients had significant uterine descent pre-operatively. In contrast to Chao et al., we did standardise the traction force by using the mid-quartile mean force of 10 gynaecologists pulling to the degree they would usually apply in theatre, via a spring strain gauge. Using this force (3.6 kg) [2], the uteri of the 35 patients in our study could all be pulled down to within 1 cm of the hymenal ring, yet 34 of these had returned to the preoperative level at follow-up. It is interesting that a traction force of as little as 0.5 kg had already been shown to result in significant uterine descent intraoperatively [3]. We are now completing medium-term follow-up of our patients, and will report soon. In the study by Chao et al., the significant difference between the pre-operative and intra-operative point C measurement in the non-traction group may suggest that many of these women would have undergone VH unnecessarily if the decision had been made in theatre. The smaller but still significant difference between point C measurement in the traction group, preand intraoperatively, suggests that the cervix can be “always brought down” if enough traction is used, whether in theatre or in the outpatient setting. Although Chao et al. show that cervical traction in clinic might be tolerated by and acceptable to women, we believe that it may still lead to over-diagnosis of uterine descent, and subsequent unnecessary VH. Our practice for all patients with prolapse is to perform a POPQ assessment in the clinic, in the standing position with maximum Valsalva, to “naturally” reproduce the maximum degree of uterovaginal descent, while A reply to this comment is available at doi 10.1007/s00192-0121956-z

Urethral and bladder injuries after mid-urethral sling procedures – do we always need to cystoscope?

Sir, I was interested to read the communication from Morton and Hilton describing their tertiary referral experience of urethral injuries following the insertion of various midurethral tapes. The occurrence of urinary tract injury with tension-free vaginal tape (TVT), led in part to the development of the obturator tapes (i.e. TOT), with a suggestion that routine cystourethroscopy was not required with TOT in uncomplicated procedures. Meta-analyses of studies comparing TVT with TOT (in its various forms) have subsequently suggested a reduced urinary tract perforation rate with the TOTs, and in many parts of the UK, a TOT is now the first line surgical treatment of stress urinary incontinence, in place of TVT, with this as the suggested justification. In my personal series of TVTs, the bladder perforation rate has been 0.3% (2 in 650), mainly due, I believe, to routine transvaginal, retropubic hydrodisection with 100 ml of 0.5% prilocaine solution. With care, the perforation rate can be very much less than the IQR of 3–7%. We should therefore be reluctant to change from conventional retropubic TVT to an obturator tape to reduce what can be a tiny incidence of bladder perforation, in view of the longer efficacy data available for TVT. (5-year follow up from comparative controlled trials and now 11 years in the Scandinavian cohort study). I do insert TOTs in randomised controlled trials, and in patients with previous retropubic surgery with scarring. Despite my low bladder perforation rate, however, I will continue to recommend routine cystoscopy during TVT or TOT placement, to avoid the serious consequences of any missed bladder or urethral perforation. Because of the small risk of urethral trauma with TOTs, it may also be sensible to urethroscope with a 0 scope for the urethra, and a conventional 70 scope for the bladder. Primum non nocere. j References

Authors response to: Use of C‐reactive protein as a predictor of chorioamnionitis in preterm prelabour rupture of the membranes: a systematic review

Sir, We thank Dr van der Ham et al.1 for their interest in our review. We agree that the definition of chorioamnionitis is difficult as there is no consensus as to whether clinical or histological evidence should be used. In women with preterm prelabour rupture of membranes (PPROM), once clinical signs of chorioamnionitis appear, which tend to be late, most clinicians would be inclined to deliver. The decision is more difficult when infection is suspected but there are no clear clinical signs. An early warning test of impending infection would be useful, and C-reactive protein (CRP) is being used in many centres in this role. Whether it is useful is the question we wanted to answer with this review and hence the decision to opt for histological chorioamnionitis as the reference standard. The study of Ismail et al.was not included because it was not possible to extract or obtain raw data, and the study of Berardi et al.was rejected because it did not use histological chorioamnionitis as the reference test. The studies of Kurki et al. and Sereepapong et al., aswell as all the other studies included in the review, fulfilled the required methodological quality criteria. In contrast, their discussion about the possibility of a metaanalysis seems to support the inappropriateness of having pooled data in the review. They suggested that the ideal test should be highly sensitive for women with PPROM at or near term and highly specific for earlier gestations. We certainly agree with that. However, in practice, that is not the case, and to our knowledge, no study has shown variation of CRP performance with gestational age. Therefore, an ideal test should aim for both high sensitivity and specificity at any gestation. Finally, our review followed all the required standards for this type of study, except having more than one reviewer.We believe that there is currently insufficient evidence to recommend the use of CRP to guide management in women with PPROM. j

Transvaginal ultrasound in the management of women with suspected cervical incompetence

Sir, The paper by Fox et al. on transvaginal ultrasound and suspected cervical incompetence (Vol 103, September 1996)’ is helpful in contributing further information to the growing use of transvaginal ultrasound (TVS) in pregnancies at high risk of preterm delivery2, but there were points we felt worthy of comment. The causes behind the appearance of beaking of the internal 0s or a short cervix are not known, and neither has this sign been proven to be the ultrasonographic appearance of ‘cervical incompetence’. Indeed, the natural progression of these cervical appearances without intervention has been assumed rather than demonstrated. The suggestion from Quinn3 of over-diagnosis of cervical incompetence by a factor of ten is still valid, as the criteria used in this study for the label ‘cervical incompetence’ are presently unsubstantiated. Progression from an altered cervical appearance on TVS to an early delivery or some accepted demonstration of cervical incompetence, such as visible membranes on speculum examination, would provide more objective support for the hypothesis. Such an observational study is at present underway in our department. The criteria for repeat sutures are not clearly defined; the phrase, “further evidence of effacement” is used, and would merit explanation. If the indication for a repeat suture was simply widening of the internal 0s rather than herniation of amniotic membranes past the original suture (i.e. a suture failure) then we feel this could be overtreatment. A study by Quinn3 has suggested that with ‘true’ cervical incompetence the internal 0s remains open even after suturing as it is impossible to reach the internal 0s with standard (vaginal) cerclage, and our unpublished observations support this view. An internal 0s which is completely closed after cerclage (especially after the use of fundal pressure) may imply a cervix which did not require a suture. We feel the purpose of a cervical suture is to prevent any further cervical shortening and dilatation, rather than achieving closure of the internal 0s. One of the major advantages of ultrasound over digital examinations is the possibility for objective measurements; an advantage which was not fully exploited. Descriptions of ‘moderate’ or ‘severe’ cervical changes require more definition and objective measurements would have been helpful. Analysis of the outcomes in this study is difficult, both due to a large number of secondary interventions (antibiotics, bed rest and tocolytics) and also as there was no division between those who received cerclage and those in whom it was not felt necessary. From the authors own criteria, these women (12 and 7, respectively) were in two different risk categories due to their cervical appearances on TVS, but there was no separation of these results. This could have assisted the analysis. Transvaginal ultrasonography is a promising technique for the diagnosis and management of potential cervical incompetence. The evolution of abnormal cervical appearances has not been fully evaluated, and this is vital prior to the randomised trial suggested in this paper.