Obstetrics and Gynaecology

Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study (2019)

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Type of publication:
Journal article

Author(s):
Al Wattar, Bassel H; Lakhiani, Aarti; Sacco, Adalina; Siddharth, Aditi; Bain, Alexandra; Calvia, Alexandra; Kamran, Atiyah; Tiong, Bing; Warwick, Bethan; MacMahon, Caroline; Marcus, Diana; Long, Emma; Coyle, Gillian; Lever, Gillian Elizabeth; Michel, Gina; Gopal, Gomathy; Baig, Hana; Price, Hannah Louise; Badri, Hawra; Stevenson, Helen; Hoyte, Helene; Malik, Humaira; Edwards, Jade; Hartley, Jennifer; Hemers, Jennifer; Tamblyn, Jennifer; Dalton, John Alexander William; Frost, Jonathan; Subba, Kamana; Baxter, Kathryn; Sivakumar, Kavitha; Murphy, Kelly; Papadakis, Konstantinos; Bladon, Laura Rachel; Kasaven, Lorraine; Manning, Louisa; Prior, Mathew; Ghosh, Mausumi; Couch, Melanie; Altunel, Melis; Pearce, Melissa; Cocker, Michael; Stephanou, Michael; Jie, Michelle; Mistry, Minesh; Wahby, Mohammed Osama; Saidi, Nabila Shahid; Ramshaw, Nicola Louise; Tempest, Nicola; Parker, Nina; Tan, Phoebe L; Johnson, Racheal Louise; Harris, Rachel; Tildesley, Rachel; Ram, Ramya; Painuly, Ritu; Cuffolo, Romana; Bugeja, Roberta; Ngadze, Rose; Grainger, Rosie; Gurung, Sabitra; Mak, Sammy; Farrell, Sara; Cowey, Sarah; Neary, Sarah; Quinn, Sarah; Nijjar, Simrit Kaur; Kenyon, Sophie; Lamb, Stephanie; Tracey, Susan; Lee, Tara; Kinsella, Therese; Davidson, Trecia; Corr, Trent; Sampson, Uzo; McQueen, Victoria; *Parry-Smith, William; Castling, Zora; AB-FAB study group

Citation:
European Journal of Obstetrics, Gynecology, and Reproductive Biology; Sep 2019; vol. 240 ; p. 62-67

Abstract:
OBJECTIVE To evaluate the value of fetal scalp blood sampling (FBS) as an adjunct test to cardiotocography, to predict adverse neonatal outcomes. STUDY DESIGN A multicentre service evaluation observational study in forty-four maternity units in the UK. We collected data retrospectively on pregnant women with singleton pregnancy who received FBS in labour using a standardised data collection tool. The primary outcome was prediction of neonatal acidaemia diagnosed as umbilical cord arterial pH < 7.05, the secondary outcomes were the prediction of Apgar scores<7 at 1st and 5th minutes and admission to the neonatal intensive care unit (NICU). We evaluated the correlation between the last FBS blood gas before birth and the umbilical cord blood and adjusted for time intervals. We constructed 2 × 2 tables to calculate the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and generated receiver operating curves to report on the Area Under the Curve (AUC). RESULTS In total, 1422 samples were included in the analysis; pH values showed no correlation (r = 0.001, p = 0.9) in samples obtained within an hour (n = 314), or within half an hour from birth (n = 115) (r=-0.003, p = 0.9). A suboptimal FBS pH value (<7.25) had a poor sensitivity (22%) and PPV (4.9%) to predict neonatal acidaemia with high specificity (87.3%) and NPV (97.4%). Similar performance was noted to predict Apgar scores <7 at 1st (sensitivity 14.5%, specificity 87.5%, PPV 23.4%, NPV 79.6%) and 5th minute (sensitivity 20.3%, specificity 87.4%, PPV 7.6%, NPV 95.6%), and admission to NICU (sensitivity 20.3%, specificity 87.5%, PPV 13.3%, NPV 92.1%). The AUC for FBS pH to predict neonatal acidaemia was 0.59 (95%CI 0.59-0.68, p = 0.3) with similar performance to predict Apgar scores<7 at 1st minute (AUC 0.55, 95%CI 0.51-0.59, p = 0.004), 5th minute (AUC 0.55, 95%CI 0.48-0.62, p = 0.13), and admission to NICU (AUC 0.58, 95%CI 0.52-0.64, p = 0.002). Forty-one neonates had acidaemia (2.8%, 41/1422) at birth. There was no significant correlation in pH values between the FBS and the umbilical cord blood in this subgroup adjusted for sampling time intervals (r = 0.03, p = 0.83). CONCLUSIONS As an adjunct tool to cardiotocography, FBS offered limited value to predict neonatal acidaemia, low Apgar Scores and admission to NICU.

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Perivascular epitheloid cell tumor and mesonephric adenocarcinoma of the uterine cervix: an unknown co-existence (2019)

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Type of publication:
Journal article

Author(s):
*Dimitrios Papoutsis, *Banchhita Sahu, *Joanna Kelly, Angeliki Antonakou

Citation:
Oxford Medical Case Reports, Volume 2019, Issue 1, January 2019

Abstract:
A 67-year-old woman with post-menopausal bleeding and a suspicious endocervical mass was referred to gynaecology outpatients’ for diagnosis and management. Cervical punch biopsies taken showed a benign cervical perivascular epithelioid cell tumour (PEComa), with MRI imaging and PET-CT scan indicating a 3–4 cm endocervical tumour with malignant features. The patient underwent radical hysterectomy with lymph node dissection and the surgical specimen histopathology demonstrated a residual benign PEComa and a stage IIB mesonephric adenocarcinoma (MNA) of the cervix. There is no disease recurrence 12 months after surgery. Cervical PEComas are extremely rare tumours of mesenchymal origin deriving from the perivascular epithelioid cells with only 14 cases described so far. Cervical MNAs are rare tumours originating from the remnants of the mesonephric duct of Wolff with only 40 cases reported. Our case adds to the existing literature and highlights the challenges with regard to preoperative diagnosis, treatment and prognosis.

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Audit of 2-week wait referrals to the Gynecology Department in District General Hospital and investigating patient awareness of the reasons and importance behind the referral (2018)

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Type of publication:
Conference abstract

Author(s):
Wilkinson M.; *Sahu B

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology; Dec 2018; vol. 125 ; p. 48

Abstract:
Introduction Two-week wait referrals to gynecology services are at a premium with pressure on numbers. Referrals can be inappropriate. Patients are often unaware the appointment is for suspected cancer. Methods Two-week wait referrals were examined during a six month period. The gynecologist in clinic collected data. Patients were asked about their 2-week wait referral, gauging awareness around their referral. Clinical symptoms and signs were compared to those in referral. Appropriateness of the referral was assessed by symptoms fitting the 2-week wait criteria or clinical findings on referral not consistent with the presenting symptoms and findings in clinic. Results A total of 172 patients were referred under the 2-week wait criteria; mean age was 58 years, range (17-95). Referrals were from 50 separate primary care practices. Suspected cancer referrals were composed of 111 endometrial, 15 ovarian, 22 cervical, 15 vulva/vaginal and 9 of mixed pathology. There was awareness of referral for cancer in 90 cases (52%), awareness of "2-week wait" in 124 cases (72%) and aware that the appointment could be at either hospital within the trust in 96 cases (56%). The referral was considered appropriate for 2-week wait referral in 123 (72%) of cases. Conclusion The majority of patients were referred correctly. A wide range of pathologies was seen. A significant number could have been referred as routine referrals or advice requested. Patient awareness of it being a referral due to suspected cancer was poor with better appreciation of the urgency of referral.

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A survey of management of vulvar disorders in the primary health care setting in an urban area of England (2018)

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Type of publication:
Journal article

Author(s):
*Kandanearachchi P.; *Sahu B.; *Antonakou A.; *Papoutsis D.

Citation:
Archives of Hellenic Medicine; 2018; vol. 35 (no. 3); p. 405-411

Abstract:
OBJECTIVE To determine the frequency of consultation for vulvar diseases in the primary health care setting, and their investigation and management patterns, and to identify the training needs of general practitioners (GPs) in vulvar disease. METHOD A survey was conducted using a 13-item questionnaire handed out to GPs during their regional post-graduate seminars in the area of Shropshire in the West Midlands in England. RESULTS Of 120 questionnaires distributed, a total of 107 responses were received (response rate: 89.1%). Of the participants, 67.3% reported that they see more than 5 patients per month with vulvar symptoms, and 24.6% that they see more than 5 patients per month with recurrent vulvar symptoms. The predominant symptom was pruritus vulvae (77.5%), with 94.5% of practitioners considering lichen sclero-sus as the most likely diagnosis. For recurrent pruritus vulvae a gynecological referral was made in most cases (86%). In contrast, when there was vulvar pain, only few practitioners would refer the patient to a gynecologist (8.4%) or a dermatologist (17.3%). Only 41.1% of GPs had ever received any kind of training, with all (100%) agreeing that formal training in the diagnosis and management of vulvar diseases would benefit their care of their patients. CONCLUSIONS This survey showed that a substantial number of women consult their GP with vulvar symptoms. A variety of approaches were reported in the diagnosis and management of these cases. All the GPs agreed that there is a need for formal training in vulvar disease.

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The paediatrician and the management of common gynaecological conditions (2018)

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Type of publication:
Journal article

Author(s):
*Ritchie, Joanne K; Latthe, Pallavi; Jyothish, Deepthi; Blair, Joanne C

Citation:
Archives of disease in childhood; Jul 2018, 103(7), p. 703-706

Abstract:
Paediatric gynaecology is an emerging discipline. Since 2000, there has been an advanced training programme in paediatric gynaecology available for obstetric and gynaecology trainees; additionally, a set of clinical standards1 for the care of paediatric and adolescent patients has been developed by The British Society of Paediatric and Adolescent Gynaecology (BritSPAG). BritSPAG is a multidisciplinary group of professionals including gynaecologists, paediatricians, paediatric urologists and endocrinologists.Girls with gynaecological conditions are often seen in general paediatric services; it is important that those assessing them are confident in identifying patients who require more specialist care. Despite this, gynaecology does not appear in the Royal College of Paediatrics and Child Health curriculum. This article aims to increase the knowledge base and confidence of paediatricians in dealing with common paediatric and adolescent gynaecological conditions.

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Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study (2018)

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Type of publication:
Journal article

Author(s):
*Papoutsis, Dimitrios; *Underwood, Martyn ; *Parry-Smith, William; *Panikkar, Jane

Citation:
Archives of Gynecology and Obstetrics; Apr 2018; Vol.297(4):1015-1025

Abstract:
PURPOSE To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia. METHODS This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded. RESULTSWe identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p = 0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17 months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32 weeks and 34 weeks, respectively. CONCLUSION We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.

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The role of the myosure hysteroscopic tissue removal system in the office setting at detecting abnormal pathology in women with post-menopausal bleeding, who have had blind endometrial sampling reported as inadequate, inactive or benign endometrium (2017)

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Type of publication:
Conference abstract

Author(s):
*Underwood M. ; *Chadha R.; *Hudda A.; *Green J.; *Fry M.; *Barker V.

Citation:
Journal of Minimally Invasive Gynecology; 2017; vol. 24 (no. 7)

Abstract:
Study Objective: Identify any histological discrepancy between blind endometrial sampling (ES) reported as inadequate, inactive or benign endometrium and office based hysteroscopy with the MyoSure tissue removal system in women with post-menopausal bleeding (PMB). Design: retrospective review of cases from our PMB clinic. Setting:Women attending the PMB clinic who's ES is reported as benign, inactive or inadequate. MyoSure Lite or Classic devices were used for the removal of these lesions. Patients:Women with PMB having an endometrial polypectomy using the MyoSure tissue removal system. Intervention: The MyoSure Lite & Classic tissue removal systems were used to remove endometrial polyps in women with PMB who's ES was inactive, inadequate or benign. Histological comparison between the ES and MyoSure histology was made. Measurements and Main Results: 616 women underwent hysteroscopic evaluation for abnormal uterine 2017; 399 were post-menopausal of which 186 women (46.6%) had inactive endometrium, 82 women (20.6%) had inadequate, 109 (27.3%) had benign/polyp and 22 (5.5%) had simple hyperplasia or higher grade disease detected on the blind endometrial sampling prior to polypectomy. The MyoSure polypectomy of those women with "Proliferative/benign endometrium" demonstrated that 19.3% had higher grade disease (Simple, complex, complex with atypia or cancer) than the ES, for the "inactive group 10.8% had high grade disease and those with an inadequate ES 13.4% had higher grade disease. (Table presented) Endometrial thickness in the PMB group ranged from 1.5-45 mm with a mean of 10.6 mm. There were no reported complications in all 616 cases. Conclusion: This retrospective review of patients with inadequate, inactive or benign ES has demonstrated the significant benefit to patient of having the polyp removed simply without complication in the office setting using the MyoSure tissue removal system. Between 10.8-19.3% will have higher grade disease detected using the MyoSure device, which would have an impact on their medical management.

Does CIN2 Have the Same Aggressive Potential As CIN3? A Secondary Analysis of High-Grade Cytology Recurrence in Women Treated with Cold-Coagulation Cervical Treatment (2017)

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Type of publication:
Journal article

Author(s):
*Papoutsis D.; *Underwood M .; *Parry-Smith W.; *Panikkar J.

Citation:
Geburtshilfe und Frauenheilkunde; Mar 2017; vol. 77 (no. 3); p. 284-289

Abstract:
Introduction To determine whether women with CIN2 versus CIN3 on pretreatment cervical punch biopsy have less high-grade cytology recurrence following cold-coagulation cervical treatment. Materials and Methods This was a retrospective study of women having had cold coagulation between 2001-2011 in our colposcopy unit. Women with previous cervical treatment were excluded. Results We identified 402 women with 260 (64.7?%) cases of CIN2 and 142 (35.3?%) cases of CIN3 on pretreatment cervical punch biopsy. In the total sample, the mean age of women was 27.5 years (SD = 4.9), 75.1?% were nulliparous and 36.6?% were smokers. Referral cytology and pretreatment colposcopic appearance were high-grade in 62.7?% and 57.1?%. The mean follow-up period was 2.8 years (SD = 2.1). Women with CIN2 on pretreatment cervical biopsy when compared to those with CIN3 had less frequently high-grade referral cytology and high-grade pretreatment colposcopic appearances, and had less pretreatment cervical biopsies taken. During the follow-up period, women with CIN2 on pretreatment cervical biopsy had less high-grade cytology recurrence when compared to those women with CIN3 (1.9 vs. 5.6?%, p = 0.046). Multiple stepwise Cox regression analysis showed that women with CIN3 on pretreatment cervical biopsy had 3.21 times greater hazard for high-grade cytology recurrence (HR = 3.21, 95?% CI: 1.05-9.89; p = 0.041) in comparison with CIN2 cases. Conclusion We found that women with CIN2 on pretreatment cervical punch biopsy had less high-grade cytology recurrence following cold-coagulation treatment in comparison to those with CIN3. This finding lends support to the theory that CIN2 even though a high-grade abnormality might not have the same aggressive potential as CIN3.

Comparison of cure rates in women treated with cold-coagulation versus LLETZ cervical treatment for CIN2-3 on pretreatment cervical punch biopsies: a retrospective cohort study (2017)

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Type of publication:
Journal article

Author(s):
*Papoutsis D, *Underwood M , *Parry-Smith W, *Panikkar J.

Citation:
Archives of Gynecology and Obstetrics. 2017 Apr;295(4):979-986

Abstract:
PURPOSE:
To compare the cure rates between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia grade 2 (CIN2) or 3 (CIN3) on pretreatment cervical punch biopsies.
METHODS:
This was a retrospective cohort study of women having had a single cervical treatment for CIN2 or CIN3 on pretreatment cervical punch biopsies between 2010 and 2011. The cure rates were defined as the absence of any dyskaryosis (mild/moderate/severe) on cytology tests during follow-up and were determined at 6 and 12 months after treatment.
RESULTS:
We identified 411 women having had cervical treatment with 178 cases of cold-coagulation and 233 cases of LLETZ. The cure rates at 6 months following cold-coagulation and LLETZ treatment were 91.6 versus 97.1% (p = 0.02), whereas at 12 months, they were 96.5 versus 97.3% (p = 0.76). Multivariable analysis showed that after adjusting for confounding factors, there was a fourfold higher cure rate with LLETZ in comparison with cold-coagulation at 6 months after treatment (adjusted OR 4.50, 95% CI 1.20-16.83; p = 0.026), with this difference disappearing at 12 months. The lower cure rates with cold-coagulation were due to its higher rates of mild dyskaryosis cytology tests at 6 months. The rates of moderate/severe dyskaryosis cytology tests were similar between the two treatment methods at 6 and 12 months.
CONCLUSION:
We found that women with CIN2 or CIN3 on pretreatment cervical punch biopsies, after adjusting for multiple confounding factors, had higher cure rates when treated with LLETZ versus cold-coagulation at 6 months, with this difference disappearing at 12 months.