Obstetrics and Gynaecology

A rare case of vulval myxoid chondrosarcoma (2015)

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Type of publication:
Conference abstract

Author(s):
*Abdelsalam H., *Malcolm A.

Citation:
Journal of Pathology, September 2015, vol./is. 237/(S46)

Abstract:
Introduction: Primary Extraskeletal Myxoid Chondrosaroma (EMC) of the vulva is a rare mesenchymal neoplasm. The myxoid tumour differential diagnosis on a core biopsy can be quite challenging. To date, few cases have been reported in the literature. Case Report: A 42-year old woman noticed a swelling on the right side of the labia, thought to be a Bartholin's cyst i n 2011. She was managed conservatively. She had drainage and marsupialization under general anaesthesia. This resulted in extreme bruising of the vulva. This was managed with antibiotics and non-steroidal anti-inflammatory medication, and it resolved after 3 weeks. Six months later, the patient presented again with a persistent vulval mass. A biopsy was obtained under general anaesthesia, and it showed a myxoid tumour with differential diagnosis of low grade chondroid tumour. An MRI was performed to assess the extent of the disease. The tumour was excised. At surgery, a 7 x 5 cm lobulated, extremely vascular vulval tumour was found. The tumour was inseparable from the inferior pubic ramus of the pelvic bone. A complete macroscopic resection was obtained. Histology confirmed low grade myxoid chondrosarcoma. Conculsion: Vulval lesions with unusual characteristics or insidious evolution in the labia majora or Bartholin's glands area should be carefully and pr omptly investigated. Differential diagnosis of myxoid tumours in the vulva should include myxoid chondrosarcoma amongst other diagnoses.

Endocervical Crypt Involvement by CIN2-3 as a Predictor of Cytology Recurrence After Excisional Cervical Treatment. (2015)

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Type of publication:
Journal article

Author(s):
*Papoutsis, Dimitrios, *Panikkar, Jane, *Underwood, Martyn, Blundell, Sue, *Sahu, Banchita, *Blackmore, Jill, *Reed, Nicholas

Citation:
Journal of Lower Genital Tract Disease, Oct 2015, vol. 19, no. 4, p. 311-318

Abstract:
The primary objective was to determine whether endocervical crypt involvement (ECI) by cervical intraepithelial neoplasia (CIN) on the excised cervical tissue after large loop excision of the transformation zone (LLETZ) represents a predictor of cytology recurrence. Secondary objective was to identify the ability of a pretreatment cervical punch biopsy to predict cytology recurrence. This was a case series study conducted in an NHS hospital. Women with LLETZ treatment performed over a 2-year period (2010-2011) were identified through our colposcopy database. Women with previous cervical treatment, cervical cancer on cone histopathology, or missing follow-up data were excluded. A group of 526 eligible women was identified over the study period. Crypt involvement was not a predictor of recurrence in the total sample. However, in the subgroup of women with CIN2-3 on pretreatment punch biopsy and with ECI on cone specimen in comparison to those without ECI, we identified an increased risk for overall cytology recurrence (HR, 3.1; 95% CI, 1.04-9.28; P = 0.043) and a trend for increased risk of high-grade cytology recurrence (HR, 4.62; 95% CI, 0.84-25.28; P = 0.07). A pretreatment punch biopsy showing crypt involvement by CIN2-3 was indicative of women at risk for abnormal cytology after excision. In women with CIN2-3 on pretreatment punch biopsy and ECI on excised tissue, the high-grade cytology recurrence was significantly reduced if more than 1.9 cm of cervix was removed. It seems that the presence of crypt involvement on the excised cervix in the subgroup of women with CIN2-3 on pretreatment punch biopsy is predictive of cytology recurrence.

Thrombolysis for stroke in pregnancy at 39 weeks gestation with a subsequent normal delivery (2015)

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Type of publication:
Journal article

Author(s):
*Ritchie J., *Lokman M., *Panikkar J.

Citation:
BMJ Case Reports, August 2015, vol./is. 2015

Abstract:
Stroke during pregnancy is fortunately a rare event, however, it can have severe consequences, with 9.5% of all maternal deaths being related to stroke. The most common presentation is an ischaemic stroke. There has been much debate as to the correct treatment for such cases' and whether thrombolysis can be used safely in pregnancy. Our case describes a 28-year-old woman with a previous normal vaginal delivery presenting in her third trimester with a sudden onset of dense left hemiparesis. She was successfully treated with alteplase, an intravenous recombinant tissue-type plasminogen activator, and made a full recovery after normal delivery of a healthy infant. This case report highlights one of the first documented successful outcomes from thrombolysis for this condition in the UK and may help inform future management of these women.

Link to full-text: http://casereports.bmj.com/content/2015/bcr-2015-209563.full.pdf

Cytological follow-up after hysterectomy: is vaginal vault cytology sampling a clinical governance problem? The University Hospital of North Staffordshire approach (2015)

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Type of publication:
Journal article

Author(s):
Parry-Smith W., Thorpe D., Ogboro-Okor L., *Underwood M. , Ismaili E., Kodampur M., Todd R., Douce G., Redman C.W.E.

Citation:
Cytopathology, June 2015, vol./is. 26/3(188-193)

Abstract:
Objectives: Vaginal vault cytology sampling following hysterectomy is recommended for specific indications in national guidelines. However, clinical governance issues surround compliance with guidance. Our first study objective was to quantify how many patients undergoing hysterectomy at the University Hospital of North Staffordshire (UHNS) had vault cytology advice in their histology report and, if indicated, whether it was arranged. The second was to devise a vault cytology protocol based on local experience and national guidance. Methods: The local cancer registry was searched. Clinical, clerical and histological data for all patients undergoing hysterectomy were collected. Results: In total, 271 patients were identified from both the gynae-oncology and benign gynaecology teams. Of these, 24% (65/271) were gynae-oncology patients with a mean age of 69 years. The benign gynaecology team had 76% (206/271) of patients with a mean age of 55 years. Subsequently, 94% (256/271) had cytology follow-up advice in their histopathology report. Ultimately, from both cohorts, 39% (18/46) had follow-up cytology performed when indicated. Conclusion: A high proportion of cases complied with national guidance. However, a disappointingly high number did not have vault cytology sampling when this was indicated. This is probably a result of the complex guidance that is misunderstood in both primary and secondary care. Vault follow-up of patients after hysterectomy rests with the team performing the surgery. Vault cytology, if indicated, should be performed in secondary care and follow-up should be planned. The protocol set out in this article should be followed to avoid unnecessary clinical governance failings.

Does a preprinted Evacuation of Retained Products of Conception (ERPC) consent form improve information provided to patients who are undergoing an ERPC compared to a generic hospital consent form? (2015)

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Type of publication:
Conference abstract

Author(s):
*Khattak H., *Bakhai K., *Zainab O.M., *Jones C., *Swain K., *Biswas N.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(21)

Abstract:
Introduction The General Medical Council (GMC) highlights in Good Medical Practice that obtaining informed consent is one of the duties of a doctor. The GMC advocate in the consent guidelines that the process of consenting is a partnership between the doctor and patient to come to a mutually agreed decision. There may be important medico-legal implications for doctors who obtain uninformed consent. This audit investigated the documentation of this clinical interaction. In the light of this, an original audit on 'ERPC Consent' was carried out in 2013. The audit highlighted that 'serious risks' were not consistently recorded. We therefore encouraged the use of a preprinted ERPC consent form. A re-audit was carried out in 2014. Methods A total of 30 case notes and consent forms were obtained, which is 71% of total ERPCs performed over a 3-month period in 2013. These were analysed using a pro forma and results presented at a local clinical governance meeting. As a result of this meeting, the preprinted form was re-introduced. A re-audit was performed, using the same pro forma with 25 case notes (51% of all ERPCs) over a 3 month period in 2014. The results were analysed and also presented to clinical governance. Results The original audit found that in 2013 only 20% of the forms used to take consent were the ERPC specific forms. After re-auditing in 2014, the number rose to 80%. This showed significant results for improvement in documentation for serious risks, in particular infertility (from 37% to 80%), significant cervical trauma (from 10% to 52%), damage to blood vessels (from 47% to 84%) and thrombosis (from 80% to 88%). Conclusion In conclusion, the complete audit cycle showed that there is a significant improvement in documentation of serious risk factors associated with surgical management of miscarriage and provision of information leaflets to the patients about ERPC. However, we recognise that small sample size may have limited our results and therefore propose a re-audit of all ERPCs performed in 2014.

Link to full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201504001-00048&LSLINK=80&D=ovft

High-grade vaginal intraepithelial neoplasia (VAIN2/3): comparison of clinical outcomes between treated and untreated patients in an observational cohort study (2015)

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Type of publication:
Conference abstract

Author(s):
*Pandey B., *Papoutsis D., *Guttikonda S., *Ritchie J., *Reed N., *Panikkar J., *Blundell S.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(149)

Abstract:
Introduction We aimed to compare the clinical outcomes between treated and untreated patients with high-grade vaginal intraepithelial neoplasia (VAIN2/3) in our colposcopy unit. Methods The clinical records of all patients diagnosed with VAIN and vaginal cancer over the time period of 1981-2012 were retrieved and reviewed. The primary outcome was to identify the progression of treated versus untreated patients with VAIN2/3 to vaginal cancer and to compare persistent VAIN disease in both subgroups. The secondary outcome was to identify any associations between particular demographic features of treated/ untreated VAIN2/3 patients with their clinical outcome. Results During the time period of this observational cohort study 36 patients of which 11 patients with VAIN1, 19 with VAIN2/3 disease and 6 with vaginal cancer were identified. In those with VAIN2/3 (n = 19) the diagnosis was made in a younger age in the subgroup of treated patients (n = 8) versus the untreated patients (n = 11) (47 +/- 7.1 versus 54.3 +/- 11.5 years old). Nulliparity and smoking status were similar between the two cohorts. The median follow-up for the untreated women was 7 years (range 1-22 years). In the treated VAIN2/3 group, median time from diagnosis to treatment was 4 years (range 0.2-7 years), and median follow-up after treatment was 7 years (range 0.5-18 years). Treatment methods were ablation (n = 4), excision of lesion (n = 2) and vaginectomy (n = 2). There were no cases of treated VAIN2/3 patients (0%) that progressed to vaginal cancer, whereas n = 3 cases of untreated VAIN2/3 patients (21.4%) progressed to vaginal cancer. Following initial VAIN2/3 diagnosis, 8/11 cases of untreated VAIN2/3 (72.7%) had persistent disease as identified in follow-up cytology/colposcopy/vaginal biopsies. In the treated VAIN2/3 patients, 5/5 cases (100%) had persistent disease post-diagnosis but after treatment this decreased to 2/7 cases (28.5%). Conclusion Treated VAIN2/3 patients were of younger age but of similar smoking status and parity in comparison to untreated patients. Three cases of untreated VAIN2/3 progressed to vaginal cancer, whereas there were no such cases of patients receiving treatment for VAIN2/3. The VAIN2/3 patients who received treatment had a higher rate of persistent VAIN disease at followup post-diagnosis (100% versus 72.7%), but after treatment this rate fell down to 28.5%. Further studies are needed to conclude whether treatment of VAIN2/3 disease reduces the rate of VAIN disease persistence and affects the progression to vaginal cancer.

Link to full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201504001-00343&LSLINK=80&D=ovft

Teenage pregnancy: incidence and outcomes in a rural Shropshire district general hospital trust (2015)

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Type of publication:
Conference abstract

Author(s):
*Moores K.L., Ritchie J., *Calcott G., *Underwood M. , *Oates S.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(319)

Abstract:
Introduction The UK has the highest rate of teenage pregnancy across Western Europe; however, the rate has been reducing and is currently at its lowest since 1969. Perceptions exist of worse outcomes in teenage pregnancies among healthcare professionals and the public alike. The review sought to determine outcomes of teenage pregnancy (2013-2014) and compare rates of teenage pregnancy (2008-2013) at Shrewsbury and Telford Hospitals (SaTH) NHS Trust and compare with local population outcomes. Methods A 12-month retrospective review of teenage pregnancy outcomes and comparison with outcomes of all deliveries at SaTH between April 2013 and March 2014, a total of 4916 deliveries, was conducted. Data sources included the MEDWAY Hospital Database. Recorded pregnancy outcomes were classified into two categories: outcomes in mothers aged 19 years or younger at time of delivery and outcomes in all mothers who delivered at SaTH in the study period. Parameters assessed included mode of delivery; blood loss; perineal trauma; birthweight; Apgar scores. Teenage pregnancy rates over the last 6 years were compared to recorded rates in 1996. Results The rate of teenage pregnancy has continued to reduce; especially in those aged <16 years. Over 90% of teenage mothers had a vaginal delivery and were half as likely to require caesarean delivery (RR 0.49; 95% CI 0.33-0.75). Low rates of instrumental deliveries were seen in each category; no failed instrumental deliveries occurred among teenage mothers. Teenage mothers were not at a statistically significant increased risk of preterm delivery; however, mean term birthweights were lower among teenage mothers; 3302 g compared with 3464 g in the total population; and mean Apgar scores were the same in both groups. No difference was seen in rates of severe perineal trauma; however, more than 60% of teenage mothers had an intact perineum. Furthermore, teenage mothers had significantly lower rates of postpartum haemorrhage (RR 0.66, 95% CI 0.48-0.90). Conclusion Thus, one may suggest a lower risk of harm to teenage parturients and their babies compared with the local population, contrary to current general beliefs.

Link to full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201504001-00718&LSLINK=80&D=ovft

Success rate of cold coagulation for the treatment of cervical intraepithelial neoplasia: a retrospective analysis of a series of cases (2015)

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Type of publication:
Journal article

Author(s):
*Parry-Smith W, *Underwood M , De Bellis-Ayres S, *Bangs L, Redman CW, *Panikkar J.

Citation:
Journal of Lower Genital Tract Disease, January 2015, vol./is. 19/1(17-21), 1089-2591;1526-0976 (13 Jan 2015)

Abstract:
OBJECTIVE: To establish the cure rate at 1 year of patients who have undergone cold coagulation for the treatment of cervical intraepithelial neoplasia (CIN).DESIGN: Retrospective review of data for all patients at Shrewsbury and Telford NHS Trust who had undergone cold coagulation as part of their treatment for CIN between 2001 and 2011. Follow-up data up to December 2012 were analyzed. SETTING: Colposcopy Department, Shrewsbury and Telford NHS Trust, United Kingdom.POPULATION: Women undergoing cold coagulation for the treatment of CIN between 2001 and 2011, with cytologic follow-up until December 2012. METHODS: Patients were identified using a local colposcopy database. Data were obtained via the local histopathology reporting systems. Statistical analyses were performed using Stata/IC 10.1 software. MAIN OUTCOME MEASURES: Posttreatment cytology and whether subsequent treatment was required, with histology results. RESULTS: Data on 557 patients were collected and analyzed. Pre-cold coagulation treatment histologic findings were CIN 1 in 156 patients (28.01%), CIN 2 in 260 patients (46.68%), and CIN 3 in 141 patients (25.31%). The median length of time between cold coagulation treatment and first follow-up smear, used to calculate cure rates at around 1 year, was 406 days (interquartile range 123 days, range 169-3,116 days). The cure rate after cold coagulation was 95.7% at around 1 year. CONCLUSIONS: Cold coagulation has a cure rate comparable to that of excisional treatments such as large loop excision of the transformation zone and should be considered more widely in patients undergoing primary treatment for CIN, where there is no suspicion of invasive disease on history, examination and cytologic results.

 

The first case of thrombolysis for stroke in pregnancy in the UK (2014)

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Type of publication:
Conference abstract

Author(s):
*Ritchie J., *Lokman M., *Panikkar J.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, November 2014, vol./is. 121/(7), 1470-0328 (November 2014)

Abstract:
Case: A healthy 28-year-old Caucasian woman presented to the Royal Shrewsbury Hospital (RSH) in her second pregnancy at 39 weeks of gestation with a sudden onset of dense left hemiparesis. This woman had no preceding risk factors. An urgent CT scan showed no acute changes suggesting a diagnosis of ischaemic stroke. Through discussion between the stroke specialist and consultant obstetrician, it was decided for thrombolysis which was performed in the emergency department prior to transfer to a larger hospital with stroke facilities. We wished to discover how many other women had undergone thrombolysis for stoke in pregnancy and the associated risks. We conducted a literature review concentrating on stroke and pregnancy including known risk factors and thrombolyis in pregnancy. We have found no other documented case of thromboylsis being used for stroke in pregnancy in the UK. Additionally there are many case reports not from the UK that demonstrate good maternal and fetal outcomes after thromobolysis. Conclusion: Our case appears to be the first reported case of thrombolysis for stroke in pregnancy in the UK. All post investigations have so far come back as normal, which is unusual as most other cases have had known risk factors for stroke. Our patient has recovered well post thrombolysis, which demonstrates the importance of dealing with stroke in pregnancy efficiently to allow thrombolysis to be achieved quickly. Although the risks and benefits need to be weighed up on an individual basis, our case and the relevant literature show that thrombolyiss can be safely used in pregnancy with good maternal and fetal outcomes.

Link to more details or full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201411006-00021&LSLINK=80&D=ovft