Evaluating Colposcopy with Dynamic Spectral Imaging During Routine Practice at Five Colposcopy Clinics in Wales: Clinical Performance.

BACKGROUND: The diagnostic accuracy of colposcopy is poor for detecting precancerous cervical lesions. OBJECTIVES: We assessed the performance of colposcopy for identifying cervical intraepithelial neoplasia grade 2 or worse (CIN2+), before and after including a dynamic spectral imaging (DSI) map that quantifies and maps acetowhitening to assist subsequent biopsy of suspicious lesions. METHODS: Four hundred and twenty-five women were examined at a multi-center setting in Wales, of which 393 women were included in the final analysis. RESULTS: For all referrals, the sensitivity of conventional colposcopy for histologically confirmed CIN2+ was 51.5%, the specificity was 92.0%, the positive predictive value was 56.7%, and the negative predictive value (NPV) was 90.4%. With the incorporation of the DSI map in predicting CIN2+, these became 84.8, 61.5, 30.8, and 95.3% respectively. The increase of sensitivity was statistically significant (p < 0.001). For the 236 women having colposcopy after low-grade (LG) cytology, with the incorporation of DSI, the sensitivity for CIN2+ increased from 27.3 to 86.4% (p < 0.001) and the NPV from 92.6 to 97.8%. CONCLUSIONS: Colposcopy with DSI results in improved sensitivity to detect CIN2+ and maintains a high NPV for all referrals and especially for those with LG referral cytology.

Evidence-based management of non-tubal ectopic pregnancies.

Recent advances in ultrasonography and the use of other modalities including magnetic resonance imaging scans have led to the early and more accurate diagnosis of non-tubal ectopic pregnancies (NTE). As a result, the management of these pregnancies has evolved. This article addresses the management options currently available for NTE. While surgical management remains the mainstay of treatment for ovarian, abdominal and cornual ectopics, there is growing evidence that some of these can be managed medically. Many authors have utilised a combination of medical and surgical approaches in the management of cervical and caesarean section (CS) scar ectopic pregnancies with good outcome. The availability of dedicated early pregnancy units has further improved diagnosis and more importantly the follow-up care for these patients. The rarity of cases and the difficulty of ethically organising randomised trials for NTE remain a problem in formulating consistent pathways for optimum management of women with NTE.

Beyond Guidelines: Effectiveness of a Programme in Achieving Operative Laparoscopy for all Women Requiring Surgical Management of Ectopic Pregnancy.

BACKGROUND/AIMS: Operative laparoscopy (OL) is considered the gold standard surgical treatment of ectopic pregnancy (EP). We questioned whether a training programme to foster OL treatment is able to ensure that all women needing surgical management are treated by OL irrespective of the site of EP, haemodynamic status and clinical complexity. METHODS: A 13-year cohort study of 963 women who underwent surgical management was conducted. We instituted a 'universal OL' programme in 2003 for the management of all the types of EP irrespective of the haemodynamic status. RESULTS: There were 802 women in the prospective (2003-2013) and 161 in the retrospective arm (2000-2002). The rate of OL before 2003 was 34%. During the year of programme implementation, the OL rate rose from 89% in 2003 to 96% in 2004. It took 4 years to achieve a 100% OL rate in haemodynamically stable patients. In 2013, we were able to achieve OL treatment for all patients irrespective of haemodynamic status, the complexity of surgery or the location of EP. CONCLUSION: Our study demonstrates that a dedicated team with special training in minimal invasive surgery can improve surgical management of all categories of EPs, and this goal should be achievable across most units.

Extranodal diffuse large B-cell lymphoma involving the uterine cervix.

This is a case of primary diffuse large B-cell lymphoma involving the uterine cervix which presented with irregular vaginal bleeding. The diagnosis was confirmed following multiple cervical biopsies. Treatment with a combination of immunotherapy, chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP)) and radiotherapy produced a good response.

A Case of Pyocolpos in a Postmenopausal Woman With a History of Lichen Sclerosus and Postmenopausal Bleeding.

Pyocolpos refers to the buildup of pus within the vaginal cavity. Pyocolpos in the background of lichen sclerosis and postmenopausal bleeding (PMB) has not been previously described. A 69-year-old para 3 patient presented with a history of PMB with a long-standing history of lichen sclerosis. The vaginal examination was impossible due to vaginal adhesions. Vulval appearances revealed the loss of the clitoral architecture. Further imaging revealed an endometrial thickness of 4-5 mm, a focal abnormality within the posterior ectocervix compatible with a hemorrhagic cystic lesion distending the posterior fornix, and some free fluid within the pelvis. A hysteroscopy was abandoned as the vagina was completely obliterated. After a multidisciplinary assessment, the patient had a total abdominal hysterectomy, and the presence of a pyocolpos was noticed at the opening into the vault. We could not find any previous case reports of pyocolpos that are associated with lichen sclerosus. The long-standing history of lichen sclerosus may have caused an obstruction of the outflow tract, which was secondarily infected and slowly progressed into the formation of pyocolpos. Other management options could have been explored if the diagnosis of pyocolpos had been made preoperatively. Pyocolpos should be considered in patients with a history of a long-standing lichen sclerosus who present with abdominal pain and a pelvic mass on imaging.

Simulation-Based Education for Enhancing Obstetric Emergency Response: A Needs Impact Evaluation.

Simulation is an ideal method for procedural training in obstetrics. To maximise training opportunities through simulation, the evaluation of these educational activities should be based on a standardised evidence-based approach. As such, the tools used in the evaluative process should be validated for content and context, as this ensures consistency of approach. It also makes the findings and recommendations acceptable, applicable and credible. More so, the information can be used for planning further learning, assessment of the competency of the trainers and educational governance purposes. In our view, simulation should be used in conjunction with other forms of procedural assessment such as mini-clinical examinations and case-based discussions to translate skills to actual life events. The learners will be able to further consolidate their learning, improve professional skills and feel involved throughout the programme.

A rare case of acute abdomen: spontaneous rupture of degenerated fibroid.

A 29-year-old nulliparous woman presented with an acute abdomen. She had a large uterus with multiple fibroids and was on the waiting list for elective surgery. An urgent CT scan demonstrated an extensive intraperitoneal fluid collection suspicious for fibroid rupture. She required an emergency laparotomy which identified a rupture of the largest degenerative fibroid. There was 2 Litres of pus in the peritoneal cavity. This case was a rare presentation of spontaneous fibroid rupture due to degeneration and necrosis, and acute abdomen from peritoneal irritation. Imaging was vital in making the diagnosis, and urgent surgical intervention was essential to reduce morbidity and mortality.